PEBB - Kaiser Permanente CDHP

Annual Costs	2013 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	2013 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
Hospital services
Inpatient	15%
Outpatient	15%
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.