PEBB - Kaiser Permanente Value

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Benefit Summary

Contact Information

Local Phone: 503-813-2000
Toll-Free Phone: 1-800-813-2000
TTY/TDD Phone: 1-800-735-2900
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Visit the Plan's Website

Benefit Summary

Annual Costs

2009 Coverage

2010 Coverage

Annual deductible

Medical Services:
Enrollee pays $100 per person/$300 per family (three or more people)

Annual deductible does not apply to some benefits, including preventive care.

Prescription drugs:
None

$300/person
$900/family

Annual out-of-pocket maximum

Enrollee pays $1,500 per person/$3,000 per family

$2,000/person
$4,000/family

Annual prescription drug deductible

Does not apply

Medical Benefits	2009 Coverage	2010 Coverage
Ambulance services
(air)	Enrollee pays 10% coinsurance (not subject to annual deductible)	25%/trip
(ground)	Enrollee pays 10% coinsurance (not subject to annual deductible)	25%/trip
Diagnostic tests, laboratory, and X-rays	Enrollee pays 10% coinsurance	25%
Durable medical equipment, supplies, and prostheses	Enrollee pays 20% coinsurance (not subject to annual deductible)	20%
Emergency room (copay waived if admitted) When should I go to the emergency room?	$100 copay per visit	$100
Hearing
(routine annual exam)	$20 copay per exam	$30
(hardware)	$800 maximum plan payment every 36 consecutive months for hearing aid and rental/repair (not subject to annual deductible)	Enrollee pays any costs above $800, allowed every 36 months for hearing aid and rental/repair combined
Hospital services
(inpatient)	Enrollee pays 10% coinsurance	25%
(outpatient)	Enrollee pays 10% coinsurance	25%
Mental health care
(outpatient)	$20 copay per visit, up to 50 visits per year (not subject to annual deductible)	$30
Obstetric care
(inpatient)	Enrollee pays inpatient hospital copay for mother only	25%
(outpatient)	Covered in full	Enrollee pays $0
Office visits	$20 copay per visit (not subject to annual deductible)	$30 primary care; $40 specialty care; $50 urgent care
Physical, occupational, and speech therapy (per-visit cost for 60 visits/year combined)	Inpatient Includes massage therapy Enrollee pays inpatient hospital copay, up to 60 days per year Outpatient Includes massage therapy $20 copay per visit, up to 60 visits per year for all therapies combined (not subject to annual deductible)	$40
Prescriptions How can I find out more about drugs and supplements?
tier 1 (retail pharmacy, 30-day supply)	Not subject to annual deductible Formulary generic, all insulin, and all disposable diabetic supplies, $10 copay	$20
tier 2 (retail pharmacy, 30-day supply)	Not subject to annual deductible Formulary brand-name drugs, $30 copay	$40
tier 3 (retail pharmacy, 30-day supply)	N/A	N/A
tier 1 (mail order, 90-day supply)	Not subject to annual deductible Formulary generic, all insulin, and all disposable diabetic supplies, $20 copay	$40
tier 2 (mail order, 90-day supply)	Not subject to annual deductible Formulary brand-name drugs, $60 copay	$80
tier 3 (mail order, 90-day supply)	N/A	N/A
Preventive care Which immunizations are needed and when?	Covered in full (not subject to annual deductible)	Enrollee pays $0 (See Certificate of Coverage or check with plan for full list of services)
Spinal manipulations (per-visit cost for 10 visits/year)	$20 copay per visit, up to 10 visits per year (not subject to annual deductible)	$40
Vision care
(annual exam)	$20 copay per exam; one annual eye exam	$30
(glasses and contact lenses)	$150 maximum plan payment every 2 calendar years for frames, lenses, contacts, and fitting fees combined (not subject to annual deductible)	Enrollee pays any costs above $150 every 24 months for frames, lenses, contacts, and fitting fees combined.