AttachC_PlanDesigns.pdf

PEBB 2026 Summary of Benefits Page 1

PEBB Medical & Pharmacy Benefits RFP OregonBuys Bid No. S-44300-00014758 Attachment C

PEBB Medical and Pharmacy Plan Designs

I. The following current medical plan designs are available to all members for the 2026 PY. Full time employees have access to these plan designs via negotiated contributions. Part time employees can pay the difference between the part time plan cost and these full-time plan costs in addition to their part-time contributions to access these benefits.

II. In addition to the below plan designs, tables A and B, Proposals must meet the following criteria:

a. Proposer has submitted a Proposal that includes, at minimum, one plan design that is comparable to or better than the plan design described for that particular type of Proposal (statewide PPO or Regional CCM or HMO) in this Attachment.

b. Plan design should not be contingent on being the pharmacy benefit manager (PBM) as well.

c. Plan design should have the ability to integrate with a PBM should PEBB choose a separate PBM vendor.

d. Plans offered by Proposer will not be contingent upon being the only plan offered in the service area.

e. Plans offered by Proposer will not include minimum participation or employer contribution requirements.

f. Plans offered by Proposer will be offered to all Eligible Employees as determined by PEBB, with no exclusions or waiting periods.

g. Plans offered by Proposer will provide unbiased referrals, based on quantitative and actionable quality and price information, to Members for medical services.

h. Plans offered by Proposer will meet PEBB’s minimum requirements for all communications (digital, verbal, and written) as indicated in Attachment I, Sample Group Benefits Contract (see Exhibit C, Statement of Work of Attachment I).

Table A.

Vendor Health Plan Kaiser Deductible Kaiser Traditional Moda Synergy Coordinated Care

(PCP 360) Providence Statewide PPO Providence Choice

(medical home)

Work status Full-time and part-time Full-time and part-time Full-time and part-time Full-time and part-time

Network Kaiser network Kaiser network In network13 Out of network In network Out of network Medical home Out of network1

Service Area Regional service area determined by Kaiser Full Oregon service area and some border counties.

Out-of-state services covered under a wrap network.

Nationwide, robust, open provider network Full Oregon service area with the exception of Columbia and Gilliam Counties and some border counties. Out-of-state services covered under a wrap network.

Standard deductible2 $250/individual, $750/family

$0 $250/individual, $750/family

$500/individual, $1,500/family

$250/individual $750/family

$500/individual, $1,500/family

$250/individual $750/family

$500/individual, $1,500/family

Out-of-pocket max (some deductibles, copays, services don't apply)

$1,500/individual, $4,500/family

$600/individual, $1,200/family

$1,500/individual, $4,500/family

$4,000/individual, $12,000/family

$1,900/individual, $5,700 family

$4,800/individual, $14,400/family

$1,500/individual, $4,500/family

$4,000/individual, $12,000/family

Primary care visit $5, deductible waived $5 $1013 first four visits, deductible waived

30% 15% or 10%3 first four visits, per calendar year, deductible waived

30% $10, first four visits, per calendar year, deductible waived

30%

Chronic care visit4 $5, deductible waived $5 $0, deductible waived 30% 0%, deductible waived 30% $0, deductible waived 30%

Specialty care visit $5 with referral, $5 with referral $10 30% 15% 30% $10 30%

PEBB 2026 Summary of Benefits Page 2

Outpatient mental health care $5, deductible waived $5 $10, deductible waived 30% 15%, deductible waived 30% $10 deductible waived 30% Substance Use Disorder Treatment $0, deductible waived $0 $0, deductible waived 30% outpatient, 40% inpatient 0%, deductible waived 30% $0, deductible waived 30%

Maternity prenatal and postnatal services

$0, deductible waived $0 $0, deductible waived 30% 0%, deductible waived prenatal, 15% postnatal

30% $0, deductible waived 30%

Maternity services and professional delivery

Inpatient delivery subject to inpatient hospital charges

Inpatient delivery subject to inpatient hospital charges

$0, deductible waived 30% 15% 30% $0, deductible waived 30%

Delivery facility charges Included with maternity services and professional delivery

