PEBB HEM Subcommittee Recommendations May 17, 2014 an Additional Cost Tier] OEBB Quality | Services secre! | Providence ae Patni | worgoup, | commision | 2% |peem amet Notes savings | AegumustesRecommendes Treatments SEOW rating | coverage or 7 me Cost savings 10-Pay’ line er Ercse Fron Coreg re ue Tol paar or say coun War 1 ee ee = ee 12 | roteowre |v | sio7.000 exc Vareaee van net cover 8, olde nee 2 reowres | w | $588.00 = [ i suse 1s reteoveres |v __| —s7a.000 Tice Ganglion sugen| 14 [not covered |v | 3228000 [Cite Come, neuromas Raum, as Gams neurones [rewome <2 necovered | vw | _s4e0.00 xc Burionetony 10 | roteovres |v seaio0 Tice Breast reducion | | not covered |v —seeo.c00 Ercude FSC coverage foray Rado tequeney ot covere wher cance, setae Ras 2 covered sesc0o | wihivercancer, Is3,907,| s3.007686 | Exc sscl ont ter Sa RENAL Coe Tar Tarn Goere Sinus surge 6 | 99,500 | sizaoono | Remoorerers | sero [saaraeee | _ss00 ‘meow EBB nt n Resurfacing 0h cost er or 2011- esa ve | Sree ne ssss.o00 | Sehcostterfor 2011. | ssasro9 | sxaooa6s | $500 relacerent OEBR nuded Sa Hp atiopaty | 16 | et seorn.7ar | OCBR nctedin 348 | o 758 | exonzt24 | 3600 Geer nucwar oath | diagnosis possi tein EB Leadeahip Task], aye ssio000 | Sedition copay | s7os00 | s4areeze | sto0 ‘mecing Fercoit | covered foc acrenced meg ‘iftota charges excaes 85000, copay = $500, total charges are les than $5000, copay = $100, Board Document 20110517 Page 1 of 1