Pre-Medicare, former employees, surviving dependents, and COBRA participants : option period guide.

              Plan Year 2012
January 1 through December 31, 2012
Health
Dental
Life
Vision
www.sib.ok.gov or www.healthchoiceok.com
State Bird, Scissortailed Flycatcher
State Animal, Buffalo
State Wild Flower, Indian Blanket
State Reptile, Mountain Boomer
Former Employees
Surviving Dependents
and COBRA Participants
OPTION PERIOD Guide
#2557
Oklahoma State and Education
Employees Group Insurance Board
A Division of the Office of State Finance
Update to Printed Version of This Guide
Update to the HMO ZIP Code List on pages 12 and 14:
CommunityCare HMO is available in ZIP Code areas 73141 and 74464.
These rates do not reflect any retirement system contribution
HEALTH PLANS MEMBER SPOUSE CHILD CHILDREN
HealthChoice High $$449.48 $$ 668.10 $$228.20 $$352.08
HealthChoice High Alternative $$449.48 $$ 668.10 $$228.20 $$352.08
HealthChoice Basic $$391.64 $$ 571.84 $$201.82 $$310.80
HealthChoice Basic Alternative $$391.64 $$ 571.84 $$201.82 $$310.80
HealthChoice S-Account $$382.56 $$ 542.52 $$190.18 $$291.90
HealthChoice USA $$688.82 $$ 688.82 $$226.22 $$348.86
CommunityCare Standard HMO $$803.22 $$1,148.58 $$401.60 $$642.56
CommunityCare Alternative HMO $$553.96 $$ 792.14 $$276.98 $$443.16
CommunityCare Wellness Alternative Plus HMO $$528.96 $$ 792.14 $$276.98 $$443.16
GlobalHealth Standard HMO $$402.84 $$ 660.72 $$212.27 $$338.44
GlobalHealth Alternative HMO $$366.24 $$ 600.68 $$193.00 $$307.70
GlobalHealth Wellness Alternative Plus HMO $$341.24 $$ 600.68 $$193.00 $$307.70
UnitedHealthcare Standard HMO $$768.80 $$1,105.36 $$384.12 $$614.72
UnitedHealthcare Alternative HMO $$530.20 $$ 762.32 $$264.90 $$423.94
UnitedHealthcare Wellness Alternative Plus HMO $$505.20 $$ 762.32 $$264.90 $$423.94
DENTAL PLANS MEMBER SPOUSE CHILD CHILDREN
HealthChoice Dental $$30.20 $$30.20 $$25.18 $$65.32
Assurant Freedom Preferred $$28.83 $$28.67 $$21.50 $$57.80
Assurant Heritage Plus with SBA (Prepaid) $$11.74 $$ 8.86 $$ 7.60 $$15.20
Assurant Heritage Secure (Prepaid) $$ 7.20 $$ 5.98 $$ 5.20 $$10.38
CIGNA Dental Care Plan (Prepaid) $$ 9.26 $$ 6.06 $$ 7.08 $$15.32
Delta Dental PPO $$33.64 $$33.62 $$29.26 $$74.04
Delta Dental Premier $$38.36 $$38.36 $$33.38 $$84.46
Delta Dental PPO - Choice $$15.06 $$34.18 $$34.44 $$83.60
Before choosing a plan, it is very important that you review the list of Network Providers
available in your area for that plan. Although a plan may be available in your area, the
number of Network Providers may be limited. See the network provider listing on each plan’s
website or contact their customer service. See Help Lines on page 28 for contact information.
