Compare medical plans

Things to think about when choosing a medical plan

Choosing a medical plan is an important decision. Many people think first about cost and which doctors and hospitals are in the network. All PEBB medical plans, except for Premera Blue Cross Medicare Supplement Plan F and Plan G, cover the same basic health care services but vary in other ways, such as provider networks, monthly plan costs, and prescription drug coverage.

When selecting a PEBB medical plan, your options are limited based on eligibility and where you live. You must consider which plans are available in your county and whether you and any eligible dependents you wish to enroll are enrolled in Medicare Part A and Part B. Remember, if you cover eligible dependents, everyone must enroll in the same medical, dental, and vision plans (with some exceptions, based on eligibility for Medicare Part A and Part B).

As you research your plan options, consider these questions:

Am I eligible to enroll in the plan?

Not everyone qualifies to enroll in a CDHP with a health savings account (HSA) or a UMP Plus plan. See Health plans with health savings account (non-Medicare) (for CDHP eligibility information).

Do I live in the plan's service area?

In most cases, you must live in a medical plan’s service area to join the plan. See Medical plans available by county. If you move out of your plan's service area, you may need to change your plan. You must report your new address to your payroll or benefits office no later than 60 days after your move.

How do I compare the plans?

All medical plans, except for Premera Blue Cross Medicare Supplement Plan F and Plan G, cover the same basic health care services but vary in other ways, such as provider networks, premiums, and drug formularies. Get a side-by-side comparison of common medical benefits and costs for services.

• Medical Benefits Comparison Tool (online)
• Medical Benefits At-a-Glance Comparison (printable)
• Benefits At-a-Glance for PEBB Medicare plans (printable)

Plan differences to consider

When choosing a plan to best meet your needs, here are some things to consider:

Premiums

Premiums vary by plan. A higher premium doesn’t necessarily mean higher quality of care or better benefits. Generally, the classic plans have higher premiums than the value plans. However, classic plans may have lower annual deductible, copays, or coinsurance costs. See Medicare plan premiums, non-Medicare plan premiums, life insurance premiums, and long-term disability insurance premiums.

Deductibles

Most medical plans require you to pay an annual deductible before the plan pays for covered services. For some services, like covered preventive care, you do not have to pay your deductible before the plan covers the service.

Plan benefits

Look at the plans' benefits booklets and Summaries of Benefits and Coverage to find out what is covered and your costs for care. See Benefits and coverage by plan.

Coinsurance or copays

Some plans require you to pay a fixed amount, called a copay. Other plans require you to pay a percentage of an allowed fee when you receive care, called a coinsurance.

Out-of-pocket limit

The annual out-of-pocket limit is the most you pay in a calendar year for covered benefits. 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. Read each plan’s certificate of coverage for details.

Prescription drug coverage

If you’re currently taking medication, a change in your health coverage may affect your medication costs—and in some cases, your medication may not be covered by another plan. You may want to check if your current medications are listed in drug formularies for other health coverage. A drug formulary is a list of prescription drugs (both generic and brand name) that are preferred by your health plan.

Referral procedures

Some plans allow you to self-refer to any network provider; others require you to have a referral from your primary care provider. All plans allow self-referral to a participating provider for women’s health care services.

Your provider

Use the health plans' provider directories to find a provider near you and make sure the provider is in your plan's network. See Find a provider.

Network adequacy

All health carriers in Washington are required to maintain provider networks that offer members reasonable access to covered services. Check the plans’ 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 or RCW 48.43.765 (Brennen’s Law).

Paperwork

In general, PEBB plans don’t require you to file claims. However, UMP Classic members may need to file a claim if they receive services from a nonnetwork provider. CDHP members should also keep paperwork received from their provider or from qualified health care expenses to verify eligible payments or reimbursements from their health savings account.

Coordination with your other benefits

All PEBB medical plans coordinate benefit payments with other group plans, Apple Health (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 plan to ask how they coordinate benefits. This is especially important for those coordinating benefits between the PEBB and SEBB programs, and those enrolled in Apple Health (Medicaid). One exception to coordination of benefits: PEBB medical plans that cover prescription drugs will not coordinate prescription-drug coverage with Medicare Part D. (All PEBB medical plans cover prescription drugs except Premera Blue Cross Medicare Supplement Plan F and Plan G.) If you enroll in a stand-alone Medicare Part D plan, you must enroll in Plan G or lose your PEBB retiree health plan coverage. Keep in mind that the UnitedHealthcare Medicare Advantage Prescription Drug plans include Medicare Part D coverage.

How do the PEBB Program plans work with Medicare?

You must be enrolled in Medicare Part A and Part B to enroll in the Medicare Advantage or Medicare Supplement plans. Also, not everyone qualifies to enroll in a consumer-directed health plan (CDHP) with a health savings account (HSA). See Medicare and turning age 65.

What type of plan should I select?

Your options are limited to plans that are available in your county and whether you or your covered dependents are enrolled in Medicare Part A and Part B. The PEBB Program offers three types of medical plans.

Consumer-directed health plans (CDHPs)

CDHPs let you use a health savings account (HSA) to help pay for out-of-pocket medical expenses tax free, have a lower monthly premium than most plans, and a higher deductible and a higher out-of-pocket limit. Remember, if you cover eligible dependents, everyone must enroll in the same medical and dental plans (with some exceptions, based on eligibility for Medicare Part A and Part B). See Health plans with health savings account (HSAs)

Managed-care plans

Managed-care plans may require you to select a primary care provider within its network to fulfill or coordinate all of your health care needs. You can change providers at any time, for any reason within the contracted network. The plan may not pay benefits if you see a noncontracted provider.

Preferred provider organization (PPO) plans

PPOs allow you to self-refer to any approved provider type in most cases, but usually provide a higher level of coverage if the provider contracts with the plan.

Medical plan options

In general, PEBB retirees may choose from the plans listed below. Your options are limited to the plans available in your county and whether you are enrolled in Medicare Part A and Part B. Remember, if you cover eligible dependents, everyone must enroll in the same medical plan (with some exceptions, based on eligibility for Medicare Part A and Part B). PEBB Continuation Coverage (Unpaid Leave) subscribers are not eligible for Medicare plans.

Medicare options

For members enrolled in Medicare Part A and B.

• Kaiser Permanente NW Senior Advantage with Part D
• Kaiser Permanente WA Medicare Advantage with Part D
• Medicare Supplement Plan G, administered by Premera Blue Cross
• UMP Classic Medicare with Part D (PDP), administered by Regence BlueShield
• UnitedHealthcare PEBB Balance (MAPD)
• UnitedHealthcare PEBB Complete (MAPD)

Non-Medicare options

For members enrolled in Medicare Part A or not eligible for Medicare only. Value-based plans noted in bold.

Consumer-directed health plans (CDHPs)

• Kaiser Permanente NW CDHP
• Kaiser Permanente WA CDHP
• UMP CDHP, administered by Regence BlueShield

Managed-care plans

• Kaiser Permanente NW Classic
• Kaiser Permanente WA Classic
• Kaiser Permanente WA SoundChoice (Note: At least one dependent must not be enrolled in Medicare Part A and Part B.)
• Kaiser Permanente WA Value

Preferred-provider (PPO) plans

• UMP Classic, administered by Regence BlueShield
• UMP Select, administered by Regence BlueShield
• UMP Plus–Puget Sound High Value Network, administered by Regence BlueShield
• UMP Plus–UW Medicine Accountable Care Network, administered by Regence BlueShield