Included with maternity services and professional delivery

Inpatient delivery subject to inpatient hospital charges

Inpatient delivery subject to inpatient hospital charges

Inpatient delivery subject to inpatient hospital charges

Inpatient delivery subject to inpatient hospital charges

Inpatient delivery subject to inpatient hospital charges

Inpatient delivery subject to inpatient hospital charges

Doula services $0, deductible waived; up to 8 prenatal and postnatal visits/ pregnancy, plus 1 labor and delivery visit

$0; up to 8 prenatal and postnatal visits/ pregnancy, plus 1 labor and delivery visit

$0, deductible waived; up to 8 prenatal and postnatal visits/ pregnancy, plus 1 labor and delivery visit

$0, deductible waived; up to 8 prenatal and postnatal visits/ pregnancy, plus 1 labor and delivery visit

$0, deductible waived; up to 8 prenatal and postnatal visits/ pregnancy, plus 1 labor and delivery visit

$0, deductible waived; up to 8 prenatal and postnatal visits/ pregnancy, plus 1 labor and delivery visit

$0, deductible waived; up to 8 prenatal and postnatal visits/ pregnancy, plus 1 labor and delivery visit

$0, deductible waived; up to 8 prenatal and postnatal visits/ pregnancy, plus 1 labor and delivery visit

Fertility services Refer to Member Handbook

Refer to Member Handbook

Refer to Member Handbook

Refer to Member Handbook

Refer to Member Handbook

Refer to Member Handbook

Refer to Member Handbook

Refer to Member Handbook

Preventive $0, deductible waived $0 $0, deductible waived 30% 0%, deductible waived 30% $0, deductible waived 30%

Lab and X-ray $15, deductible waived $0 $0, deductible waived 30% 15% 30% $0, deductible waived 30%

Inpatient hospital per admission11

$50/day up to $250 max

$50/day, up to $250 max

$50/day, up to $250 max

$500 + 40% 15% $500 + 40% $50/day, up to $250 max

$500 + 40%

Outpatient surgery in a hospital setting11

15% $5 $10 $100 + 40% 15% $100 + 40% $10 $100 + 40%

Urgent care $25, deductible waived

$5 $25 $25 15% 15% $25 $25

PEBB 2026 Summary of Benefits Page 3

Emergency department5 $150 $150 $150 $150 $150 + 15% $150 + 15% $150 $150

Durable medical equipment 15%, deductible waived $0 15% 30% 15% 30% 15% 30%

Insulin, diabetic supplies $0, deductible waved $0 $0, deductible waived14 $0, deductible waived14 0%, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived

Additional cost tier ($1006 copay/$5007 copay – does not apply to Kaiser)

$100, deductible waived for specialty scans and sleep studies

$100 for specialty scans and sleep studies only

$1006/$5007 $1006 + 30%/$5007 + 30%

$1006 + 15%/ $5007

+ 15%

$1006 + 30%/

+ 30%

$1006/$5007 $1006 + 30%/

+ 30%

Spinal manipulation and acupuncture 11, $10; Spinal manipulation:

20 visit annual limit

Acupuncture: 12 visit annual limit

$10; Spinal manipulation: 20 visit annual limit

Acupuncture: 12 visit annual limit

$10; Spinal manipulation: 20 visit annual limit

Acupuncture: 12 visit annual limit

30%; Spinal manipulation: 20 visit annual limit

Acupuncture: 12 visit annual limit

15%, up to 60 services/year max combined. Not applied to out-of- pocket max

30%, up to 60 services/year max combined. Not applied to out-of- pocket max

$10; Spinal manipulation: 20 visit annual limit.

Acupuncture: 12 visit annual limit.

Not applied to out-of-pocket max

30%; Spinal manipulation: 20 visit annual limit.

Acupuncture: 12 visit annual limit.

Not applied to out-of-pocket max

Massage therapy services11,12 $25, deductible waived; 12 visits/ year max

N/A $10, up to $1,000/ year max

30%, up to $1,000/year max

15%, up to $1,000/year max.

Not applied to out-of-pocket max

30%, up to $1,000/year max.

Not applied to out-of-pocket max

$10, up to $1000/ year max. Not applied to out-of-pocket max

30%, up to $1,000/year max.

