PEBB - Kaiser Permanente CDHP

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Contact Information

Portland area: 503-813-2000
Toll-Free: 1-800-813-2000
TTY/TDD: 1-800-735-2900
Find a Provider | Visit the Plan's Website

Benefits Booklet (Certificate of Coverage)

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?	$1,400/individual $2,800/Subscriber with 1 or more dependents (must meet family deductible before plan pays benefits)
Out-of-pocket maximum What is the difference between deductibles and out-of-pocket maximums?	$4,200 individual/$8,400 family (must meet family out-of-pocket maximum before plan pays 100%)
Prescription drug deductible	Included in deductible

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