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PlanDesign Choice Client: Oregon Public Employees Benefit Board (PEBB) Incumbent Vendor: Providence
| Plan Design Summary | |
| Please provide responses below for the 2024 and 2025 Rx plan designs. |
| Complete this exhibit separately for each unique Rx plan design |
| Note: "Domestic Pharmacy" includes onsite pharmacies, inhouse pharmacies, and client owned pharmacies. |
| Vendor comments, if any: | |
A. Rx plan design corresponding to experience data (2024):
| GROUP/PLAN NAME: | PEBB Choice |
| Who is/are the current medical carriers for this plan? | Providence Health Plan |
| Number of employees/retirees currently enrolled in this specific plan design: | 18,289 |
| Number of total members (includes covered dependents) currently enrolled in this specific plan design: | 44,849 |
| Above enrollment is as of what date? | 7/1/25 |
| Individual | Family | |
| Annual deductible, if any | $50.00 | $150.00 | Per claim, if applicable |
| Member out-of-pocket maximum, if applicable | $1,000.00 | $3,000.00 | $ |
| Are the above amounts for Rx only or combined medical/Rx? | Rx only | | |
| Tier-1 | Tier-2 | Tier-3 | Days supply limit |
| Select from the drop down menus to describe the plan's copay/coinsurance tiers | Value | Generic | Brand | |
| Copay ($) or coinsurance (%) – please include any minimum or maximum copays, if applicable | | | | |
| • Retail-30 non-specialty | $ - 0 | $ 10.00 | $ 30.00 | 30 |
| • Retail-30 specialty drugs | N/A | N/A | N/A | N/A |
| • Retail-90 non-mail pricing | $ - 0 | $ 25.00 | $ 75.00 | 90 |
| • Mail order | $ - 0 | $ 25.00 | $ 75.00 | 90 |
| • Specialty pharmacy (mail) | $ - 0 | $ 100.00 | $ 100.00 | 30 |
| • Domestic Pharmacies (30 day), if applicable | N/A | N/A | N/A | N/A |
| • Domestic Pharmacies (90 day), if applicable | N/A | N/A | N/A | N/A |
| • Domestic Pharmacies (specialty), if applicable | N/A | N/A | N/A | N/A |
| | | | After how many |
| If the plan charges a higher copay/coinsurance after a specified number of fills at retail, specify applicable copays/coinsurance | Value | Generic | Brand | retail fills? |
| N/A | N/A | N/A | N/A |
| Describe the retail network (e.g., Broad national network, select/custom network excluding a specific pharmacy chain(s)) | Broad National Network |
| Are all generic drugs on Tier-1? | No |
| Does client use your Retail-90 network (e.g., pricing for 90 day supply at certain retail pharmacies, with pricing in between retail pricing and mail order pricing)? | Yes |
| Does client use your "Mail at Retail" network (e.g., mail order pricing for 90 day supply at certain retail pharmacies)? | NO |
| If so, which pharmacy chains, are included in the Mail at Retail network (mail order pricing for 90 day supply at certain retail pharmacies)? | N/A |
| Is there mandatory mail order OR retail refill limits/penalties for non-specialty drugs? | Mandatory Mail Order |
| How are specialty drugs covered? (Open = no restrictions; Refill Limit = must use specialty pharmacy after specified # of fills at retail; Exclusive = only covered at PBM's specialty pharmacy) | Retail Lockout |
| For specialty drugs, how many grace fills are allowed at retail, if any? | None |
| What days' supply (DS) is allowed for Specialty Pharmacy claims (30 DS limit, 90 DS limit, clinical DS is used, other please specify) | 30 DS limit |
| What is the name of the formulary drug list? | Providence Formulary D: PEBB |
| Is this an Open formulary or does this formulary have drug exclusions? | Drug exclusions |
| If the formulary has exclusions, are these hard edits or is there a PA process for drugs on the "excluded drug list"? | PA process for excluded drugs |
| Has PBM's standard formulary been customized for Client? If so, how? (e.g., moved a drug from formulary to non-formulary status, eliminated coverage for certain non-formulary products)? | No |
| Is the above formulary also used at Domestic Pharmacies? | N/A |
| Is this a HDHP? with HRA? or HSA? | No |
| Does the plan use the PBM’s standard HDHP Preventive Drug List or a custom HDHP Preventive Drug List? | Custom Preventive Drug List |
| Does Client's HDHP Preventive Drug List include brand and generics OR only generics? | brand & generic |
| Do drugs on Client's HDHP Preventive Drug List: (a) bypass the deductible and subject to the standard cost-share; or (b) bypass the deductible and have a $0 copay? | (b) |
| Does Client's HDHP Preventive Drug List include diabetes testing supplies? | Yes |
| Does Client utilize a variable copay/coupon maximization program? If so, please specify the name of program(s) in place. | Yes |
| Does it apply to specialty, non-specialty, or both? | Specialty |
| Does it track dollars to apply true member out-of-pocket expenses to accumulators? | Yes |
| Does it maximize copays/coinsurance within the plan design member cost share? | No |
| Does it maximize copays/coinsurance with the maximum available from pharmaceutical manufacturers? | Yes |
| Briefly describe any other key Rx plan design features not captured above (e.g., DAW penalties.) | |
| No DAW Penalty, self-administered chemo benefit processes at the better of the medical self-administered chemotherapy cost share or the pharmacy cost share, diabetic supplies covered in full before deductible, infertility drugs covered in full with no max paid by plan, abortion medications covered in full before deductible, sexual dysfunction drugs covered at the drug tier limited to 8 pills per month, travel benefits covered in full including travel vaccines and medications, medications used to treat alopecia areata covered at the tier level. | |