Not applied to out-of-pocket max

Routine vision exam $5, deductible waived

$5 N/A N/A N/A N/A N/A N/A

Vision hardware allowance $200/year $200/year N/A N/A N/A N/A N/A N/A

Prescription drugs

All plans have formularies that list which drugs are covered. Contact your vendor for a copy of their formularies or to find out if a drug is covered.15

• No deductible

• Copays accumulate to out-of-pocket max

• $5 generic

• $25 brand

• 50%, up to $100 max non-formulary brand

• Copays accumulate to out-of-pocket max

• $5 generic

• $25 brand

• 50%, up to $100 max non-formulary brand

• $50/individual, $150/family deductible8

• $1,000/ individual,

• out-of-pocket max9

• $0 value, not subject to deductible10

• $10 generic

• $30 preferred brand

• In-network deductible, out-of-pocket max apply

• $0 value, not subject to deductible10

• $10 generic

• $30 preferred brand

• $100 specialty

• $50/individual,

• $1,000 out of pocket max9

• $0 value, not subject to deductible10

• $10 generic

• $30 brand

• Urgent, emergent and out-of-country

• In-network deductible, out-of-pocket max apply

• Reimbursed as if filled in network;

member pays difference between in-network rate and billed amount

• $50/individual,

• $150/family deductible8

• $1,000 out of pocket max9

• $0 value, not

• subject to

• Urgent, emergent and out-of-country

• In-network deductible, out-of-pocket max apply

• Reimbursed as if filled in-network; member pays difference between in-network rate and billed amount

PEBB 2026 Summary of Benefits Page 4

• $50 specialty

• Mail order: 1 copay for up to 90-day supply, $5 generic, $25 formulary brand, 50% up to $100 max non-formulary brand

• $50 specialty

• Mail order: 1 copay for up to 90-day supply, $5 generic, $25 formulary brand, 50% up to $100 max non-formulary brand

• Mandatory Mail Order

Copay x 2.5 for 90-day

• $10 generic specialty

• $100 brand specialty

• Member pays difference between in-network rate and billed amount

• $30 brand

Copay x 2.5 for 90-day

PEBB 2026 Summary of Benefits Page 5

Table B.

The following plan designs are only available to part time employees. They will pay the lowest cost for these benefits compared to the full-time plans.

Vendor Health Plan

Kaiser Deductible Kaiser Traditional Moda Synergy Coordinated Care (PCP 360) Providence Statewide PPO Providence Choice (medical home)

Work status Part-time only Part-time only Part-time only Part-time only Network Kaiser network Kaiser network In network13 Out of network In network Out of network Medical home Out of network1

Service Area Regional service area determined by Kaiser Full Oregon service area and some border counties. Out-of-state services covered under a wrap network.

Nationwide, robust, open provider network Full Oregon service area with the exception of Columbia and Gilliam Counties and some border counties. Out-of-state services covered under a wrap network.

Standard deductible2 $250/individual, $750/family

$0 $500/individual, $1,500/family

$1,000/individual, $3,000/family

$500/individual, $1,500/family

$1,000/individual, $3,000/family

$500/individual, $1,500/family

$1,000/individual, $3,000/family

Out-of-pocket max (some deductibles, copays, services don't apply) $1,500/individual, $4,500/family

$1,500/individual, $3,000/family

$2,500/ individual, $7,500/family

$6,000/ individual, $18,000/family

$3,200/ individual, $9,600/family

$7,500/individual, $22,500/family

$2,500/ individual, $7,500/family

$6,000/ individual, $18,000/family

Primary care visit $30, deductible waived $30 $4013 first four visits, deductible waived

50% 20% or 15%3 first four visits, per calendar year, deductible waived

50% $40 first four visits, per calendar year, 50%

Chronic care visit4 $30, deductible waived $30 $0, deductible waived

50% 0%, deductible waived

50% $0, deductible waived

50%

Specialty care visit $30 with referral, deductible waived

$30 with referral $40 50% 20% 50% $40 50%

Outpatient mental health care $30, deductible waived

$30 $40, deductible waived

50% 20%, deductible waived

50% $40, deductible waived

50%

Substance Use Disorder Treatment $0, deductible waived

$0 $0, deductible waived

50% 0%, deductible waived

50% $0, deductible waived

50%

Maternity prenatal and postnatal services $0, deductible waived

$0 $0, deductible waived

50% 0%, deductible waived prenatal, 20% postnatal

50% $0, deductible waived

50%

Maternity services and professional delivery Inpatient delivery subject to inpatient hospital charges

