PEBB - Secure Horizons Classic

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Benefit Summary

Contact Information

Toll-Free Phone: Current Members: 1-866-572-9396 Non-members: 1-800-647-7328
TTY/TDD Phone: Current Members: 711 or 1-888-685-8480 Non-members: 1-800-387-1074
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Benefit Summary

Annual Costs	2009 Coverage	2010 Coverage
Annual deductible	None	$0
Annual out-of-pocket maximum	$750 per person per year	$750/person
Annual prescription drug deductible	Does not apply	Does not apply

Medical Benefits	2009 Coverage	2010 Coverage
Ambulance services
(air)	$50 copay	$50/trip
(ground)	$50 copay	$50/trip
Diagnostic tests, laboratory, and X-rays	Plan pays 100%	Enrollee pays $0
Durable medical equipment, supplies, and prostheses	Plan pays 100%	Enrollee pays $0
Emergency room (copay waived if admitted) When should I go to the emergency room?	$50 copay per visit	$50
Hearing
(routine annual exam)	$10 copay per exam	$10
(hardware)	$800 maximum plan benefit every 36 months	Enrollee pays any amount over $800 every 36 months for hearing aid and rental/repair combined
Hospital services
(inpatient)	$150 copay per day; maximum $600 per person per year	$150/day for 1-4 days
(outpatient)	Plan pays 100%	Enrollee pays $0
Mental health care
(outpatient)	$10 copay per visit	$10
Obstetric care
(inpatient)	Information unavailable, contact your plan	Information unavailable, contact your plan
(outpatient)	Information unavailable, contact your plan	Information unavailable, contact your plan
Office visits	$10 copay per visit	$10
Physical, occupational, and speech therapy (per-visit cost for 60 visits/year combined)	Inpatient Physical, occupational, and speech therapies: Subject to inpatient hospital copay Massage therapy not covered Outpatient Physical, occupational, and speech therapies: $10 copay per visit Massage therapy not covered	$10
Prescriptions How can I find out more about drugs and supplements?
tier 1 (retail pharmacy, 30-day supply)	$10 copay per prescription or refill Medicare-approved diabetic supplies: plan pays 100%	$10
tier 2 (retail pharmacy, 30-day supply)	$25 copay per prescription or refill	$25
tier 3 (retail pharmacy, 30-day supply)	$40 copay per prescription or refill	$40
tier 1 (mail order, 90-day supply)	$20 copay per prescription or refill Medicare-approved diabetic supplies: plan pays 100%	$20
tier 2 (mail order, 90-day supply)	$50 copay per prescription or refill	$50
tier 3 (mail order, 90-day supply)	$80 copay per prescription or refill	$80
Preventive care Which immunizations are needed and when?	Plan pays 100%	Enrollee pays $0
Spinal manipulations (per-visit cost for 10 visits/year)	$10 copay per visit, up to 10 visits per calendar year	$10
Vision care
(annual exam)	$10 copay per exam	$10
(glasses and contact lenses)	Hardware every 24 months; either lenses and frames, or contact lenses. Lenses: Plan pays 100% every 12 months Frames: $150 plan maximum Contact lenses (in lieu of lenses and frames): $150 plan maximum every 12 months	Any amount over $150 every 12 months