B. Were any Rx plan design changes made for 2025? Yes Please complete section C below.
| C. | 2025 Rx plan design (only need to complete if different from 2024) |
| GROUP/PLAN NAME: |
| Who is/are the current medical carriers for this plan? |
| Number of employees/retirees currently enrolled in this specific plan design: |
| Number of total members (includes covered dependents) currently enrolled in this specific plan design: |
| Above enrollment is as of what date? |
| Individual | Family | |
| Annual deductible, if any | $ | $ | Per claim, if applicable |
| Member out-of-pocket maximum, if applicable | $ | $ | $ |
| Are the above amounts for Rx only or combined medical/Rx? | ? | | |
| Tier-1 | Tier-2 | Tier-3 | Days supply limit |
| Select from the drop down menus to describe the plan's copay/coinsurance tiers | ? | Generic | Brand | |
| Copay ($) or coinsurance (%) – please include any minimum or maximum copays, if applicable | | | | |
| • Retail-30 non-specialty | | | | |
| • Retail-30 specialty drugs | | | | |
| • Retail-90 non-mail pricing | | | | |
| • Mail order | | | | |
| • Specialty pharmacy (mail) | | | | |
| • Domestic Pharmacies (30 day), if applicable | | | | |
| • Domestic Pharmacies (90 day), if applicable | | | | |
| • Domestic Pharmacies (specialty), if applicable | | | | |
| | | | After how many |
| If the plan charges a higher copay/coinsurance after a specified number of fills at retail, specify applicable copays/coinsurance | ? | Generic | Brand | retail fills? |
| Describe the retail network (e.g., Broad national network, select/custom network excluding a specific pharmacy chain(s)) | |
| Are all generic drugs on Tier-1? | |
| Does client use your Retail-90 network (e.g., pricing for 90 day supply at certain retail pharmacies, with pricing in between retail pricing and mail order pricing)? | |
| Does client use your "Mail at Retail" network (e.g., mail order pricing for 90 day supply at certain retail pharmacies)? | |
| If so, which pharmacy chains, are included in the Mail at Retail network (mail order pricing for 90 day supply at certain retail pharmacies)? | |
| Is there mandatory mail order OR retail refill limits/penalties for non-specialty drugs? | ? |
| How are specialty drugs covered? (Open = no restrictions; Refill Limit = must use specialty pharmacy after specified # of fills at retail; Exclusive = only covered at PBM's specialty pharmacy) | |
| For specialty drugs, how many grace fills are allowed at retail, if any? | |
| What days' supply (DS) is allowed for Specialty Pharmacy claims (30 DS limit, 90 DS limit, clinical DS is used, other please specify) | |
| What is the name of the formulary drug list? | |
| Is this an Open formulary or does this formulary have drug exclusions? | |
| If the formulary has exclusions, are these hard edits or is there a PA process for drugs on the "excluded drug list"? | |
| Has PBM's standard formulary been customized for Client? If so, how? (e.g., moved a drug from formulary to non-formulary status, eliminated coverage for certain non-formulary products)? | |
| Is the above formulary also used at Domestic Pharmacies? | |
| Is this a HDHP? with HRA? or HSA? | |
| Does the plan use the PBM’s standard HDHP Preventive Drug List or a custom HDHP Preventive Drug List? | |
| Does Client's HDHP Preventive Drug List include brand and generics OR only generics? | ? |
| Do drugs on Client's HDHP Preventive Drug List: (a) bypass the deductible and subject to the standard cost-share; or (b) bypass the deductible and have a $0 copay? | ? |
| Does Client's HDHP Preventive Drug List include diabetes testing supplies? | |
| Does Client utilize a variable copay/coupon maximization program? If so, please specify the name of program(s) in place. | |
| Does it apply to specialty, non-specialty, or both? | |
| Does it track dollars to apply true member out-of-pocket expenses to accumulators? | |
| Does it maximize copays/coinsurance within the plan design member cost share? | |
| Does it maximize copays/coinsurance with the maximum available from pharmaceutical manufacturers? | |
| Briefly describe any other key Rx plan design features not captured above (e.g., DAW penalties.) | |
| When does/did this plan design go into effect? | mm/dd/yyyy |
| Briefly describe any other key Rx plan design features not captured above (e.g., DAW penalties.) | |
| Effective 2025: Member pay difference applies to DAW 1 and 2, no other plan changes. | |
&10&K000000PEBB Medical & Pharmacy Benefit RFP OregonBuys Bid No. S-44300-00014758 &10&K000000Attachment P Pharmacy Plan Design
PlanDesign Choice PT Client: Oregon Public Employees Benefit Board (PEBB) Incumbent Vendor: Providence
| Plan Design Summary | |
| Please provide responses below for the 2024 and 2025 Rx plan designs. |
| Complete this exhibit separately for each unique Rx plan design |
| Note: "Domestic Pharmacy" includes onsite pharmacies, inhouse pharmacies, and client owned pharmacies. |
| Vendor comments, if any: | |
A. Rx plan design corresponding to experience data (2024):
| GROUP/PLAN NAME: | PEBB Choice |
| Who is/are the current medical carriers for this plan? | Providence Health Plan |
| Number of employees/retirees currently enrolled in this specific plan design: | 230 |
| Number of total members (includes covered dependents) currently enrolled in this specific plan design: | 532 |
| Above enrollment is as of what date? | 7/1/25 |
| Individual | Family | |
| Annual deductible, if any | $50.00 | $150.00 | Per claim, if applicable |
| Member out-of-pocket maximum, if applicable | $1,000.00 | $3,000.00 | $ |
| Are the above amounts for Rx only or combined medical/Rx? | Rx only | | |
| Tier-1 | Tier-2 | Tier-3 | Days supply limit |
| Select from the drop down menus to describe the plan's copay/coinsurance tiers | Value | Generic | Brand | |
| Copay ($) or coinsurance (%) – please include any minimum or maximum copays, if applicable | | | | |
| • Retail-30 non-specialty | $ - 0 | $ 20.00 | $ 50.00 | 30 |
| • Retail-30 specialty drugs | N/A | N/A | N/A | N/A |
| • Retail-90 non-mail pricing | $ - 0 | $ 50.00 | $ 125.00 | 90 |
| • Mail order | $ - 0 | $ 50.00 | $ 125.00 | 90 |
| • Specialty pharmacy (mail) | $ - 0 | $ 100.00 | $ 100.00 | 30 |
| • Domestic Pharmacies (30 day), if applicable | N/A | N/A | N/A | N/A |
| • Domestic Pharmacies (90 day), if applicable | N/A | N/A | N/A | N/A |
| • Domestic Pharmacies (specialty), if applicable | N/A | N/A | N/A | N/A |
| | | | After how many |
| If the plan charges a higher copay/coinsurance after a specified number of fills at retail, specify applicable copays/coinsurance | Value | Generic | Brand | retail fills? |
| N/A | N/A | N/A | N/A |
| Describe the retail network (e.g., Broad national network, select/custom network excluding a specific pharmacy chain(s)) | Broad National Network |
