Oregon 2019 Small Group Rates
Print Date:
Print Time:
Group Number:
Effective Date:
1/1/2019
Plan
= Deductible Waived PCP Copay Spec Copay
In-Network
Coinsurance
Out-of-
Network
Coinsurance
Deductible
Out-of-
pocket
Maximum
Preferred
Generics
Non-
Preferred
Generics
Pref
Brand
Name
Non-Pref
Brand
Name
Preferred Specialty Non-Preferred Specialty
EE
Tier
ES
Tier
EF
Tier
EC
Tier
Total Enhanced 7000 Silver
$50 $70
30% 40% $7,000 $7,900
$15 $25 $65 40%
50%
$323.55 $647.10 $922.10 $598.55
Total Enhanced 5500 Gold
$30 $50
20% 40% $5,500 $6,000
$10 $20 $40 30%
50%
$354.10 $708.20 $1,009.20 $655.10
Total Enhanced 4500 Gold
$30 $50
20% 40% $4,500 $6,000
$10 $20 $40 30%
50%
$362.50 $725.00 $1,033.15 $670.65
Total Enhanced 3500 Gold
$30 $50
20% 40% $3,500 $6,000
$10 $20 $40 30%
50%
$381.55 $763.10 $1,087.40 $705.85
Total Enhanced 2500 Gold
$30 $50
20% 40% $2,500 $6,000
$10 $20 $40 30%
50%
$398.65 $797.30 $1,136.15 $737.50
Total Enhanced 1500 Gold
$30 $50
20% 40% $1,500 $6,000
$10 $20 $40 30%
50%
$430.60 $861.20 $1,227.20 $796.60
Total Enhanced 1000 Gold
$30 $50
20% 40% $1,000 $6,000
$10 $20 $40 30%
50%
$452.75 $905.50 $1,290.35 $837.60
Total Enhanced 500 Platinum
$20 $30
10% 30% $500 $3,500
$10 $15 $25 30%
50%
$507.00 $1,014.00 $1,444.95 $937.95
Total Enhanced 250 Platinum
$20 $30 10% 30%
$250 $3,500
$10 $15 $25 30%
50%
$515.65 $1,031.30 $1,469.60 $953.95
Tier Key: EE = Employee Only, ES = Employee + Spouse, EF = Employee + Spouse + Child(ren), EC = Employee + Child(ren)
Coalition of Graduate Employees Local 6069
112701
• Most comprehensive coverage, with platinum, gold and silver options
• Broadest provider network access with Providence Signature Network
• Deductible is waived for in-network diabetic supplies such as needles, lancets and test strips.
• No deductible for in-network doctor and specialist visits, emergency room, urgent care, lab, x-ray and vision. Express Care Virtual covered in full.
• Combined in-network and out-of-network deductible and out-of-pocket maximum
• Pharmacy included, no deductible for most prescriptions
• Chiropractic manipulation & acupuncture included, no deductible, $25 copay to in-network providers, limit of 15 visits combined per calendar year
• Pediatric dental, and pediatric and adult vision (12/12/12) included
9/18/2018
1:48:41 PM
Total Enhanced Plans (Providence Signature Network)
Medical
Prescription Drug
Rates
Page 1 of 7
Oregon 2019 Small Group Rates
Print Date:
Print Time:
Group Number:
112701
9/18/2018
1:48:41 PM
Effective Date:
1/1/2019
Plan
= Deductible Waived PCP Copay Spec Copay
In-Network
Coinsurance
Out-of-
Network
Coinsurance
Deductible
Out-of-
pocket
Maximum
Preferred
Generics
Non-
Preferred
Generics
Pref
Brand
Name
Non-Pref
Brand
Name
Preferred Specialty Non-Preferred Specialty
EE
