All medical plans cover the same basic health care services but vary in other ways, such as provider networks and premiums. Use the tools below to compare plan benefits.
- Premiums
-
View monthly premiums.
A premium is the monthly amount the employee or employer pays to the plan to cover the cost of insurance. The premium does not cover copays, coinsurance, or deductibles. A higher premium doesn't necessarily mean higher quality of care or better benefits; each plan has the same basic level of benefits.
Note: Employees who work for a city, county, port, tribal government, water district, hospital, etc., need to contact their payroll or benefits office to find their monthly premiums.
- Your provider
-
If you have a long-term relationship with your doctor or health care provider, you should verify whether they are in the plan's network. See Find a provider.
- Your current care
-
If you are currently receiving care, are on a treatment plan, have an upcoming surgery or are taking prescription medications, some things you will want to consider for you and your dependents are:
- Whether you can continue to receive care with your current providers or facilities as in network.
- If your current prescription drugs are in the plans' formulary and under which tier.
- How to transfer your care or treatment to another plan.
- If you are ok paying different cost-shares, for example, the deductible or out-of-pocket maximum levels and coinsurance or copays.
- Deductibles
-
The amount you should expect to pay out of pocket before a plan begins to pay their portion. Plans have deductible exemptions for certain types of care. For instance, certain preventive care is covered before meeting your deductible. Your plan will cover costs for qualifying care before you meet the deductible.
- Coinsurance or copays
-
A copay is a fixed fee you pay when you receive care.
Coinsurance is a percentage of the allowed amount charged by the provider that you pay.
- Out-of-pocket limit
-
The annual out-of-pocket limit is the most you pay in a calendar year for covered benefits. Some plans have a separate out-of-pocket limit for prescription drugs. Once you have reached the out-of-pocket limit, the plan pays 100 percent of allowed charges for most covered benefits for the rest of the calendar year. Certain charges (such as your annual deductible, copays, and coinsurance) may count toward your out-of-pocket limit. Others, such as your monthly premiums, do not count toward your out-of-pocket limit.
- Referral procedures
-
Some plans allow you to self-refer to network providers for specialty care. Others require you to have a referral from your primary care provider. After you join a medical plan, you may change your provider, although the rules vary by plan.
- Network adequacy
-
All health carriers in Washington State are required to maintain provider networks that provide members reasonable access to covered services. Check the plan's provider directories to see how many providers are accepting new patients and what the average wait time is for an appointment. For more information, see Behavioral health services by plan and Brennen's Law (RCW 48.43.765).
- Coordination with your other benefits
-
All PEBB medical plans coordinate benefit payments with other group plans, Medicaid, and Medicare. This is called coordination of benefits. It ensures the highest level of reimbursement for services when a person is covered by more than one plan. Payment will not exceed the benefit amount. If you are also covered by another health plan, call the medical plans directly to ask how they will coordinate benefits. This is especially important for those coordinating benefits between the PEBB and SEBB programs, and those also enrolled in Medicaid.
- Type of plan
-
The PEBB Program offers three types of medical plans:
- Managed-care plans: These plans may require you to choose an in-network primary care provider to coordinate your health care needs. The play may not pay benefits if you see an out-of-network provider.
- Preferred provider organization (PPO) plans: PPOs allow you to self-refer to any approved provider in most cases and usually provide a higher level of coverage if the provider is in-network.
- Consumer-directed health plans (CDHP): A CDHP lets you use a health savings account (HSA) to help pay for out-of-pocket medical expenses tax-free. These plans have a lower monthly premium, a higher deductible, and a higher out-of-pocket limit than most other plans. Visit Health plans with health savings account for more information.