– IMPORTANT – IMPORTANT – IMPORTANT – IMPORTANT –
– IMPORTANT – IMPORTANT – IMPORTANT – IMPORTANT –
Oklahoma State and Education Employees Group Insurance Board
A Division of the Office of State Finance
Monthly Premiums for Former Employees and Surviving Dependents
Plan Year January 1, 2012 - December 31, 2012
Monthly Life Insurance Premiums for Surviving Dependents
SURVIVING DEPENDENTS OF
CURRENT EMPLOYEES
LOW OPTION
$2.60
STANDARD OPTION
$4.32
PREMIER OPTION
$8.64
Spouse $6,000 of coverage $10,000 of coverage $20,000 of coverage
Child (age 6 months to 26) $3,000 of coverage $ 5,000 of coverage $10,000 of coverage
Child (live birth to 6 months) $1,000 of coverage $ 1,000 of coverage $ 1,000 of coverage
SURVIVING DEPENDENTS
OF FORMER EMPLOYEES $0.94 Per $500 Unit, Per Dependent
LIFE PLAN PRE-MEDICARE RETIREE/VESTS
From $5,000 to $40,000 $1.88 Per $1,000
Age-Rated Supplemental Life Cost Per $1,000 for $41,000 and Up
< 30 ---------- $0.03 45 - 49 ------- $0.10 65 - 69 ------- $0.51
30 - 34 ------- $0.03 50 - 54 ------- $0.17 70 - 74 ------- $0.87
35 - 39 ------- $0.04 55 - 59 ------- $0.27 75+ ----------- $1.35
40 - 44 ------- $0.06 60 - 64 ------- $0.31
DEPENDENT LIFE $$0.94 Per $500 Unit, Per Dependent
VISION PLANS MEMBER SPOUSE CHILD CHILDREN
Humana/CompBenefits VisionCare Plan $$6.76 $$5.06 $$3.57 $$ 4.46
Primary Vision Care Services $$9.25 $$8.00 $$8.50 $$10.75
Superior Vision Plan $$7.14 $$7.10 $$6.72 $$13.80
UnitedHealthcare Vision $$8.18 $$5.79 $$4.59 $$ 6.98
Vision Service Plan (VSP) $$8.76 $$5.87 $$5.62 $$12.64
You should have already received a schedule of retiree Option Period meetings. If you
plan to attend one of these meetings, please bring this Guide with you.
Your Option Period Enrollment/Change Form must be postmarked by December 7, 2011.
By law, the premiums for current employees and pre-Medicare former employees must be the same.
For information on how this reduces your premium, see the Frequently Asked Questions section of
the OSEEGIB website and search for blended rates.
Oklahoma State and Education Employees Group Insurance Board
A Division of the Office of State Finance
Monthly Premiums for Former Employees and Surviving Dependents
Plan Year January 1, 2012 - December 31, 2012
*It is OSEEGIB’s policy that for any benefit continued under COBRA, one person must always pay the
primary member premium. In cases where a spouse, child, or children are insured under a particular benefit
and the member did not keep coverage, one person will always be billed at the primary member rate.