Tier
ES
Tier
EF
Tier
EC
Tier
Balance 7900 Bronze $65 $125 50% 50%
$7,900 $7,900
$35 $60 0% 0% 0% 0%
$288.05 $576.10 $820.95 $532.90
Balance 7000 Bronze $65 $125 50% 50%
$7,000 $7,900
$35 $60 50% 50%
50%
$297.80 $595.60 $848.75 $550.95
Balance 6000 Silver $45 $65 30% 50%
$6,000 $7,900
$20 $45 $75 50%
50%
$320.15 $640.30 $912.45 $592.30
Balance 4500 Silver $45 $65 30% 50%
$4,500 $7,900
$20 $45 $75 50%
50%
$332.60 $665.20 $947.90 $615.30
Balance 3500 Silver $45 $65 30% 50%
$3,500 $7,900
$20 $45 $75 50%
50%
$344.85 $689.70 $982.80 $637.95
Balance 2500 Silver $45 $65 30% 50%
$2,500 $7,900
$20 $45 $75 50%
50%
$361.50 $723.00 $1,030.30 $668.80
Balance 1500 Gold $35 $55 20% 50%
$1,500 $5,500
$15 $20 $50 50%
50%
$411.05 $822.10 $1,171.50 $760.45
Balance 750 Gold $35 $55 20% 50%
$750 $5,500
$15 $20 $50 50%
50%
$449.75 $899.50 $1,281.80 $832.05
Tier Key: EE = Employee Only, ES = Employee + Spouse, EF = Employee + Spouse + Child(ren), EC = Employee + Child(ren)
Balance Plans (Providence Signature Network)
Medical
Prescription Drug
Rates
• A balance of cost saving features and first dollar coverage for the most commonly used services
• Broadest provider network access with Providence Signature Network
• No referrals required
• No deductible for in-network doctor and specialist visits, urgent care and vision. Express Care Virtual covered in full.
• Separate in-network and out-of-network deductibles and out-of-pocket maximums
• Pharmacy included, no deductible for most prescriptions
• Chiropractic manipulation & acupuncture included, no deductible, $25 copay to in-network providers, limit of 10 visits combined per calendar year
• Pediatric dental, and pediatric and adult vision (12/24/24) included
Coalition of Graduate Employees Local 6069
Page 2 of 7
Oregon 2019 Small Group Rates
Print Date:
Print Time:
Group Number:
112701
9/18/2018
1:48:41 PM
Effective Date:
1/1/2019
Plan
= Deductible Waived
PCP
Coinsurance
Spec
Coinsurance
In-Network
Coinsurance
Out-of-
Network
Coinsurance
Deductible
Out-of-
pocket
Maximum
Preferred
Generics
Non-
Preferred
Generics
Pref
Brand
Name
Non-Pref
Brand
Name
Preferred Specialty Non-Preferred Specialty
EE
Tier
ES
Tier
EF
Tier
EC
Tier
HSA Qualified 6650 Bronze 0% 0% 0% 0% $6,650 $6,650 0% 0% 0% 0% 0% 0%
$261.45 $522.90 $745.15 $483.70
HSA Qualified 5500 Bronze 50% 50% 50%
50%
$5,500 $6,650 50% 50% 50% 50%
50%
$268.05 $536.10 $763.95 $495.90
HSA Qualified 4500 Bronze 50% 50% 50% 50% $4,500 $6,650 50% 50% 50% 50%
50%
$284.00 $568.00 $809.40 $525.40
HSA Qualified 3000 Silver 30% 30% 30% 50% $3,000 $6,650 30% 30% 30% 30%
50%
$325.45 $650.90 $927.55 $602.10
HSA Qualified 2500 Silver 30% 30% 30% 50% $2,500 $6,650 30% 30% 30% 30%
50%
$340.00 $680.00 $969.00 $629.00
HSA Qualified 1700 Silver 30% 30% 30% 50% $1,700
