PEBB - Group Health Classic

Notice

The HCA will close its Lacey office at 3 p.m. Friday, February 17, to relocate staff to its office at Cherry Street Plaza, 626 8th Avenue SE, in Olympia. Details.

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Contact Information

Local: 206-901-4636
Toll-Free: 1-888-901-4636
TTY/TDD: 711 or 1-800-833-6388
Find a Provider | Visit the Plan's Website

Benefits Booklet (Certificate of Coverage)

2011 Employees Certificate of Coverage
2011 Retirees Certificate of Coverage (enrollees under 65 and enrollees not in a Medicare Advantage plan)

The 2012 benefits booklet will be posted as soon as they are available. If you have questions about the certificate of coverage, or to receive a copy, contact the plan.

Benefits Summary

Annual Costs	2012 Coverage
	Member Pays
Deductible What is the difference between deductibles and out-of-pocket maximums?	$250/person $750/family
Out-of-pocket maximum What is the difference between deductibles and out-of-pocket maximums?	$2,000/person $4,000/family
Prescription drug deductible	N/A

Medical Benefits	2012 Coverage
	Member Pays
Ambulance
Per trip, air	20%
Per trip, ground	20%
Diagnostic tests, laboratory, and x-rays	$0; MRI/CT/PET scan $30
Durable medical equipment, supplies, and prostheses	20%
Emergency room (Copay waived if admitted) When should I go to the emergency room?	$150
Hearing
Hardware	Any amount over $800 every 36 months after deductible has been met for hearing aid and rental/repair combined.
Routine annual exam	$15
Home health	$0
Hospital services
Inpatient	$150/day; $750 maximum/admission
Outpatient	$150
Mental health care
Outpatient	Information unavailable, contact your plan
Obstetric care
Inpatient	Information unavailable, contact your plan
Outpatient	Information unavailable, contact your plan
Office visit
Chemotherapy	$15
Mental health	$15
Primary care	$15
Radiation	$30
Specialist	$30
Urgent care	$15
Physical, occupational and speech therapy (Per-visit cost for 60 visits/year combined)	$15
Prescription drugs How can I find out more about drugs and supplements?
Mail order (up to a 90-day supply) Value tier	$10
Mail order (up to a 90-day supply) Tier 1	$40
Mail order (up to a 90-day supply) Tier 2	$80
Mail order (up to a 90-day supply) Tier 3	50% up to $750
Retail pharmacy (up to a 30-day supply) Value tier	$5
Retail pharmacy (up to a 30-day supply) Tier 1	$20
Retail pharmacy (up to a 30-day supply) Tier 2	$40
Retail pharmacy (up to a 30-day supply) Tier 3	50% up to $250
Preventive care Which immunizations are needed and when?	$0; See certificate of coverage or check with plan for full list of services.
Spinal manipulations	$15
Vision care
Exam (annual)	$15
Glasses and contact lenses	Any amount over $150 every 24 months (or two calendar years for UMP) for frames, lenses, contacts, and fitting fees combined.