| Are all generic drugs on Tier-1? | No |
| Does client use your Retail-90 network (e.g., pricing for 90 day supply at certain retail pharmacies, with pricing in between retail pricing and mail order pricing)? | Yes |
| Does client use your "Mail at Retail" network (e.g., mail order pricing for 90 day supply at certain retail pharmacies)? | NO |
| If so, which pharmacy chains, are included in the Mail at Retail network (mail order pricing for 90 day supply at certain retail pharmacies)? | N/A |
| Is there mandatory mail order OR retail refill limits/penalties for non-specialty drugs? | Mandatory Mail Order |
| How are specialty drugs covered? (Open = no restrictions; Refill Limit = must use specialty pharmacy after specified # of fills at retail; Exclusive = only covered at PBM's specialty pharmacy) | Retail Lockout |
| For specialty drugs, how many grace fills are allowed at retail, if any? | None |
| What days' supply (DS) is allowed for Specialty Pharmacy claims (30 DS limit, 90 DS limit, clinical DS is used, other please specify) | 30 DS limit |
| What is the name of the formulary drug list? | Providence Formulary D: PEBB |
| Is this an Open formulary or does this formulary have drug exclusions? | Drug exclusions |
| If the formulary has exclusions, are these hard edits or is there a PA process for drugs on the "excluded drug list"? | PA process for excluded drugs |
| Has PBM's standard formulary been customized for Client? If so, how? (e.g., moved a drug from formulary to non-formulary status, eliminated coverage for certain non-formulary products)? | No |
| Is the above formulary also used at Domestic Pharmacies? | N/A |
| Is this a HDHP? with HRA? or HSA? | No |
| Does the plan use the PBM’s standard HDHP Preventive Drug List or a custom HDHP Preventive Drug List? | Custom Preventive Drug List |
| Does Client's HDHP Preventive Drug List include brand and generics OR only generics? | brand & generic |
| Do drugs on Client's HDHP Preventive Drug List: (a) bypass the deductible and subject to the standard cost-share; or (b) bypass the deductible and have a $0 copay? | (b) |
| Does Client's HDHP Preventive Drug List include diabetes testing supplies? | Yes |
| Does Client utilize a variable copay/coupon maximization program? If so, please specify the name of program(s) in place. | Yes |
| Does it apply to specialty, non-specialty, or both? | Specialty |
| Does it track dollars to apply true member out-of-pocket expenses to accumulators? | Yes |
| Does it maximize copays/coinsurance within the plan design member cost share? | No |
| Does it maximize copays/coinsurance with the maximum available from pharmaceutical manufacturers? | Yes |
| Briefly describe any other key Rx plan design features not captured above (e.g., DAW penalties,etc.) | |
| No DAW Penalty, self-administered chemo benefit processes at the better of the medical self-administered chemotherapy cost share or the pharmacy cost share, diabetic supplies covered in full before deductible, infertility drugs covered in full with no max paid by plan, abortion medications covered in full before deductible, sexual dysfunction drugs covered at the drug tier limited to 8 pills per month, travel benefits covered in full including travel vaccines and medications, medications used to treat alopecia areata covered at the tier level. | |
B. Were any Rx plan design changes made for 2025? Yes Please complete section C below.
| C. | 2025 Rx plan design (only need to complete if different from 2024) |
| GROUP/PLAN NAME: |
| Who is/are the current medical carriers for this plan? |
| Number of employees/retirees currently enrolled in this specific plan design: |
| Number of total members (includes covered dependents) currently enrolled in this specific plan design: |
| Above enrollment is as of what date? |
| Individual | Family | |
| Annual deductible, if any | $ | $ | Per claim, if applicable |
| Member out-of-pocket maximum, if applicable | $ | $ | $ |
| Are the above amounts for Rx only or combined medical/Rx? | ? | | |
| Tier-1 | Tier-2 | Tier-3 | Days supply limit |
| Select from the drop down menus to describe the plan's copay/coinsurance tiers | ? | Generic | Brand | |
| Copay ($) or coinsurance (%) – please include any minimum or maximum copays, if applicable | | | | |
| • Retail-30 non-specialty | | | | |
| • Retail-30 specialty drugs | | | | |
| • Retail-90 non-mail pricing | | | | |
| • Mail order | | | | |
| • Specialty pharmacy (mail) | | | | |
| • Domestic Pharmacies (30 day), if applicable | | | | |
| • Domestic Pharmacies (90 day), if applicable | | | | |
| • Domestic Pharmacies (specialty), if applicable | | | | |
| | | | After how many |
| If the plan charges a higher copay/coinsurance after a specified number of fills at retail, specify applicable copays/coinsurance | ? | Generic | Brand | retail fills? |
| Describe the retail network (e.g., Broad national network, select/custom network excluding a specific pharmacy chain(s)) | |
| Are all generic drugs on Tier-1? | |
| Does client use your Retail-90 network (e.g., pricing for 90 day supply at certain retail pharmacies, with pricing in between retail pricing and mail order pricing)? | |
| Does client use your "Mail at Retail" network (e.g., mail order pricing for 90 day supply at certain retail pharmacies)? | |
| If so, which pharmacy chains, are included in the Mail at Retail network (mail order pricing for 90 day supply at certain retail pharmacies)? | |
| Is there mandatory mail order OR retail refill limits/penalties for non-specialty drugs? | ? |
| How are specialty drugs covered? (Open = no restrictions; Refill Limit = must use specialty pharmacy after specified # of fills at retail; Exclusive = only covered at PBM's specialty pharmacy) | |
| For specialty drugs, how many grace fills are allowed at retail, if any? | |
| What days' supply (DS) is allowed for Specialty Pharmacy claims (30 DS limit, 90 DS limit, clinical DS is used, other please specify) | |
| What is the name of the formulary drug list? | |
| Is this an Open formulary or does this formulary have drug exclusions? | |
| If the formulary has exclusions, are these hard edits or is there a PA process for drugs on the "excluded drug list"? | |
| Has PBM's standard formulary been customized for Client? If so, how? (e.g., moved a drug from formulary to non-formulary status, eliminated coverage for certain non-formulary products)? | |
| Is the above formulary also used at Domestic Pharmacies? | |
| Is this a HDHP? with HRA? or HSA? | |
| Does the plan use the PBM’s standard HDHP Preventive Drug List or a custom HDHP Preventive Drug List? | |
| Does Client's HDHP Preventive Drug List include brand and generics OR only generics? | ? |