$6,650
30% 30% 30% 30%
50%
$367.95 $735.90 $1,048.65 $680.70
Tier Key: EE = Employee Only, ES = Employee + Spouse, EF = Employee + Spouse + Child(ren), EC = Employee + Child(ren)
• Health Savings Account qualified plans
• Broadest provider network access with Providence Signature Network
• No referrals required
• Separate in-network and out-of-network deductibles and out-of-pocket maximums
• Preventive care, prenatal care, pediatric vision and adult vision exams covered without deductible
• Integrated enrollment and claims with our banking partner, HealthEquity when this service is purchased
• Pharmacy, chiropractic manipulation and acupuncture included, subject to deductible
• HSA formulary includes safe harbor medications that are deductible waived, subject to applicable tier cost share
• Pediatric vision (exam and hardware), adult vision (exam only) and pediatric dental included
Coalition of Graduate Employees Local 6069
HSA Qualified Plans (Providence Signature Network)
Medical
Prescription Drug
Rates
Page 3 of 7
Oregon 2019 Small Group Rates
Print Date:
Print Time:
Group Number:
112701
9/18/2018
1:48:41 PM
Effective Date:
1/1/2019
Plan
= Deductible Waived PCP Copay Spec Copay
In-Network
Coinsurance
Out-of-
Network
Coinsurance
Deductible
Out-of-
pocket
Maximum
Preferred
Generics
Non-
Preferred
Generics
Pref
Brand
Name
Non-Pref
Brand
Name
Preferred Specialty Non-Preferred Specialty
EE
Tier
ES
Tier
EF
Tier
EC
Tier
Connect 7900 Bronze $65 $125
50% 50% $7,900
$7,900 $35 $60 0% 0% 0% 0%
N/A N/A N/A N/A
Connect 7000 Bronze $65 $125
50% 50% $7,000
$7,900 $35 $60 50% 50%
50%
N/A N/A N/A N/A
Connect 6000 Silver $45 $65
30% 50% $6,000
$7,900 $20 $45 $75 50%
50%
N/A N/A N/A N/A
Connect 4500 Silver $45 $65
30% 50% $4,500
$7,900 $20 $45 $75 50%
50%
N/A N/A N/A N/A
Connect 3500 Silver $45 $65
30% 50% $3,500
$7,900 $20 $45 $75 50%
50%
N/A N/A N/A N/A
Connect 2500 Silver $45 $65
30% 50% $2,500
$7,900 $20 $45 $75 50%
50%
N/A N/A N/A N/A
Connect 1500 Gold $35 $55
20% 50% $1,500
$5,500 $15 $20 $50 50%
50%
N/A N/A N/A N/A
Connect 750 Gold $35 $55 20% 50%
$750
$5,500 $15 $20 $50 50%
50%
N/A N/A N/A N/A
Tier Key: EE = Employee Only, ES = Employee + Spouse, EF = Employee + Spouse + Child(ren), EC = Employee + Child(ren)
Coalition of Graduate Employees Local 6069
Connect Plans (Connect Network)
Medical
Prescription Drug
Rates
• Providence's exclusive Connect medical home network available to employees residing in Multnomah, Clackamas, Washington and Hood River counties as well as Newberg
• Referrals required & care coordinated through the medical home for all in-network coverage
• No deductible for in-network or referred office visits, urgent care and vision. Express Care Virtual and Express Care Retail Health Clinic visits covered in full.
