2016-2017 Medical Plans PLAN VARIATIONS HIGHLIGHTED IN RED/WHITE
BIRCH In-Network, You pay
CEDAR
Out-ofNetwork, You pay
DOGWOOD
Out-ofIn-Network, In-Network, Network, You You pay You pay pay
Out-ofNetwork, You pay
EVERGREEN (H.S.A Required) In-Network, You Out-of-Network, pay You pay²
Plan-year costs Deductible per person / family (In Network)
$800 / $2,400
$1,200 / $3,600
$1,600 / $4,800
$1,600 / $3,2002
Out-of-pocket maximum per person
$4,000
$8,000
$5,000
$10,000
$6,850
$13,700
$6,5502
Out-of-pocket maximum per family
$12,000
$24,000
$13,700
$27,400
$13,700
$27,400
$13,100³
Maximum cost share per person (Includes OOP, ACT, and Rx)
$6,850
NA
$6,850
NA
$6,850
NA
NA
Maximum cost share per family (Includes OOP, ACT, and Rx)
$13,700
NA
$13,700
NA
$13,700
NA
NA
Moda Health Medical Home wellness visit (ages 21 and over)
$0
Not covered
$0
Not covered
$0
Not covered
$0
Not covered
Periodic health exams, routine women’s exams, annual obesity screening, immunizations
$0
50%
$0
50%
$0
50%
$0
50%
Moda Health medical home incentive $15 copay¹ care
50%
$15 copay¹
50%
$15 copay¹
50%
20%
50%
Incentive office and home visits
20%¹
50%
20%¹
50%
20%¹
50%
20%
50%
Moda Health medical home primary office visits
$30 copay¹
50%
$30 copay¹
50%
$30 copay¹
50%
20%
50%
Primary care/specialist office visits
20%
50%
20%
50%
20%
50%
20%
50%
$30 copay¹
50%
$30 copay¹
50%
$30 copay¹
50%
20%
50%
20%
50%
20%
50%
20%
50%
20%
50%
$0
50%
$0
50%
$0
50%
20%
50%
50%
20%
50%
20%
50%
Preventive Care
Incentive Care Services
Professional Services
Mental health office visits Mental health inpatient/residental services Chemical dependency services
Alternative Care Services ($2,000 plan year maximum) Acupuncture, Chiropractic & Naturopathic Care
20%
50%
20%
Maternity Care Outpatient Maternity Care
20%
50%
20%
50%
20%
50%
20%
50%
Physician or midwife services & hospital stay
20%
50%
20%
50%
20%
50%
20%
50%
Outpatient and Hospital Services Inpatient care/surgery and outpatient surgery/facility care
20%
50%
20%
50%
20%
50%
20%
50%
Skilled nursing facility care (60 days per plan year)
20%
50%
20%
50%
20%
50%
20%
50%
$100 copay $100 copay + $100 copay $100 copay + $100 copay $100 copay + + 20% 50% + 20% 50% + 20% 50%
20%
50%
ACT 100: $100 Additional Cost Tier: $100 copay $100 copay + $100 copay $100 copay + $100 copay $100 copay + spinal injections, tonsillectomies + 20% 50% + 20% 50% + 20% 50%
20%
50%
ACT 500: $500 Additional Cost Tier: Spine surgery, knee and hip $500 copay $500 copay + $500 copay $500 copay + $500 copay $500 copay + + 20% 50% + 20% 50% + 20% 50% replacement3, knee and shoulder arthroscopy, hernia repair.
