PEBB Statewide plan:

• 2023 Member Handbook (PDF)
• 2024 Member Handbook (PDF)

PEBB Choice plan:

• 2023 Member Handbook (PDF)
• 2024 Member Handbook (PDF)

2024 Statewide plan benefit summaries:

• PEBB Statewide plan (PDF)
• PEBB Statewide plan - Spanish (PDF)
• PEBB Statewide +100 plan (PDF)
• PEBB Statewide +100 plan - Spanish (PDF)
• PEBB Statewide prescription drug plan (PDF)
• PEBB Statewide prescription drug plan - Spanish (PDF)
• PEBB Statewide plan (part-time) (PDF)
• PEBB Statewide plan (part-time) - Spanish (PDF)
• PEBB Statewide +100 plan (part-time) (PDF)
• PEBB Statewide +100 plan (part-time) - Spanish (PDF)
• PEBB Statewide prescription drug plan (part-time) (PDF)
• PEBB Statewide prescription drug plan (part-time) - Spanish (PDF)

2024 Choice plan benefit summaries:

• Providence Choice plan (PDF)
• PEBB Choice plan - Spanish (PDF)
• Providence Choice +100 plan (PDF)
• PEBB Choice +100 plan - Spanish (PDF)
• Providence Choice prescription drug plan (PDF)
• PEBB Choice prescription drug plan - Spanish (PDF)
• Providence Choice plan (part-time) (PDF)
• PEBB Choice plan (part-time) - Spanish (PDF)
• Providence Choice +100 plan (part-time) (PDF)
• PEBB Choice +100 plan (part-time) - Spanish (PDF)
• Providence Choice prescription drug plan (part-time) (PDF)
• PEBB Choice prescription drug plan (part-time) - Spanish (PDF)

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)

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.

2024 PEBB Statewide plans SBCs:

• PEBB Statewide (PDF)
• PEBB Statewide - Spanish (PDF)
• PEBB Statewide (part-time) (PDF)
• PEBB Statewide (part-time) - Spanish (PDF)
• PEBB Statewide +100 (PDF)
• PEBB Statewide +100 - Spanish (PDF)
• PEBB Statewide +100 (part-time) (PDF)
• PEBB Statewide +100 - Spanish (part-time)(PDF)

2024 PEBB Choice plans SBCs:

• Providence Choice (PDF)
• PEBB Choice - Spanish (PDF)
• Providence Choice (part-time) (PDF)
• PEBB Choice (part-time) - Spanish (PDF)
• Providence Choice +100 (PDF)
• PEBB Choice +100 - Spanish (PDF)
• Providence Choice +100 (part-time) (PDF)
• PEBB Choice +100 (part-time) - Spanish (PDF)

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)

Request access to your health plan records:

• Member Request to Access Protected Health Information (PDF)

Make changes to your health plan records:

• Member Request to Amend a Designated Record Set (PDF)

Restrict access to your health plan records:

• Member Request to Restrict Access to Designated Record Set (PDF)

Request for confidential communications:

• Request for Confidential Communication (PDF) Oregon

Allow Providence Health Plans to share your protected health information with a third party:

• Member Authorization Form (PDF)

• Transition of Care Request (PDF)

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)

• Prescription Drug Reimbursement Request Form (PDF)
• Prescription Drug Prior Authorization Form (PDF)

• PEBB Medical Home Selection Instruction Flyer (PDF)
• PEBB Medical Home Selection Instruction Flyer - Spanish (PDF)
• Providence Choice Medical Home Selection Form (PDF)

• Travel Reimbursement Form (PDF)