| Do drugs on Client's HDHP Preventive Drug List: (a) bypass the deductible and subject to the standard cost-share; or (b) bypass the deductible and have a $0 copay? | ? |
| Does Client's HDHP Preventive Drug List include diabetes testing supplies? | |
| Does Client utilize a variable copay/coupon maximization program? If so, please specify the name of program(s) in place. | |
| Does it apply to specialty, non-specialty, or both? | |
| Does it track dollars to apply true member out-of-pocket expenses to accumulators? | |
| Does it maximize copays/coinsurance within the plan design member cost share? | |
| Does it maximize copays/coinsurance with the maximum available from pharmaceutical manufacturers? | |
| Briefly describe any other key Rx plan design features not captured above (e.g., DAW penalties,etc.) | |
| When does/did this plan design go into effect? | mm/dd/yyyy |
| Briefly describe any other key Rx plan design features not captured above (e.g., DAW penalties,etc.) | |
| Effective 2025: Member pay difference applies to DAW 1 and 2, no other plan changes. | |
OregonBuys Bid No. S-44300-00014758 &10&K000000Attachment P
PlanDesign Statewide Client: Oregon Public Employees Benefit Board (PEBB) Incumbent Vendor: Providence
| Plan Design Summary | |
| Please provide responses below for the 2024 and 2025 Rx plan designs. |
| Complete this exhibit separately for each unique Rx plan design |
| Note: "Domestic Pharmacy" includes onsite pharmacies, inhouse pharmacies, and client owned pharmacies. |
| Vendor comments, if any: | |
A. Rx plan design corresponding to experience data (2024):
| GROUP/PLAN NAME: | PEBB Statewide |
| Who is/are the current medical carriers for this plan? | Providence Health Plan |
| Number of employees/retirees currently enrolled in this specific plan design: | 16,724 |
| Number of total members (includes covered dependents) currently enrolled in this specific plan design: | 40,155 |
| Above enrollment is as of what date? | 7/1/25 |
| Individual | Family | |
| Annual deductible, if any | $50.00 | $150.00 | Per claim, if applicable |
| Member out-of-pocket maximum, if applicable | $1,000.00 | $3,000.00 | $ |
| Are the above amounts for Rx only or combined medical/Rx? | Rx only | | |
| Tier-1 | Tier-2 | Tier-3 | Days supply limit |
| Select from the drop down menus to describe the plan's copay/coinsurance tiers | Value | Generic | Brand | |
| Copay ($) or coinsurance (%) – please include any minimum or maximum copays, if applicable | | | | |
| • Retail-30 non-specialty | $ - 0 | $ 10.00 | $ 30.00 | 30 |
| • Retail-30 specialty drugs | N/A | N/A | N/A | N/A |
| • Retail-90 non-mail pricing | $ - 0 | $ 25.00 | $ 75.00 | 90 |
| • Mail order | $ - 0 | $ 25.00 | $ 75.00 | 90 |
| • Specialty pharmacy (mail) | $ - 0 | $ 100.00 | $ 100.00 | 30 |
| • Domestic Pharmacies (30 day), if applicable | N/A | N/A | N/A | N/A |
| • Domestic Pharmacies (90 day), if applicable | N/A | N/A | N/A | N/A |
| • Domestic Pharmacies (specialty), if applicable | N/A | N/A | N/A | N/A |
| | | | After how many |
| If the plan charges a higher copay/coinsurance after a specified number of fills at retail, specify applicable copays/coinsurance | Value | Generic | Brand | retail fills? |
| N/A | N/A | N/A | N/A |
| Describe the retail network (e.g., Broad national network, select/custom network excluding a specific pharmacy chain(s)) | Broad National Network |
| Are all generic drugs on Tier-1? | No |
| Does client use your Retail-90 network (e.g., pricing for 90 day supply at certain retail pharmacies, with pricing in between retail pricing and mail order pricing)? | Yes |
| Does client use your "Mail at Retail" network (e.g., mail order pricing for 90 day supply at certain retail pharmacies)? | NO |
| If so, which pharmacy chains, are included in the Mail at Retail network (mail order pricing for 90 day supply at certain retail pharmacies)? | N/A |
| Is there mandatory mail order OR retail refill limits/penalties for non-specialty drugs? | Mandatory Mail Order |
| How are specialty drugs covered? (Open = no restrictions; Refill Limit = must use specialty pharmacy after specified # of fills at retail; Exclusive = only covered at PBM's specialty pharmacy) | Retail Lockout |
| For specialty drugs, how many grace fills are allowed at retail, if any? | None |
| What days' supply (DS) is allowed for Specialty Pharmacy claims (30 DS limit, 90 DS limit, clinical DS is used, other please specify) | 30 DS limit |
| What is the name of the formulary drug list? | Providence Formulary D: PEBB |
| Is this an Open formulary or does this formulary have drug exclusions? | Drug exclusions |
| If the formulary has exclusions, are these hard edits or is there a PA process for drugs on the "excluded drug list"? | PA process for excluded drugs |
| Has PBM's standard formulary been customized for Client? If so, how? (e.g., moved a drug from formulary to non-formulary status, eliminated coverage for certain non-formulary products)? | No |
| Is the above formulary also used at Domestic Pharmacies? | N/A |
| Is this a HDHP? with HRA? or HSA? | No |
| Does the plan use the PBM’s standard HDHP Preventive Drug List or a custom HDHP Preventive Drug List? | Custom Preventive Drug List |
| Does Client's HDHP Preventive Drug List include brand and generics OR only generics? | brand & generic |
| Do drugs on Client's HDHP Preventive Drug List: (a) bypass the deductible and subject to the standard cost-share; or (b) bypass the deductible and have a $0 copay? | (b) |
| Does Client's HDHP Preventive Drug List include diabetes testing supplies? | Yes |
| Does Client utilize a variable copay/coupon maximization program? If so, please specify the name of program(s) in place. | Yes |
| Does it apply to specialty, non-specialty, or both? | Specialty |
| Does it track dollars to apply true member out-of-pocket expenses to accumulators? | Yes |
| Does it maximize copays/coinsurance within the plan design member cost share? | No |
| Does it maximize copays/coinsurance with the maximum available from pharmaceutical manufacturers? | Yes |
| Briefly describe any other key Rx plan design features not captured above (e.g., DAW penalties,etc.) | |
| No DAW Penalty, self-administered chemo benefit processes at the better of the medical self-administered chemotherapy cost share or the pharmacy cost share, diabetic supplies covered in full before deductible, infertility drugs covered in full with no max paid by plan, abortion medications covered in full before deductible, sexual dysfunction drugs covered at the drug tier limited to 8 pills per month, travel benefits covered in full including travel vaccines and medications, medications used to treat alopecia areata covered at the tier level. | |