• Separate in-network and out-of-network deductibles and out-of-pocket maximums
• Pharmacy included, no deductible for most prescriptions
• Chiropractic manipulation & acupuncture included, no deductible, $25 copay to in-network providers, limit of 10 visits combined per calendar year
• Pediatric vision (exam and hardware), adult vision (exam only) and pediatric dental included
• Must be offered alongside a broader PHP Signature Network product
• Additional cost tier for selected services, such as knee and hip replacements and sinus surgery
Page 4 of 7
Oregon 2019 Small Group Rates
Print Date:
Print Time:
Group Number:
112701
9/18/2018
1:48:41 PM
Effective Date:
1/1/2019
Plan
= Deductible Waived PCP Copay Spec Copay
In-Network
Coinsurance
Out-of-
Network
Coinsurance
Deductible
Out-of-
pocket
Maximum
Preferred
Generics
Non-
Preferred
Generics
Pref
Brand
Name
Non-Pref
Brand
Name
Preferred Specialty Non-Preferred Specialty
EE
Tier
ES
Tier
EF
Tier
EC
Tier
Providence Oregon Standard Bronze Plan $0 $0 0% 0%
$6,550
$6,550 $0 $0 $0 0% 0% 0%
$291.55 $583.10 $830.90 $539.35
Providence Oregon Standard Silver Plan $40 $80 30% 50% $2,850 $7,900 $15 $15 $60 50% 50% 50%
$349.50 $699.00 $996.10 $646.60
Providence Oregon Standard Gold Plan $20 $40 20% 50% $1,000 $6,850 $10 $10 $30 50%
50%with $500 per script
cap
$430.75 $861.50 $1,227.65 $796.90
Tier Key: EE = Employee Only, ES = Employee + Spouse, EF = Employee + Spouse + Child(ren), EC = Employee + Child(ren)
Coalition of Graduate Employees Local 6069
Standard Plans (Providence Signature Network)
Medical
Prescription Drug
Rates
• State of Oregon mandated plans
• Broadest provider network access with Providence Signature Network
• Separate in-network and out-of-network deductibles and out-of-pocket maximums
• Pharmacy included, no deductible for most prescriptions (Excludes Bronze)
•Pediatric vision included
•Providence dental plans cannot be purchased with Standard Plans for employers applying for the small business tax credit (SHOP)
Page 5 of 7
Oregon 2019 Small Group Rates
Print Date:
Print Time:
Group Number:
112701
9/18/2018
1:48:41 PM
Effective Date:
1/1/2019
Plan
Deductible
EE
Tier
ES
Tier
EF
Tier
EC
Tier
Essential Dental $50
$29.00 $57.95 $82.60 $52.00
Essential Access Dental
$50 $34.70 $69.40 $98.90 $62.25
Advantage Access Dental
$25 $38.60 $77.20 $110.05 $69.25
Preventive Dental
$0 $10.20 $20.15 $30.55 $20.65
Account Type
Health Savings Account
Health Reimbursement Account
Flexible Spending Account
Limited Flexible Spending Account (paired with an HSA)
Group Size
Coalition of Graduate Employees Local 6069
• Optional account administration through banking partner HealthEquity
• Automated HSA and HRA enrollment through Providence Health Plan when paired with HealthEquity
• Integrated enrollment, billing and claims administration when choosing HealthEquity
• Manage contributions and view reporting from HealthEquity employer portal
• View integrated claims, pay providers, request reimbursement and obtain tax information via HealthEquity employee portal
• 24/7 customer service
Employee Assistance Program
Structure
Rate
2-25 Employees
Capitated - up to 3 sessions
$2.10 per employee per month
Capitated - up to 6 sessions
$2.90 per employee per month
26-50 Employees
Capitated - up to 3 sessions
• Preferred Providence Health Plan partner rates
• EAP rates are based on total company rate
• The EAP benefit is offered to ALL employees and their dependents, up to age 26 regardless of their enrollment status
• The EAP premium is billed separately from your PHP medical premiums
• Contact Providence EAP directly at 503-216-7979 or go to www.providence.org/eap for details and assistance with enrollment
$2.00 per employee per month
Capitated - up to 6 sessions
$2.55 per employee per month
Free
$250-$500
$3.45 per employee
Free
Free
$1.95 per employee
Free
No Additional Charge
No Additional Charge
Free
$250-$500
$3.45 per employee
• No waiting periods
• Preventive Services do not apply to the annual maximum benefit
• Endodontics, periodontics and oral surgery are covered under Class II Basic Services
• Broad in and out-of-network provider access
• Ortho is not a covered service
Tier Key: EE = Employee Only, ES = Employee + Spouse, EF = Employee + Spouse + Child(ren), EC = Employee + Child(ren)
Spending Accounts
Employee
Set-Up Fee
Employer
Set-Up Fee
Monthly
Administration Fee
$1,500
Covered In Full
20%
50%
90th UCR
N/A
Covered In Full
Not Covered
Not Covered
MAC
$1,000
Covered In Full
20%
50%
MAC
$1,000
Covered In Full
20%
50%
90th UCR
Benefits
Rates
Annual Benefit Maximum
In-Network Preventive
In-Network Basic
In-Network Major
OON Reimbursement
Dental Plans
Page 6 of 7
Oregon 2019 Small Group Rates
Print Date:
Print Time:
Group Number:
112701
9/18/2018
1:48:41 PM
Effective Date:
1/1/2019
Plan Requirements
1) If a small group employer chooses a Connect Plan, the employer must also choose at least one Signature plan - Total Enhanced, Balance, Standard or HSA health plan -
to ensure any current or future out of area employees receive sufficient access to in-network coverage.
