PDF COBRA Moda Health 2019-20 Plan Year Plans and Monthly Imputed ...

OEBB Plan

Moda Medical Plans

Moda Medical Plan 1 Moda Medical Plan 2 Moda Medical Plan 3 Moda Medical Plan 4 Moda Medical Plan 5 Moda Medical Plan 6* Moda Medical Plan 7*

COBRA Moda Health 2019-20 Plan Year Plans and Monthly Imputed Income Amounts

(Effective October 1, 2019)

Member Services 1-888-469-6322

OEBB.Benefits@state.or.us

Medical & Pharmacy

Tier-Rated Groups

Domestic Partner

$830.24 $772.40 $726.11 $689.07 $637.15 $652.50 $608.98

Domestic Partner's Child(ren) Only

$622.71 $579.32 $544.62 $516.83 $477.88 $489.40 $456.76

Domestic Partner + Domestic Partner's Child(ren)

$1,452.95 $1,351.72 $1,270.73 $1,205.90 $1,115.03 $1,141.90 $1,065.74

OEBB Plan

Moda Medical Plans Select

Moda Medical Plan 1 Select1 Moda Medical Plan 2 Select1 Moda Medical Plan 3 Select1 Moda Medical Plan 4 Select1 Moda Medical Plan 5 Select1 Moda Medical Plan 6 Select1* Moda Medical Plan 7 Select1*

Medical & Pharmacy - Select1

Tier-Rated Groups

Domestic Partner

$830.24 $772.40 $719.50 $671.50 $637.15 $610.90 $591.07

Domestic Partner's Child(ren) Only

$622.71 $579.32 $539.64 $503.65 $477.88 $458.20 $443.31

Domestic Partner + Domestic Partner's Child(ren)

$1,452.95 $1,351.72 $1,259.14 $1,175.15 $1,115.03 $1,069.10 $1,034.38

* This plan MAY be paired with an HSA (Health Savings Account), but the HSA is not required. Pharmacy is included in this plan as any other covered medical expense. Rx's are applied to the deductible. Once the deductible is met Rx's are paid at the same level as other covered medical expenses. 1 Select rates apply only to members whose most recent OEBB medical plan enrollment between June 30, 2019 and September 30, 2019 was in a Moda CCM Synergy/Summit Plan.

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COBRA Moda Health/Delta Dental 2019-20 Plan Year Plans and Monthly Imputed Income Amounts

(Effective October 1, 2019)

Member Services 1-888-469-6322

OEBB.Benefits@state.or.us

OEBB Plan

Provider network noted in plan name below

Premier Plan 1 - Delta Dental Premier Network Premier Plan 5 - Delta Dental Premier Network Premier Plan 6* - Delta Dental Premier Network Exclusive PPO Plan** - Delta Dental PPO Network

Dental and Orthodontia

Tier-Rated Groups

Domestic Partner

$66.52 $58.70 $43.87 $39.25

Domestic Partner's Child(ren) Only $81.57 $72.00 $45.19 $48.13

Domestic Partner + Domestic Partner's Child(ren) $148.09 $130.70 $89.06 $87.38

* This plan has no orthodontia coverage

** This plan has no out-of-network benefit. Services performed by providers outside the Delta Dental PPO network are not covered unless for a dental emergency. Covered emergencies consist of problem focused exam, palliative treatment and x-rays. All other services are considered non-covered.

COBRA Moda Health 2019-20 Plan Year Plans and Monthly Imputed Imputed Income Amounts

(Effective October 1, 2019)

OEBB Plan

May use any licensed provider

Opal Plan Pearl Plan Quartz Plan

Vision

Domestic Partner $29.65 $24.29 $17.15

Tier-Rated Groups

Domestic Partner's Child(ren) Only $22.20 $18.21 $12.84

Domestic Partner + Domestic Partner's Child(ren) $51.85 $42.50 $29.99

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COBRA Kaiser Permanente 2019-20 Plan Year Plans and Monthly Imputed Income Amounts

(Effective October 1, 2019)

Member Services 1-888-469-6322

OEBB.Benefits@state.or.us

OEBB Plan

Medical and Pharmacy

Tier-Rated Groups

Must use Kaiser Permanente facilities and providers for all non-emergency services

Kaiser Medical Plan 1 Kaiser Medical Plan 2 Kaiser Medical Plan 3*

Domestic Partner

$807.13 $667.83 $487.59

Domestic Partner's Child(ren) Only

$605.35 $500.24 $364.98

Domestic Partner + Domestic Partner's Child(ren)

$1,412.48 $1,168.07 $852.57

* This plan MAY be paired with an HSA (Health Savings Account), but the HSA is not required. Pharmacy is included in this plan as any other covered medical expense. Rx's are applied to the deductible. Once the deductible is met Rx's are paid at the same level as other covered medical expenses.

OEBB Plan

Must use Kaiser Permanente facilities and providers for all non-emergency services

Kaiser Dental Plan

Dental and Orthodontia

Tier-Rated Groups

Domestic Partner $89.46

Domestic Partner's Child(ren) Only $67.09

Domestic Partner + Domestic Partner's Child(ren) $156.55

OEBB Plan

Must use Kaiser Permanente facilities and providers for all non-emergency services

Kaiser Vision Plan

Vision

Domestic Partner $10.20

Tier-Rated Groups

Domestic Partner's Child(ren) Only $7.64

Domestic Partner + Domestic Partner's Child(ren) $17.84

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COBRA Williamette Dental Group 2019-20 Plan Year Plans and Monthly Imputed Income Amounts

(Effective October 1, 2019)

Member Services 1-888-469-6322

OEBB.Benefits@state.or.us

Dental and Orthodontia

OEBB Plan

Tier-Rated Groups

Must use Willamette Dental Group facilities and providers for all non-emergency services

Willamette Dental Plan

Domestic Partner $47.42

Domestic Partner's Child(ren) Only $53.56

Domestic Partner + Domestic Partner's Child(ren) $100.98

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Member Services 1-888-469-6322

OEBB.Benefits@state.or.us

COBRA VSP Vision 2019-20 Plan Year Plans and Monthly Imputed Income Amounts

(Effective October 1, 2019)

OEBB Plan Vision plans using the VSP Choice network

VSP Choice Plus Plan VSP Choice Plan

Vision

Domestic Partner $23.02 $11.19

Tier-Rated Groups

Domestic Partner's

Domestic Partner + Domestic

Child(ren) Only

Partner's Child(ren)

$17.26

$40.28

$8.39

$19.58

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