B. Were any Rx plan design changes made for 2025? Yes Please complete section C below.
| C. | 2025 Rx plan design (only need to complete if different from 2024) |
| GROUP/PLAN NAME: |
| Who is/are the current medical carriers for this plan? |
| Number of employees/retirees currently enrolled in this specific plan design: |
| Number of total members (includes covered dependents) currently enrolled in this specific plan design: |
| Above enrollment is as of what date? |
| Individual | Family | |
| Annual deductible, if any | $ | $ | Per claim, if applicable |
| Member out-of-pocket maximum, if applicable | $ | $ | $ |
| Are the above amounts for Rx only or combined medical/Rx? | ? | | |
| Tier-1 | Tier-2 | Tier-3 | Days supply limit |
| Select from the drop down menus to describe the plan's copay/coinsurance tiers | ? | Generic | Brand | |
| Copay ($) or coinsurance (%) – please include any minimum or maximum copays, if applicable | | | | |
| • Retail-30 non-specialty | | | | |
| • Retail-30 specialty drugs | | | | |
| • Retail-90 non-mail pricing | | | | |
| • Mail order | | | | |
| • Specialty pharmacy (mail) | | | | |
| • Domestic Pharmacies (30 day), if applicable | | | | |
| • Domestic Pharmacies (90 day), if applicable | | | | |
| • Domestic Pharmacies (specialty), if applicable | | | | |
| | | | After how many |
| If the plan charges a higher copay/coinsurance after a specified number of fills at retail, specify applicable copays/coinsurance | ? | Generic | Brand | retail fills? |
| If the plan charges a higher copay/coinsurance after a specified number of fills at retail, specify applicable copays/coinsurance | | | | |
| Describe the retail network (e.g., Broad national network, select/custom network excluding a specific pharmacy chain(s)) | |
| Are all generic drugs on Tier-1? | |
| Does client use your Retail-90 network (e.g., pricing for 90 day supply at certain retail pharmacies, with pricing in between retail pricing and mail order pricing)? | |
| Does client use your "Mail at Retail" network (e.g., mail order pricing for 90 day supply at certain retail pharmacies)? | |
| If so, which pharmacy chains, are included in the Mail at Retail network (mail order pricing for 90 day supply at certain retail pharmacies)? | |
| Is there mandatory mail order OR retail refill limits/penalties for non-specialty drugs? | ? |
| How are specialty drugs covered? (Open = no restrictions; Refill Limit = must use specialty pharmacy after specified # of fills at retail; Exclusive = only covered at PBM's specialty pharmacy) | |
| For specialty drugs, how many grace fills are allowed at retail, if any? | |
| What days' supply (DS) is allowed for Specialty Pharmacy claims (30 DS limit, 90 DS limit, clinical DS is used, other please specify) | |
| What is the name of the formulary drug list? | |
| Is this an Open formulary or does this formulary have drug exclusions? | |
| If the formulary has exclusions, are these hard edits or is there a PA process for drugs on the "excluded drug list"? | |
| Has PBM's standard formulary been customized for Client? If so, how? (e.g., moved a drug from formulary to non-formulary status, eliminated coverage for certain non-formulary products)? | |
| Is the above formulary also used at Domestic Pharmacies? | |
| Is this a HDHP? with HRA? or HSA? | |
| Does the plan use the PBM’s standard HDHP Preventive Drug List or a custom HDHP Preventive Drug List? | |
| Does Client's HDHP Preventive Drug List include brand and generics OR only generics? | ? |
| Do drugs on Client's HDHP Preventive Drug List: (a) bypass the deductible and subject to the standard cost-share; or (b) bypass the deductible and have a $0 copay? | ? |
| Does Client's HDHP Preventive Drug List include diabetes testing supplies? | |
| Does Client utilize a variable copay/coupon maximization program? If so, please specify the name of program(s) in place. | |
| Does it apply to specialty, non-specialty, or both? | |
| Does it track dollars to apply true member out-of-pocket expenses to accumulators? | |
| Does it maximize copays/coinsurance within the plan design member cost share? | |
| Does it maximize copays/coinsurance with the maximum available from pharmaceutical manufacturers? | |
| Briefly describe any other key Rx plan design features not captured above (e.g., DAW penalties,etc.) | |
| When does/did this plan design go into effect? | mm/dd/yyyy |
| Briefly describe any other key Rx plan design features not captured above (e.g., DAW penalties,etc.) | |
| Effective 2025: Member pay difference applies to DAW 1 and 2, no other plan changes. | |
OregonBuys Bid No. S-44300-00014758 &10&K000000Attachment P
PlanDesign Statewide PT Client: Oregon Public Employees Benefit Board (PEBB) Incumbent Vendor: Providence
| Plan Design Summary | |
| Please provide responses below for the 2024 and 2025 Rx plan designs. |
| Complete this exhibit separately for each unique Rx plan design |
| Note: "Domestic Pharmacy" includes onsite pharmacies, inhouse pharmacies, and client owned pharmacies. |
| Vendor comments, if any: | |
A. Rx plan design corresponding to experience data (2024):
| GROUP/PLAN NAME: | PEBB Statewide |
| Who is/are the current medical carriers for this plan? | Providence Health Plan |
| Number of employees/retirees currently enrolled in this specific plan design: | 196 |
| Number of total members (includes covered dependents) currently enrolled in this specific plan design: | 409 |
| Above enrollment is as of what date? | 7/1/25 |
| Individual | Family | |
| Annual deductible, if any | $50.00 | $150.00 | Per claim, if applicable |
| Member out-of-pocket maximum, if applicable | $1,000.00 | $3,000.00 | $ |
| Are the above amounts for Rx only or combined medical/Rx? | Rx only | | |
| Tier-1 | Tier-2 | Tier-3 | Days supply limit |
| Select from the drop down menus to describe the plan's copay/coinsurance tiers | Value | Generic | Brand | |
| Copay ($) or coinsurance (%) – please include any minimum or maximum copays, if applicable | | | | |
| • Retail-30 non-specialty | $ - 0 | $ 20.00 | 40% | 30 |
| • Retail-30 specialty drugs | N/A | N/A | N/A | N/A |
| • Retail-90 non-mail pricing | $ - 0 | $ 50.00 | 40% | 90 |
| • Mail order | $ - 0 | $ 50.00 | 40% | 90 |
| • Specialty pharmacy (mail) | $ - 0 | $ 100.00 | $ 100.00 | 30 |
| • Domestic Pharmacies (30 day), if applicable | N/A | N/A | N/A | N/A |
| • Domestic Pharmacies (90 day), if applicable | N/A | N/A | N/A | N/A |
| • Domestic Pharmacies (specialty), if applicable | N/A | N/A | N/A | N/A |
| | | | After how many |
| If the plan charges a higher copay/coinsurance after a specified number of fills at retail, specify applicable copays/coinsurance | Value | Generic | Brand | retail fills? |
| N/A | N/A | N/A | N/A |
| Describe the retail network (e.g., Broad national network, select/custom network excluding a specific pharmacy chain(s)) | Broad National Network |
| Are all generic drugs on Tier-1? | No |
| Does client use your Retail-90 network (e.g., pricing for 90 day supply at certain retail pharmacies, with pricing in between retail pricing and mail order pricing)? | Yes |