HEALTH PLANS MEMBER SPOUSE* CHILD* CHILDREN*
HealthChoice High $$458.47 $$ 681.46 $$232.76 $$359.12
HealthChoice High Alternative $$458.47 $$ 681.46 $$232.76 $$359.12
HealthChoice Basic $$399.47 $$ 583.28 $$205.86 $$317.02
HealthChoice Basic Alternative $$399.47 $$ 583.28 $$205.86 $$317.02
HealthChoice S-Account $$390.21 $$ 553.37 $$193.98 $$297.74
HealthChoice USA $$702.60 $$ 702.60 $$230.74 $$355.84
CommunityCare Standard HMO $$819.28 $$1,171.55 $$409.63 $$655.41
CommunityCare Alternative HMO $$565.04 $$ 807.98 $$282.52 $$452.02
CommunityCare Wellness Alternative Plus HMO $$539.54 $$ 807.98 $$282.52 $$452.02
GlobalHealth Standard HMO $$410.90 $$ 673.93 $$216.52 $$345.21
GlobalHealth Alternative HMO $$373.56 $$ 612.69 $$196.86 $$313.85
GlobalHealth Wellness Alternative Plus HMO $$348.06 $$ 612.69 $$196.86 $$313.85
UnitedHealthcare Standard HMO $$784.18 $$1,127.47 $$391.80 $$627.01
UnitedHealthcare Alternative HMO $$540.80 $$ 777.57 $$270.20 $$432.42
UnitedHealthcare Wellness Alternative Plus HMO $$515.30 $$ 777.57 $$270.20 $$432.42
VISION PLANS MEMBER SPOUSE* CHILD* CHILDREN*
Humana/CompBenefits VisionCare Plan $$6.90 $$5.16 $$3.64 $$ 4.55
Primary Vision Care Services (PVCS) $$9.44 $$8.16 $$8.67 $$10.97
Superior Vision Services $$7.28 $$7.24 $$6.85 $$14.08
UnitedHealthcare Vision $$8.34 $$5.91 $$4.68 $$ 7.12
Vision Service Plan (VSP) $$8.94 $$5.99 $$5.73 $$12.89
DENTAL PLANS MEMBER SPOUSE* CHILD* CHILDREN*
HealthChoice Dental $$30.80 $$30.80 $$25.68 $$66.63
Assurant Freedom Preferred $$29.41 $$29.24 $$21.93 $$58.96
Assurant Heritage Plus with SBA (Prepaid) $$11.97 $$ 9.04 $$ 7.75 $$15.50
Assurant Heritage Secure (Prepaid) $$ 7.34 $$ 6.10 $$ 5.30 $$10.59
CIGNA Dental Care Plan (Prepaid) $$ 9.45 $$ 6.18 $$ 7.22 $$15.63
Delta Dental PPO $$34.31 $$34.29 $$29.85 $$75.52
Delta Dental Premier $$39.13 $$39.13 $$34.05 $$86.15
Delta Dental PPO – Choice $$15.36 $$34.86 $$35.13 $$85.27
Oklahoma State and Education Employees Group Insurance Board
A Division of the Office of State Finance
Monthly Premiums for COBRA Participants and Dependents
Plan Year January 1, 2012 - December 31, 2012
TA BLE OF CONTENTS
YOUR FORM MUST BE POSTMARKED BY DECEMBER 7, 2011
YOUR OPTION PERIOD ENROLLMENT/CHANGE FORM
IS BEING MAILED IN A SEPARATE SECURITY ENVELOPE
The participating carriers reviewed and approved the information in this Guide. There is no guarantee that a provider will remain
within a plan’s network or have open patient slots throughout the year. Please verify your provider’s participation in your plan’s
network.
2012 Plan Changes................................................................................................................... 1
Introduction............................................................................................................................. 4
Helpful Hints for Option Period.............................................................................................. 4
Health, Dental, and Vision Plans................................................................................................... 5
HealthChoice Life Insurance Plan.............................................................................................. 6
American Fidelity Health Services Administration.................................................................. 7
Instructions and Eligibility...................................................................................................... 9
Important Information About Becoming Eligible for Medicare................................................ 11
HMO ZIP Code List............................................................................................................... 12
Summary of Health Plan Deductibles and Out-of-Pocket Limits............................................ 15
Comparison of Benefits for Health Plans................................................................................... 16
Comparison of Benefits for Dental Plans............................................................................... 24
Comparison of Benefits for Vision Plans................................................................................ 26
Help Lines.............................................................................................................................. 28
This publication was printed by the Oklahoma State and Education Employees Group Insurance Board, a division of the Office of
State Finance, as authorized by 74 O.S. Section 1301, et seq. 11,750 copies have been printed at a cost of $0.55 each. Copies
have been deposited with the Publications Clearinghouse of the Oklahoma Department of Libraries.
A text version of this Guide is available on the OSEEGIB website at www.sib.ok.gov or www.healthchoiceok.com. This Guide is
also available in CD format at the Oklahoma Library for the Blind and Physically Handicapped (OLBPH). Contact OLBPH at 1-405-
521-3514, toll-free 1-800-523-0288, or TDD 1-405-521-4672.