Multiple Plan Option Requirements
1) Available for all small employers.
2) The employer must contribute a minimum of 50% of the employee only rate of the lowest premium plan chosen. If a dollar amount contribution is chosen, the amount
must at least equal 50% of the employee only rate of the lowest premium plan chosen.
3) A small employer with 1-4 enrolled employees may choose up to two small group plans. A small employer with 5 or more enrolled employees may choose
up to three small group plans.
4) There are no restrictions on plan pairings.
Additional Underwriting Requirements
1) An eligible Oregon Small Group employer is an employer having an average of at least one but not more than a combined total of 50 full-time (FT) and full time equivalent (FTE)
employees during the preceding calendar year and who employs at least one common law employee enrolled in coverage on the first day of the plan year.
2) The employer must have at least one common law employee that is enrolled in the plan, and offers the group health plan to all benefit eligible employees.
3) The employer must be located in the Providence Health Plan Oregon service area.
4) The employer must have at least 51% of enrolling employees working or residing in the Signature service area (PHP OR service area plus Clark, Klickitat and Skamania
counties in WA).
5) Connect products are only available to employers located in Clackamas, Multnomah, Hood River, Yamhill (zip code 97132 only) and Washington counties. Employees who enroll on
these plans must work or reside in these same counties.
6) Products are offered on a sole carrier basis.
7) The employer may determine hours worked for benefit eligibility between 17.5 and 40 hours per week.
8) 75% of benefit eligible employees must enroll or show proof of other valid coverage. There is no minimum participation requirement for dependents.
9) Valid waivers include those waiving for other group or individual coverage. Waivers for other types of coverage are subject to underwriting review.
10) The employer must contribute a minimum of 50% to the employee only rate of the least expensive plan offered to employees.
11) Employee only contracts are available.
12) The employer must elect a probationary period from the following: (1) Date of hire (2) Day immediately following 30, 60 or 90 days (3) First of the month following DOH, 30 or 60 days.
13) Dependents are eligible for coverage up to age 26.
14) If an employer offers different benefits to different classes of employees, all other contract provisions such as contribution, probationary period and hourly
requirements must be the same for all employees, regardless of class.
15) Premium is due on or before the first of the month for which coverage is provided. Payment at time of enrollment does not constitute coverage without UW approval.
Open Enrollment Period
1) If an employer does not meet the minimum contribution requirement, they may only enroll during the period of November 15th through December 15th, for a January 1st
effective date.
Dental Guidelines
1) Dental enrollment and eligibility must match medical enrollment.
2) Providence dental plans are only offered on a sole carrier basis and cannot be offered to a group with another dental carrier in place.
3) Employer can only choose one Providence dental plan.
4) Dental can only be purchased in conjunction with a medical plan through Providence.
This proposal is to be used for illustrative purposes only and is not an offer or contract. Providence Health Plan small group quotes are for the use of appointed agents only. The final rates will be
Coalition of Graduate Employees Local 6069
determined by Providence Health Plan in writing when the final requirements, including receipt of Group Size Determination Form demonstrating the quoted business is a valid Oregon Small
Employer, have been received and reviewed by the Underwriting department. Final rates will be based on (among other things): the most recent approved state filing for the requested final
effective date of coverage, the final plan design selected, ages of those applying for coverage, number of family members issued coverage, zip code of the employer business. This document
highlights some of the benefits available under these plans.
Page 7 of 7