| Does client use your "Mail at Retail" network (e.g., mail order pricing for 90 day supply at certain retail pharmacies)? | NO |
| If so, which pharmacy chains, are included in the Mail at Retail network (mail order pricing for 90 day supply at certain retail pharmacies)? | N/A |
| Is there mandatory mail order OR retail refill limits/penalties for non-specialty drugs? | Mandatory Mail Order |
| How are specialty drugs covered? (Open = no restrictions; Refill Limit = must use specialty pharmacy after specified # of fills at retail; Exclusive = only covered at PBM's specialty pharmacy) | Retail Lockout |
| For specialty drugs, how many grace fills are allowed at retail, if any? | None |
| What days' supply (DS) is allowed for Specialty Pharmacy claims (30 DS limit, 90 DS limit, clinical DS is used, other please specify) | 30 DS limit |
| What is the name of the formulary drug list? | Providence Formulary D: PEBB |
| Is this an Open formulary or does this formulary have drug exclusions? | Drug exclusions |
| If the formulary has exclusions, are these hard edits or is there a PA process for drugs on the "excluded drug list"? | PA process for excluded drugs |
| Has PBM's standard formulary been customized for Client? If so, how? (e.g., moved a drug from formulary to non-formulary status, eliminated coverage for certain non-formulary products)? | No |
| Is the above formulary also used at Domestic Pharmacies? | N/A |
| Is this a HDHP? with HRA? or HSA? | No |
| Does the plan use the PBM’s standard HDHP Preventive Drug List or a custom HDHP Preventive Drug List? | Custom Preventive Drug List |
| Does Client's HDHP Preventive Drug List include brand and generics OR only generics? | brand & generic |
| Do drugs on Client's HDHP Preventive Drug List: (a) bypass the deductible and subject to the standard cost-share; or (b) bypass the deductible and have a $0 copay? | (b) |
| Does Client's HDHP Preventive Drug List include diabetes testing supplies? | Yes |
| Does Client utilize a variable copay/coupon maximization program? If so, please specify the name of program(s) in place. | Yes |
| Does it apply to specialty, non-specialty, or both? | Specialty |
| Does it track dollars to apply true member out-of-pocket expenses to accumulators? | Yes |
| Does it maximize copays/coinsurance within the plan design member cost share? | No |
| Does it maximize copays/coinsurance with the maximum available from pharmaceutical manufacturers? | Yes |
| Briefly describe any other key Rx plan design features not captured above (e.g., DAW penalties,etc.) | |
| No DAW Penalty, self-administered chemo benefit processes at the better of the medical self-administered chemotherapy cost share or the pharmacy cost share, diabetic supplies covered in full before deductible, infertility drugs covered in full with no max paid by plan, abortion medications covered in full before deductible, sexual dysfunction drugs covered at the drug tier limited to 8 pills per month, travel benefits covered in full including travel vaccines and medications, medications used to treat alopecia areata covered at the tier level. | |
B. Were any Rx plan design changes made for 2025? Yes Please complete section C below.
| C. | 2025 Rx plan design (only need to complete if different from 2024) |
| GROUP/PLAN NAME: |
| Who is/are the current medical carriers for this plan? |
| Number of employees/retirees currently enrolled in this specific plan design: |
| Number of total members (includes covered dependents) currently enrolled in this specific plan design: |
| Above enrollment is as of what date? |
| Individual | Family | |
| Annual deductible, if any | $ | $ | Per claim, if applicable |
| Member out-of-pocket maximum, if applicable | $ | $ | $ |
| Are the above amounts for Rx only or combined medical/Rx? | ? | | |
| Tier-1 | Tier-2 | Tier-3 | Days supply limit |
| Select from the drop down menus to describe the plan's copay/coinsurance tiers | ? | Generic | Brand | |
| Copay ($) or coinsurance (%) – please include any minimum or maximum copays, if applicable | | | | |
| • Retail-30 non-specialty | | | | |
| • Retail-30 specialty drugs | | | | |
| • Retail-90 non-mail pricing | | | | |
| • Mail order | | | | |
| • Specialty pharmacy (mail) | | | | |
| • Domestic Pharmacies (30 day), if applicable | | | | |
| • Domestic Pharmacies (90 day), if applicable | | | | |
| • Domestic Pharmacies (specialty), if applicable | | | | |
| | | | After how many |
| If the plan charges a higher copay/coinsurance after a specified number of fills at retail, specify applicable copays/coinsurance | ? | Generic | Brand | retail fills? |
| If the plan charges a higher copay/coinsurance after a specified number of fills at retail, specify applicable copays/coinsurance | | | | |
| Describe the retail network (e.g., Broad national network, select/custom network excluding a specific pharmacy chain(s)) | |
| Are all generic drugs on Tier-1? | |
| Does client use your Retail-90 network (e.g., pricing for 90 day supply at certain retail pharmacies, with pricing in between retail pricing and mail order pricing)? | |
| Does client use your "Mail at Retail" network (e.g., mail order pricing for 90 day supply at certain retail pharmacies)? | |
| If so, which pharmacy chains, are included in the Mail at Retail network (mail order pricing for 90 day supply at certain retail pharmacies)? | |
| Is there mandatory mail order OR retail refill limits/penalties for non-specialty drugs? | ? |
| How are specialty drugs covered? (Open = no restrictions; Refill Limit = must use specialty pharmacy after specified # of fills at retail; Exclusive = only covered at PBM's specialty pharmacy) | |
| For specialty drugs, how many grace fills are allowed at retail, if any? | |
| What days' supply (DS) is allowed for Specialty Pharmacy claims (30 DS limit, 90 DS limit, clinical DS is used, other please specify) | |
| What is the name of the formulary drug list? | |
| Is this an Open formulary or does this formulary have drug exclusions? | |
| If the formulary has exclusions, are these hard edits or is there a PA process for drugs on the "excluded drug list"? | |
| Has PBM's standard formulary been customized for Client? If so, how? (e.g., moved a drug from formulary to non-formulary status, eliminated coverage for certain non-formulary products)? | |
| Is the above formulary also used at Domestic Pharmacies? | |
| Is this a HDHP? with HRA? or HSA? | |
| Does the plan use the PBM’s standard HDHP Preventive Drug List or a custom HDHP Preventive Drug List? | |
| Does Client's HDHP Preventive Drug List include brand and generics OR only generics? | ? |
| Do drugs on Client's HDHP Preventive Drug List: (a) bypass the deductible and subject to the standard cost-share; or (b) bypass the deductible and have a $0 copay? | ? |
| Does Client's HDHP Preventive Drug List include diabetes testing supplies? | |
| Does Client utilize a variable copay/coupon maximization program? If so, please specify the name of program(s) in place. | |