Inpatient delivery subject to inpatient hospital charges

$0, deductible waived

50% 20% 50% $0, deductible

50%

PEBB 2026 Summary of Benefits Page 6

Delivery facility charges Included with maternity services and professional delivery

Included with maternity services and professional delivery

Inpatient delivery subject to inpatient hospital charges

Inpatient delivery subject to inpatient hospital charges

Inpatient delivery subject to inpatient hospital charges

Inpatient delivery subject to inpatient hospital charges

Inpatient delivery subject to inpatient hospital charges

Inpatient delivery subject to inpatient hospital charges

Doula services $0, deductible waived; up to 8 prenatal and postnatal visits/ pregnancy, plus 1 labor and delivery visit

$0; up to 8 prenatal and postnatal visits/ pregnancy, plus 1 labor and delivery visit

$0, deductible waived; up to 8 prenatal and postnatal visits/ year, plus 1 labor and delivery visit

$0, deductible waived; up to 8 prenatal and postnatal visits/ year, plus 1 labor and delivery visit

$0, deductible waived; up to 8 prenatal and postnatal visits/ year, plus 1 labor and delivery visit

$0, deductible waived; up to 8 prenatal and postnatal visits/ year, plus 1 labor and delivery visit

$0, deductible waived; up to 8 prenatal and postnatal visits/ year, plus 1 labor and delivery visit

$0, deductible waived; up to 8 prenatal and postnatal visits/ year, plus 1 labor and delivery visit

Fertility services Refer to Member Handbook

Refer to Member Handbook

Refer to Member Handbook

Refer to Member Handbook

Refer to Member Handbook

Refer to Member Handbook

Refer to Member Handbook

Refer to Member Handbook

Preventive $0, deductible waived

$0 $0, deductible waived 50% 0%, deductible waived 50% $0, deductible waived 50%

Lab and X-ray $20, deductible waived

$10 Quest labs - $0, other providers 20%

50% 20% 50% 20%, deductible applies 50%

Inpatient hospital per admission11 $500 $500 $500 $500 + 50% 20% $500 + 50% $500 $500 + 50%

PEBB 2026 Summary of Benefits Page 7

Outpatient surgery in a hospital setting11 20% $30 $40/visit $100 + 50% 20% $100 + 50% $40/visit $100 + 50%

Urgent care $50, deductible

$30 $30 30% 20% 20% $40 $40

Emergency department5 $150 $150 $150 $150 $150 + 20% $150 + 20% $150 $150

Durable medical equipment 50%, deductible waived

50% 20% 50% 20% 50% 20% 50%

Insulin, diabetic supplies $0, deductible waved

$0 $0, deductible waived14 $0, deductible waived14 $0, deductible waived $0, deductible waived $0, deductible waived $0, deductible waived

Additional cost tier ($1006 copay/$5007 copay – does not apply to Kaiser)

$100, deductible waived for specialty scans and sleep studies

$100 for specialty scans and sleep studies only

$1006 / $5007 $1006 + 50%/ $5007 + 50%

$1006 + 20%/ $5007 + 20%

$1006 + 50%/ $5007 + 50%

$1006/$5007 $1006 + 50%/ $5007 + 50%

PEBB 2026 Summary of Benefits Page 8

Spinal manipulation and acupuncture11 $10; Spinal manipulation: 20 visit annual limit

Acupuncture: 12 visit annual limit

N/A $40; Spinal manipulation: 20 visit annual limit

Acupuncture: 12 visit annual limit

50%; Spinal manipulation: 20 visit annual limit

Acupuncture: 12 visit annual limit

20%, up to 60 visits/year max combined. Not applied to out-of-pocket max

50%, up to 60 visits/year max combined. Not applied to out-of-pocket max

$40; Spinal manipulation: 20 visit annual limit

Acupuncture: 12 visit annual limit

50%; Spinal manipulation: 20 visit annual limit

Acupuncture: 12 visit annual limit

Massage therapy services11,12 $25, deductible waived; 12 visits/ year max

N/A $40, up to $1,000/year max

50%, up to $1,000/year max

20%, up to $1,000/year max. Not applied to out-of-pocket max

50%, up to $1,000/year max. Not applied to out-of-pocket max

$40/visit, up to $1,000/year max. Not applied to out-of-pocket max

50%, up to $1,000/year max. Not applied to out-of-pocket max

Routine vision exam $30 $30 N/A N/A N/A N/A N/A N/A

Vision hardware allowance N/A N/A N/A N/A N/A N/A N/A N/A

Prescription drugs

All plans have formularies that list which drugs are covered.