20%
50%
Outpatient Rehabilitation: physical, occupational and speech therapy. (30 days per plan year, 60 for spinal or head injury
20%
50%
20%
50%
20%
50%
20%
50%
Outpatient diagnostic lab & x-ray
20%
50%
20%
50%
20%
50%
20%
50%
Sleep studies, specified imaging (MRI, CT, PET), upper endoscopy, lumbar discographies, viscosupplementation
Emergency Care Urgent care visit Emergency room (copay waived if admitted)
$50¹
$50¹
$50¹
20%
$100 copay + 20%
$100 copay + 20%
$100 copay + 20%
20%
20%
20%
20%
20%
Ambulance
Other Covered Services Hearing Aids - $4,000 max/48 months for members 26 and older. See handbook for State mandated benefit for children
10%
50%
10%
50%
10%
50%
20%
50%
Durable Medical Equipment
20%
50%
20%
50%
20%
50%
20%
50%
Weight Management (Subscriber and covered dependents unless noted otherwise) Up to four 13-week Weight Watchers Sessions per Plan Year
$0
$0
$0
$0 1
12 Health Coaching Sessions per Plan Year and Online Educational Resources
$0
$0
$0
$0 1
Bariatric Surgery3 Subscribers $500 copay $500 copay $500 copay $500 copay + Not Covered Not covered Not Covered Not Covered only. See Plan Handbook for specific + 20% + 20% + 20% 20% criteria 1 Deductible Waived. All amounts reflect member responsibility 2 Individual deductible and out-of-pocket maximum apply to single coverage only. Family deductible and out-of-pocket maximum apply when two or more individuals are covered on the plan. This plan now includes an embedded per member OOP max, which is set at the individual OOP amount. Under this plan, deductible must be met before benefits will be paid (except where 1 indicates deductible waived). 3 For PPO plans, OOP max includes medical copayments and coinsurance. Pharmacy copays and coinsurance and ACT copayments will continue accuring towards Maximum Cost Share. For Summit/Synergy plans, OOP max includes medical copayments, coinsurance, as well as pharmacy copays and coinsurance. ACT copayments will continue accruing towards Maximum Cost Share limit. 4 Benefit is subject to a reference price limitation. This is not applicable to Summit/Synergy Plans. Deductibles and copayments apply to the annual out-of-pocket maximum. For limitations and exclusions, visit modahealth.com/oebb/members and refer to your Member Handbook. This document is for comparison purposes only and is not intended to fully describe the benefits of each Plan. Refer to your member handbook for more details of benefit coverage. In the case of a conflict between this comparison and your member handbook, the member handbook will prevail.
2016 - 2017 Prescription drug plan Alder, Birch, Cedar, Dogwood Medical Plans
Retail PPO You pay
Mail order
Synergy You Pay
PPO You pay
Synergy You Pay
Specialty PPO You pay
Synergy You Pay
Out of Pocket Maximum
Rx applies Rx applies Rx applies Rx applies Rx applies Rx applies toward plan toward plan toward plan toward Max toward Max toward Max OOP OOP OOP cost share cost share cost share Maximum Maximum Maximum
Value Tier
$4 $0 (up to 90(up to 90day supply) day supply)
$8
$0
N/A
Select generic
$12 per 31 day supply
$24
$16
N/A
$8 per 31 day supply
Preferred
25% up to 25% up to 25% up to 25% up to 25% up to 25% up to $75 per 31- $50 per 31- $150 per 90- $100 per 90- $200 per 31- $100 per 31day supply day supply day supply day supply day supply day supply
Non-preferred brand
50% up to 50% up to 50% up to 50% up to 50% up to 50% up to $175 per 31- $150 per 31- $450 per 90- $300 per 90- $500 per 31- $300 per 31day supply day supply day supply day supply day supply day supply
2016 - 2017 Prescription drug coverage with Evergreen (HSA) Medical Plan
Retail PPO You pay
Synergy You Pay
PPO You pay
Synergy You Pay
Specialty PPO You pay
Synergy You Pay
Rx applies toward OOP Maximum
Out of pocket maximum
Value Tier
Mail order
$4 $0 (up to 90(up to 90day supply) day supply)
$8
$0
NA
Select generic
20%
20%
NA
Preferred ³, ⁴
20%
20%
20%
Non-preferred brand ⁴
20%
20%
20%
This document is for comparison purposes only and is not intended to fully describe the benefits of each Plan. Refer to your member handbook for more details of benefit coverage. In the case of a conflict between this comparison and your member handbook, the member handbook will prevail.