| Does it apply to specialty, non-specialty, or both? | |
| Does it track dollars to apply true member out-of-pocket expenses to accumulators? | |
| Does it maximize copays/coinsurance within the plan design member cost share? | |
| Does it maximize copays/coinsurance with the maximum available from pharmaceutical manufacturers? | |
| Briefly describe any other key Rx plan design features not captured above (e.g., DAW penalties,etc.) | |
| When does/did this plan design go into effect? | mm/dd/yyyy |
| Briefly describe any other key Rx plan design features not captured above (e.g., DAW penalties,etc.) | |
| Effective 2025: Member pay difference applies to DAW 1 and 2, no other plan changes. | |
OregonBuys Bid No. S-44300-00014758 &10&K000000Attachment P
PlanDesign FT Client: Oregon Public Employees Benefit Board (PEBB) Incumbent Vendor: Moda
| Plan Design Summary | |
| | Please provide responses below for the 2024 and 2025 Rx plan designs. |
| | Complete this exhibit separately for each unique Rx plan design |
| | Note: "Domestic Pharmacy" includes onsite pharmacies, inhouse pharmacies, and client owned pharmacies. |
| Vendor comments, if any: | Full Time Plan |
| A. | Rx plan design corresponding to experience data (2024): | |
| GROUP/PLAN NAME: | PEBB |
| Who is/are the current medical carriers for this plan? | Moda |
| Number of employees/retirees currently enrolled in this specific plan design: | 12,620 |
| Number of total members (includes covered dependents) currently enrolled in this specific plan design: | 31,136 |
| Above enrollment is as of what date? | 6/30/25 |
| Individual | Family | |
| Annual deductible, if any | $50.00 | $150.00 | Per claim, if applicable |
| Member out-of-pocket maximum, if applicable | $1,000.00 | $3,000.00 | $ |
| Are the above amounts for Rx only or combined medical/Rx? | Rx only | | |
| Value Tier | Tier-1 | Tier-2 | Tier-3 | Days supply limit |
| Select from the drop down menus to describe the plan's copay/coinsurance tiers | Lowest-Cost meds | Generic | Formulary Brand | Non-Formulary Brand | |
| Copay ($) or coinsurance (%) – please include any minimum or maximum copays, if applicable | | | | | |
| • Retail-30 non-specialty | $0 | $10 | $30 | $30 | 30 |
| • Retail-30 specialty drugs | N/A | N/A | N/A | N/A | N/A |
| • Retail-90 non-mail pricing | $0 | $25 | $75 | $75 | 90 |
| • Mail order | $0 | $25 | $75 | $75 | 90 |
| • Specialty pharmacy (mail) | N/A | $10 | $100 | $100 | 30 |
| • Domestic Pharmacies (30 day), if applicable | N/A | N/A | N/A | N/A | N/A |
| • Domestic Pharmacies (90 day), if applicable | N/A | N/A | N/A | N/A | N/A |
| • Domestic Pharmacies (specialty), if applicable | N/A | N/A | N/A | N/A | N/A |
| | | | | After how many |
| If the plan charges a higher copay/coinsurance after a specified number of fills at retail, specify applicable copays/coinsurance | Lowest-Cost meds | Generic | Formulary Brand | Non-Formulary Brand | retail fills? |
| N/A | N/A | N/A | N/A | N/A |
| Describe the retail network (e.g., Broad national network, select/custom network excluding a specific pharmacy chain(s)) | Core network excluding CVS |
| Are all generic drugs on Tier-1? | No. select generic medications are placed on the Value Tier. The Value Tier assigns a $0 copay to medications that are safe, effective, and high-value options. |
| Does client use your Retail-90 network (e.g., pricing for 90 day supply at certain retail pharmacies, with pricing in between retail pricing and mail order pricing)? | Yes |
| Does client use your "Mail at Retail" network (e.g., mail order pricing for 90 day supply at certain retail pharmacies)? | No |
| If so, which pharmacy chains, are included in the Mail at Retail network (mail order pricing for 90 day supply at certain retail pharmacies)? | N/A |
| Is there mandatory mail order OR retail refill limits/penalties for non-specialty drugs? | neither |
| How are specialty drugs covered? (Open = no restrictions; Refill Limit = must use specialty pharmacy after specified # of fills at retail; Exclusive = only covered at PBM's specialty pharmacy) | Retail Lockout |
| For specialty drugs, how many grace fills are allowed at retail, if any? | 0 |
| What days' supply (DS) is allowed for Specialty Pharmacy claims (30 DS limit, 90 DS limit, clinical DS is used, other please specify) | 30 DS limit |
| What is the name of the formulary drug list? | High Performance Formulary |
| Is this an Open formulary or does this formulary have drug exclusions? | Formulary has drug exclusions |
| If the formulary has exclusions, are these hard edits or is there a PA process for drugs on the "excluded drug list"? | Non-formulary drugs are approvable via an exception. Medications that fall into categorical, or benefit exclusions (i.e., cosmetic, provider administered, vitamins, non-FDA approved drugs, etc.) are automatically deemed excluded drugs upon market availability. Categorical exclusions are not coverable via an exception process. |
| Has PBM's standard formulary been customized for Client? If so, how? (e.g., moved a drug from formulary to non-formulary status, eliminated coverage for certain non-formulary products)? | Yes, high cost generics and nonpreferred brands are nonformuarly. Diabetic supplies and insulins incur a $0 copay. Travel vaccines are covered. Infertility covered with prior authorization. |
| Is the above formulary also used at Domestic Pharmacies? | N/A |
| Is this a HDHP? with HRA? or HSA? | No |
| Does the plan use the PBM’s standard HDHP Preventive Drug List or a custom HDHP Preventive Drug List? | Custom Preventive Drug List |
| Does Client's HDHP Preventive Drug List include brand and generics OR only generics? | brand & generic |
| Do drugs on Client's HDHP Preventive Drug List: (a) bypass the deductible and subject to the standard cost-share; or (b) bypass the deductible and have a $0 copay? | (b) |
| Does Client's HDHP Preventive Drug List include diabetes testing supplies? | Yes |
| Does Client utilize a variable copay/coupon maximization program? If so, please specify the name of program(s) in place. | Access guidance services |
| Does it apply to specialty, non-specialty, or both? | Both |
| Does it track dollars to apply true member out-of-pocket expenses to accumulators? | Yes |
| Does it maximize copays/coinsurance within the plan design member cost share? | Yes |
| Does it maximize copays/coinsurance with the maximum available from pharmaceutical manufacturers? | Yes |
| Briefly describe any other key Rx plan design features not captured above (e.g., DAW penalties,etc.) | |
| DAW penalty applies to MSB drugs, does not apply to OOP. Plan has a maximum combined medical and Rx cost share of $6850 per member, $13700 per family. Infertility covered under standard plan design- no dollar maximum. Diabetic supplies covered at $0. | |
B. Were any Rx plan design changes made for 2025? No
| C. | 2025 Rx plan design (only need to complete if different from 2024) |
| GROUP/PLAN NAME: |
| Who is/are the current medical carriers for this plan? |
| Number of employees/retirees currently enrolled in this specific plan design: |
