PEBB - Secure Horizons Value

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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	$300/person
Annual out-of-pocket maximum	None	$2,000/person
Annual prescription drug deductible	Does not apply	Does not apply

Medical Benefits	2009 Coverage	2010 Coverage
Ambulance services
(air)	$50 copay	$100/trip
(ground)	$50 copay	$100/trip
Diagnostic tests, laboratory, and X-rays	Plan pays 100%	20%
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)	$30 copay per exam	$30
(hardware)	$500 maximum plan benefit every 36 months	Enrollee pays any amount over $500 every 36 months
Hospital services
(inpatient)	$200 copay per day; maximum $1,000 per person per year	$250/day for 1-8 days
(outpatient)	$100 copay	$100
Mental health care
(outpatient)	$30 copay per visit	$30
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	$15 copay for primary care visit; $30 copay for specialist visit	$20 primary care; $35 specialty care
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: $30 copay per visit Massage therapy not covered	$30
Prescriptions How can I find out more about drugs and supplements?
tier 1 (retail pharmacy, 30-day supply)	$15 copay per prescription or refill Medicare-approved diabetic supplies: plan pays 100%	$15
tier 2 (retail pharmacy, 30-day supply)	$35 copay per prescription or refill	$40
tier 3 (retail pharmacy, 30-day supply)	$50 copay per prescription or refill	$55
tier 1 (mail order, 90-day supply)	$30 copay per prescription or refill Medicare-approved diabetic supplies: plan pays 100%	$30
tier 2 (mail order, 90-day supply)	$70 copay per prescription or refill	$80
tier 3 (mail order, 90-day supply)	$100 copay per prescription or refill	$110
Preventive care Which immunizations are needed and when?	Plan pays 100%	Enrollee pays $0
Spinal manipulations (per-visit cost for 10 visits/year)	Not covered	$15
Vision care
(annual exam)	$25 copay per exam	$25
(glasses and contact lenses)	$20 copay for glasses (either lenses and frames or contact lenses), up to $150 plan maximum once every 24 months	Enrollee pays any amount over $130 for glasses; any amount over $175 for contacts every 24 months