Contact your vendor for a copy of their formularies or to find out if a drug is covered.15

• Copays accumulate to out-of- pocket max

• $25 brand

• $50 specialty

• Mail order: 2 copays for up to 90-day supply

• No deductible

• Copays accumulate to out-of- pocket max

• $25 brand

• $50 specialty

• Mail order: 2 copays for up to 90-day supply

• $50/individual,

• $150/family deductible8

• $1,000/ individual, out-of-pocket max9

• $0 value, not subject to

• $20 generic

• $50 preferred brand

• Mandatory Mail

Order Copay x 2.5 for 90-day specialty

• $100 specialty

• In-network

• $0 value, not brand

• $100 specialty

• Mandatory Mail

• Member pays difference between in-net- work rate and billed amount

• $50/individual

• $150/family deductible8

• $1,000 out-of-pocket max9

• $0 value, not

• 40% preferred brand

• Mandatory Mail

• Urgent, emergent and out-of-country member pays difference between in-net- work rate and billed amount

• $50/individual,

• $1,000 out-of-pocket max9

• $0 value, not brand

• Mandatory Mail

• Urgent, emergent and out-of-country member pays difference between in network rate and billed amount

PEBB 2026 Summary of Benefits Page 9

N/A= Not applicable

1. To receive in-network benefits, members must choose a medical home in the plan, notify the plan of their choice, and receive care through providers from that medical home or from in-network specialists. Otherwise, benefits typically have higher costs or may not be covered.

See the list of medical homes on the plan’s website.

2. All medical plans have a standard plan deductible (except Kaiser Traditional). On the Kaiser deductible plans, the deductible is waived on additional services; please see the benefit summary for additional details.

3. Providence Statewide plan members whose in-network provider has been recognized by the Oregon Health Authority as a patient-centered primary care home will have the lower coinsurance.

4. These are visits for care of asthma, diabetes, cardiovascular disease and congestive heart failure. Not subject to deductible in network.

5. Copay amounts for use of a hospital emergency department are waived if the member is admitted directly to the hospital for inpatient treatment. This does not include admittance for observation. Copay does not apply to out-of-pocket max except in Kaiser plans. In plan deductible applies.

6. These procedures are MRI, CT, PET and SPECT scans; sleep studies; spinal injections; upper endoscopy; bunionectomy; surgery for hammertoe and Morton’s neuroma. Copay does not apply to out-of-pocket max. Not applied to cancer-related procedures. These procedures may be overused compared with their risks and benefits. One copay will be applied for each service billed.

Multiple copays may apply if more than one service is done in a visit.

7. These are surgical procedures for hip or knee replacement or resurfacing;

knee or shoulder arthroscopy; bariatric surgery; spine procedures; and sinus surgery. Copay does not apply to out-of-pocket max. Not applied to cancer-related procedures. These procedures may have alternatives that provide equal or better outcomes with lower risks and costs.

8. The prescription drug deductible is $50 per person or $150 for families with three or more members. It applies separately from the medical deductible.

9. The prescription drug out-of-pocket max is $1,000 per person, with a family max of $3,000. It accrues separately from the medical out-of-pocket max.

10. All plans have formularies that list covered drugs. Value drugs typically are generic drugs that are used in treating most common chronic conditions.

11. Copays and coinsurance do not apply to out-of-pocket max except for Kaiser.

12. Moda and Providence out-of-network providers may bill you for any amount over the max plan allowance.

13. Members must choose a PCP 360 with Moda and must see their chosen PCP 360 for all primary care services to be covered in network.

14. Insulin pumps/supplies does not apply. This benefit is covered under the Durable Medical Equipment.

15. Mandatory 90-day fill: PEBB members who are currently taking a maintenance drug medication will need to fill a 90-day supply through our mail order or at 90-day supply participating retail pharmacies. For more details, refer to the Handbook.