Forms & benefit information
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Member handbooks
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Benefit summaries
2023 Statewide plan benefit summaries:
- PEBB Statewide plan (PDF)
- PEBB Statewide + 100 plan (PDF)
- PEBB Statewide prescription drug plan (PDF)
- PEBB Statewide plan (part-time) (PDF)
- PEBB Statewide + 100 plan (part-time) (PDF)
- PEBB Statewide prescription drug plan (part-time) (PDF)
2023 Choice plan benefit summaries:
- Providence Choice plan (PDF)
- Providence Choice +100 plan (PDF)
- Providence Choice prescription drug plan (PDF)
- Providence Choice plan (part-time) (PDF)
- Providence Choice +100 plan (part-time) (PDF)
- Providence Choice prescription drug plan (part time) (PDF)
2022 Statewide plan benefit summaries:
- PEBB Statewide plan (PDF)
- PEBB Statewide + 100 plan (PDF)
- PEBB Statewide prescription drug plan (PDF)
- PEBB Statewide plan (part-time) (PDF)
- PEBB Statewide + 100 plan (part-time) (PDF)
- PEBB Statewide prescription drug plan (part-time) (PDF)
2022 Choice plan benefit summaries:
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Summaries of Benefits and Coverage (SBCs)
Summaries of Benefits and Coverage, or SBCs, are required under the Affordable Care Act. The intent is to allow an “apples to apples” comparison of medical health plan benefits across carriers. For more information about SBCs, visit HealthCare.gov.
2023 PEBB Statewide plans SBCs:
- PEBB Statewide (PDF)
- PEBB Statewide (part-time) (PDF)
- PEBB Statewide +100 (PDF)
- PEBB Statewide +100 (part-time) (PDF)
2023 PEBB Choice plans SBCs:
- Providence Choice (PDF)
- Providence Choice (part-time) (PDF)
- Providence Choice +100 (PDF)
- Providence Choice +100 (part-time) (PDF)
2022 PEBB Statewide plans SBCs:
- PEBB Statewide (PDF)
- PEBB Statewide (part-time) (PDF)
- PEBB Statewide +100 (PDF)
- PEBB Statewide +100 (part-time) (PDF)
2022 PEBB Choice plans SBCs:
- Providence Choice (PDF)
- Providence Choice (part-time) (PDF)
- Providence Choice +100 (PDF)
- Providence Choice +100 (part-time) (PDF)
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Member authorization & privacy forms
Request access to your health plan records:
Make changes to your health plan records:
Restrict access to your health plan records:
Request for confidential communications:
- Request for Confidential Communication (PDF) Oregon
Allow Providence Health Plans to share your protected health information with a third party:
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Transition of care
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Claims
Most providers bill Providence Health Plan directly, however there may be times when you need to submit a medical claim to Providence. If so, please use these forms:
- Medical Claim Form (also for international claims) (PDF)
- Alternative Care Claim Form (for providers) (PDF)
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Pharmacy
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Medical home selection
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