| Number of total members (includes covered dependents) currently enrolled in this specific plan design: |
| Above enrollment is as of what date? |
| Individual | Family | |
| Annual deductible, if any | $ | $ | Per claim, if applicable |
| Member out-of-pocket maximum, if applicable | $ | $ | $ |
| Are the above amounts for Rx only or combined medical/Rx? | ? | | |
| Tier-1 | Tier-2 | Tier-3 | Days supply limit |
| Select from the drop down menus to describe the plan's copay/coinsurance tiers | ? | Formulary Brand | Non-Formulary Brand | |
| Copay ($) or coinsurance (%) – please include any minimum or maximum copays, if applicable | | | | |
| • Retail-30 non-specialty | | | | |
| • Retail-30 specialty drugs | | | | |
| • Retail-90 non-mail pricing | | | | |
| • Mail order | | | | |
| • Specialty pharmacy (mail) | | | | |
| • Domestic Pharmacies (30 day), if applicable | | | | |
| • Domestic Pharmacies (90 day), if applicable | | | | |
| • Domestic Pharmacies (specialty), if applicable | | | | |
| | | | After how many |
| If the plan charges a higher copay/coinsurance after a specified number of fills at retail, specify applicable copays/coinsurance | ? | Formulary Brand | Non-Formulary Brand | retail fills? |
| Describe the retail network (e.g., Broad national network, select/custom network excluding a specific pharmacy chain(s)) | |
| Are all generic drugs on Tier-1? | |
| Does client use your Retail-90 network (e.g., pricing for 90 day supply at certain retail pharmacies, with pricing in between retail pricing and mail order pricing)? | |
| Does client use your "Mail at Retail" network (e.g., mail order pricing for 90 day supply at certain retail pharmacies)? | |
| If so, which pharmacy chains, are included in the Mail at Retail network (mail order pricing for 90 day supply at certain retail pharmacies)? | |
| Is there mandatory mail order OR retail refill limits/penalties for non-specialty drugs? | ? |
| How are specialty drugs covered? (Open = no restrictions; Refill Limit = must use specialty pharmacy after specified # of fills at retail; Exclusive = only covered at PBM's specialty pharmacy) | |
| For specialty drugs, how many grace fills are allowed at retail, if any? | |
| What days' supply (DS) is allowed for Specialty Pharmacy claims (30 DS limit, 90 DS limit, clinical DS is used, other please specify) | |
| What is the name of the formulary drug list? | |
| Is this an Open formulary or does this formulary have drug exclusions? | |
| If the formulary has exclusions, are these hard edits or is there a PA process for drugs on the "excluded drug list"? | |
| Has PBM's standard formulary been customized for Client? If so, how? (e.g., moved a drug from formulary to non-formulary status, eliminated coverage for certain non-formulary products)? | |
| Is the above formulary also used at Domestic Pharmacies? | |
| Is this a HDHP? with HRA? or HSA? | |
| Does the plan use the PBM’s standard HDHP Preventive Drug List or a custom HDHP Preventive Drug List? | |
| Does Client's HDHP Preventive Drug List include brand and generics OR only generics? | ? |
| Do drugs on Client's HDHP Preventive Drug List: (a) bypass the deductible and subject to the standard cost-share; or (b) bypass the deductible and have a $0 copay? | ? |
| Does Client's HDHP Preventive Drug List include diabetes testing supplies? | |
| Does Client utilize a variable copay/coupon maximization program? If so, please specify the name of program(s) in place. | |
| Does it apply to specialty, non-specialty, or both? | |
| Does it track dollars to apply true member out-of-pocket expenses to accumulators? | |
| Does it maximize copays/coinsurance within the plan design member cost share? | |
| Does it maximize copays/coinsurance with the maximum available from pharmaceutical manufacturers? | |
| Briefly describe any other key Rx plan design features not captured above (e.g., DAW penalties,etc.) | |
| When does/did this plan design go into effect? | mm/dd/yyyy |
| Briefly describe any other key Rx plan design features not captured above (e.g., DAW penalties,etc.) | |
OregonBuys Bid No. S-44300-00014758 &10&K000000Attachment P
PlanDesign PT Client: Oregon Public Employees Benefit Board (PEBB) Incumbent Vendor: Moda
| Plan Design Summary | |
| | Please provide responses below for the 2024 and 2025 Rx plan designs. |
| | Complete this exhibit separately for each unique Rx plan design |
| | Note: "Domestic Pharmacy" includes onsite pharmacies, inhouse pharmacies, and client owned pharmacies. |
| Vendor comments, if any: | Part Time Plan |
| A. | Rx plan design corresponding to experience data (2024): | |
| GROUP/PLAN NAME: | PEBB |
| Who is/are the current medical carriers for this plan? | Moda |
| Number of employees/retirees currently enrolled in this specific plan design: | 146 |
| Number of total members (includes covered dependents) currently enrolled in this specific plan design: | 329 |
| Above enrollment is as of what date? | 6/30/25 |
| Individual | Family | |
| Annual deductible, if any | $50.00 | $150.00 | Per claim, if applicable |
| Member out-of-pocket maximum, if applicable | $1,000.00 | $3,000.00 | $ |
| Are the above amounts for Rx only or combined medical/Rx? | Rx only | | |
| Value Tier | Tier-1 | Tier-2 | Tier-3 | Days supply limit |
| Select from the drop down menus to describe the plan's copay/coinsurance tiers | Lowest-Cost meds | Generic | Formulary Brand | Non-Formulary Brand | |
| Copay ($) or coinsurance (%) – please include any minimum or maximum copays, if applicable | | | | | |
| • Retail-30 non-specialty | $0 | $20 | $50 | $50 | 30 |
| • Retail-30 specialty drugs | N/A | N/A | N/A | N/A | N/A |
| • Retail-90 non-mail pricing | $0 | $50 | $125 | $125 | 90 |
| • Mail order | $0 | $50 | $125 | $125 | 90 |
| • Specialty pharmacy (mail) | N/A | $20 | $100 | $100 | 30 |
| • Domestic Pharmacies (30 day), if applicable | N/A | N/A | N/A | N/A | N/A |
| • Domestic Pharmacies (90 day), if applicable | N/A | N/A | N/A | N/A | N/A |
| • Domestic Pharmacies (specialty), if applicable | N/A | N/A | N/A | N/A | N/A |
| | | | | After how many |
| If the plan charges a higher copay/coinsurance after a specified number of fills at retail, specify applicable copays/coinsurance | Lowest-Cost meds | Generic | Formulary Brand | Non-Formulary Brand | retail fills? |
| N/A | N/A | N/A | N/A | N/A |
| Describe the retail network (e.g., Broad national network, select/custom network excluding a specific pharmacy chain(s)) | Core network excluding CVS |
| Are all generic drugs on Tier-1? | No. select generic medications are placed on the Value Tier. The Value Tier assigns a $0 copay to medications that are safe, effective, and high-value options. |
| Does client use your Retail-90 network (e.g., pricing for 90 day supply at certain retail pharmacies, with pricing in between retail pricing and mail order pricing)? | Yes |
| Does client use your "Mail at Retail" network (e.g., mail order pricing for 90 day supply at certain retail pharmacies)? | No |
This is the start of the file's text. The full file is on GovTribe.