Medical benefits and plan materials

As a PEBB member, you get access to high-quality medical care from a diverse network of providers, plus other perks to keep you healthy. Get the most out of your benefits, so you can avoid surprise costs while getting the best available care.

Two plans. Quality Care

Moda offers two medical plans to choose from – a Coordinated Care plan and a PPO plan. Both provide access to quality care. Choose the plan that best fits your needs, both plans include:

  • Access to Moda’s largest network, Connexus (Oregon, SW Washington, Idaho, and Alaska). For care outside of the Connexus service area, you will utilize the Aetna PPO® Network through Aetna Signature Administrators®.
  • Coverage for chiropractic, acupuncture, and massage therapy.
  • No referrals are needed to see specialists.

If you are transitioning to Moda from another health plan and need assistance logging into your Moda 360 member Dashboard or have questions have benefit offerings and coverage, please contact the Moda 360 Health Navigator team by calling: 844-776-1593.

Coordinated Care Plan:

  • If you live in Oregon and surrounding counties, you can select the Coordinated Care plan.
  • Through this plan, you must select and use a PCP 360 to receive in-network benefits.
  • Subscribers who have dependents who live outside the Connexus service area, can still enroll in the Coordinated Care plan. These dependents will use the Aetna PPO® Network, when outside of the service area.

Visit the Coordinated Care page

PPO Plan:

  • The PPO plan is available nationwide. You can select this plan if you live in Oregon or throughout the country.

Smiling doctor caring for Garner patient

Get money back when you see Top Providers with Garner

When you use Garner™ to find Top Providers in your area, you can be repaid up to:

  • PPO plan members can get reimbursed up to $1,000 for an individual or up to $2,000 with family coverage.
  • Coordinated Care plan members can get reimbursed up to $1,250 for an individual or up to $2,500 with family coverage.

Plus, you know you’ll be getting care from a provider that has the highest ratings for quality care.* That means you get quality care at a lower cost.

Get money back with Garner

*This program is not insurance. Moda Health Plan, Inc. (Moda) is not affiliated with Garner. Moda has contracted Garner for this service. Moda does not aid in data collection or provider scoring and is not responsible for any reimbursement from utilizing Garner Top Providers and does not administer HRAs.

How your coverage works

To get the most from your medical plan, there are a few things to know about how your coverage works.

Deductible

The amount you pay for covered services before your plan begins to pay benefits.

Coinsurance

The percentage of eligible services that you pay after you’ve met your deductible.

Copay

A fixed dollar amount for some services that you are responsible for paying when receiving care.

Out-of-pocket maximum

The most you’ll pay for eligible expenses during a plan year, including coinsurance, copay and deductible. Moda Health pays 100% of your eligible expenses for the rest of the plan year.

Maximum plan allowance (MPA)

The most Moda Health will reimburse when you receive care from an out-of-network provider. The provider may bill you for any amount over the MPA, which could leave you with high out-of-pocket costs.

PCP 360

A primary care provider who is part of a facility that has been certified by the Oregon Patient-Centered Primary Care Program or other similar programs. This means that a PCP 360 has to meet certain quality standards.

Benefit and plan materials

The resources below provide you with important details you need to manage your benefits.

Member handbooks

Download your member handbook for detailed information about your plan, including a description of your benefits and which services need prior authorization.

Summary of benefits and coverage

Plan summaries show how you and the plan would share the cost of covered services and answers common questions about benefits.

Female doctor consults a smiling patient in a bright office, showing how trusted care and communication supports better health outcomes.

A network that connects you to thousands of providers

Your PEBB plan uses the Connexus network, one of the largest PPO networks in the state of Oregon. It includes thousands of providers to connect you with care where it’s close to you.

You’ll get the best benefits with in-network providers. If you use out-of-network providers, they may bill you for the difference between your maximum plan allowance and their charges.

Learn about accessing care

Search for providers with Find Care

Coverage outside of the service area

You can find an in-network provider outside of the Connexus service area using Find Care and selecting the Aetna® PPO Network through Aetna Signature Administrators®. You can also call our Health Navigator team at 844-776-1593.

Dual coverage

If you have dual medical coverage under PEBB (for example, as part of a married couple), you can get coverage from both plans. To see examples of how dual coverage works, see our PEBB coverage FAQs.

Injury and surgical care

Are you considering surgery? It’s important to get the care you need. But you should also understand your options.

Some treatments cost less and are less invasive than surgery. Depending on your condition or injury, anti-inflammatory medication, weight loss and modified physical activity can work just as well.

The procedures below have an additional cost tier (ACT) that require a copay in addition to any deductible and coinsurance. This is designed to encourage you to talk to your provider about less invasive treatment options.

  • Arthroscopy
  • Bariatric surgery
  • *Bunionectomy
  • *Hammertoe surgery
  • *Hip replacement
  • *Knee replacement
  • Upper endoscopy
  • Spine surgery for pain
  • Sinus surgery
  • Spine procedures
  • Spinal injections for pain
  • Uncomplicated hernia repair
  • Morton’s Neuroma

Some procedures also require you to be seen at a Center of Excellence or COE. COE’s are facilities and/or a team of professional providers with which Moda Health has contracted and arranged to provide gender affirming facial surgery services. Centers of Excellence follow best practices and have exceptional skills and expertise in managing patients with a specific condition.
The procedures below require you be seen and treated at a COE:

  • Gender Confirming Facial Surgery
  • Bariatric Surgery

Male couple playing with their young son and toys in a living room, highlighting inclusive family care and benefits that support healthy households.

LGBTQIA+ inclusive care benefits

We encourage our LGBTQIA+ members and allies to be their healthiest selves. Your PEBB benefits include inclusive preventive care, mental health support and gender-affirming care.

  • Online or in person, LGBTQIA+-friendly behavioral health resources make it easier to take care of your mental wellness.
  • Transgender and non-conforming members can connect with safe, compassionate providers for a range of gender-affirming treatments.

Find an LGBTQIA+-friendly provider