Plan 1 2016-2017 Dental Plans
Plan 2
Plan 6
MODA PREFERRED NETWORK: DELTA DENTAL
Willamette Dental Plan 8 ‡ You must receive services at a Willamette Dental Office
Plan-year costs Deductible Benefit Maximum Dental Office Visit Copayment
$50 $2,200 N/A
$50 $1,500 N/A
$50 $1,200 N/A
N/A No maximum limit $20 3*
Preventive and Diagnostic Services *- Deductible Waived for Preventive and Diagnostic Services on Delta Plans Oral exams, X-rays, cleansings (prophylaxis), flouride treatments and space maintainers
70% + 10% each Plan Year
70% + 10% each Plan Year
100%
100% *
70% + 10% 1 each Plan Year
70% + 10% 1 each Plan Year
80% 1
100% 2*
70% + 10% each Plan Year
70% + 10% each Plan Year
80%
100%*
70% + 10% each Plan Year
70% + 10% each Plan Year
80%
100%*
70% + 10% each Plan Year
70% + 10% each Plan Year
80%
100%*
70% + 10% each Plan Year
70% + 10% each Plan Year
80%
100%*
Gold or porcelain crowns and onlays
70% + 10% each Plan Year
70% + 10% each Plan Year
80%
Implants
70% + 10% each Plan Year
70% + 10% each Plan Year
50%
100%* See Certificate of coverage for copays
Restorative Services* Routine fillings, inlays and stainless steel crowns
Simple Extraction* Simple tooth extractions
Oral Surgery * Surgical tooth extractions, including diagnosis and evaluation
Periodontics * Diagnosis, evaluation and treatment of gum disease including scaling and root planing
Endodontics * Root canal and related therapy including diagnosis and evaluation.
Major Restorative Services*
Occlusal guards (night guards)
50% up to $150 maximum, once 50% up to $150 maximum, once 50% up to $150 maximum, once every 5 years every 5 years every 5 years
100% 4
Fixed and Removable Prosthetic Services * Full and partial dentures, relines, rebases
70% + 10% each Plan Year
70% + 10% each Plan Year
50%
100%*
Bridge retainers and pontics
70% + 10% each Plan Year
70% + 10% each Plan Year
50%
100%*
No coverage
$1,500 copay + $20 per visit**
Orthodontic Services* (all plans except Delta Dental Plan 6) Moda Lifetime maximum - $1,800
80%
80%
Under Delta Dental Plans 1,2 & 3, benefits start at 70% the first plan year then increase by 10% each plan year (up to a maximum of 100%) provided the individual has visited the dentist at least once during the previous plan year. Switching between incentive plans (1 - 3) and non-incentive plans (4, 6 and 8) will have an effect on benefit level. Failure to visit the dentist at least once during the previous plan year will cause a 10% reduction in benefit payment the following plan year, although payment will never fall below 70%. * For Willamette Dental Group Plan: Office visit copayment applies at each visit, in addition to any plan copayments for services. ** Pre-orthodontic Service fee of $150 is credited toward the orthodontic benefit if patient accepts treatment plan. ‡ For Willamette Dental Plan: Services must be provided by a Willamette Dental Group provider in order for benefits to be payable. See handbook for details. 1. Posterior fillings paid to amalgam fee. 2. For Willamette Dental Plan: Fillings are covered at 100% for all amalgam tooth surfaces, composite anteriors and one-surface composite posteriors. Patients can request composite fillings, which are considered a buy-up and additional fees apply. Please contact Willamette Dental Group directly for actual fees. 3. The office visit copayment is waived for participants in the Chronic Condition Dental Management program for specific preventative services. 4. Replacement of lost or stolen appliance once every 2 years, replacement or repair of broken appliance as needed.
This document is for comparison purposes only and is not intended to fully describe the benefits of each Plan. Refer to your member handbook for more details of benefit coverage. In the case of a conflict between this comparison and your member handbook, the member handbook will prevail.
2016-2017 Vision Plans
Opal
Pearl
$600*
$400*
Plan-year costs Benefit Maximum Eye examinations (including refraction).
100% - Once per plan year
Lenses (either one pair of lenses or contacts) Plan pays 100% (up to plan maximum)
Once per plan year
Frames Plan pays 100% (up to plan maximum)
Under age 17 Once per plan year
Under age 17 Once per plan year
Age 17 and older Once every 2 plan years
Age 17 and older Once every 2 plan years
* Exam and hardware charges all apply to the Plan Year maximum on Moda Plans For limitations and exclusions, visit modahealth.com/oebb/members and refer to your member handbook. This document is for comparison purposes only and is not intended to fully describe the benefits of each Plan. Refer to your member handbook for more details of benefit coverage. In the case of a conflict between this comparison and your member handbook, the member handbook will prevail.