This information is only a brief summary of the plans. All benefits and limitations of these plans are governed in all cases by the
relevant plan document, insurance contracts, handbooks, and Rules of the Oklahoma State and Education Employees Group
Insurance Board, a division of the Office of State Finance. The Rules of the Oklahoma Administrative Code, Title 360, are
controlling in all aspects of Plan benefits. No oral statement of any person shall modify or otherwise affect the benefits, limitations,
or exclusions of any plan.
www.sib.ok.gov or www.healthchoiceok.com
1
2012 PLAN CHANGES
Plan changes are indicated by bold text in the Comparison of Benefits charts.
Health Plan Changes
HealthChoice Health Plans
Each year, tobacco use costs the HealthChoice health plans and their members approximately
$52 million. Because these costs affect the premiums of all health plan members, HealthChoice is
encouraging our members to stay or become tobacco-free by freezing the deductibles and out-of-pocket
limits of the HealthChoice High and Basic Plans at 2011 amounts for non-tobacco users.
The HealthChoice High Alternative and HealthChoice Basic Alternative Plans are being introduced
for tobacco users. The individual deductibles and out-of-pocket limits for these two plans are $250
higher than the High and Basic Plans.
To enroll or remain enrolled in the HealthChoice High or Basic Plan for Plan Year 2012, you
must attest that you and your covered dependents are tobacco-free by completing the HealthChoice
High and Basic Plans Tobacco-Free Attestation for Plan Year 2012 by December 7, 2011. The
Attestation is available to you:
♦♦ Online at www.sib.ok.gov or www.healthchoiceok.com
♦♦ Included with your Option Period Enrollment/Change Form
♦♦ By calling HealthChoice Member Services at 1-405-717-8780 or toll-free 1-800-752-9475. TDD users
call 1-405-949-2281 or toll-free 1-866-447-0436.
If you cannot complete the tobacco-free Attestation because you and/or your covered dependents
are not tobacco-free, you can still qualify for the HealthChoice High or HealthChoice Basic plan
if you can show proof of an attempt to quit using tobacco or provide a letter from your doctor. To
qualify for the tobacco-free plans, you must provide one of the following:
♦♦ A letter from Alere Wellbeing indicating you and/or your covered dependents have enrolled in the quit
tobacco program available through the Oklahoma Tobacco Settlement Endowment Trust (TSET) and
Alere Wellbeing within the previous 90 days.
♦♦ A letter from Alere Wellbeing indicating you and/or your covered dependents have completed the quit
tobacco program available through the Oklahoma Tobacco Settlement Endowment Trust (TSET) and
Alere Wellbeing within the previous 90 days.
♦♦ A letter from your doctor indicating it is not medically advisable for you or your covered dependents to
quit tobacco.
The letter from Alere Wellbeing or your doctor must be provided to HealthChoice, 3545 N.W. 58 Street,
Suite 110, Oklahoma City, OK 73112 by December 7, 2011. Be sure to write your name and member ID
number located in Section A of your pre-printed Option Period Enrollment/Change Form on your letter.
If you do not or cannot complete the tobacco-free Attestation or provide one of the letters described
previously, you and your covered dependents will be enrolled in the new HealthChoice High Alternative
Plan or Basic Alternative Plan.
HealthChoice High, High Alternative, Basic, Basic Alternative, S-Account, and USA Plans
♦♦ No limit on visits and treatment days for mental health and substance abuse.
♦♦ Non-Network emergency room visits will be covered at the Network benefit level; however, you are still
responsible for non-covered services and amounts over Allowed Charges.
♦♦ As an enhanced benefit for HealthChoice members, preventive procedures and many other services will
be covered at 100% of Allowed Charges with no out-of-pocket costs when using a Network Provider.
This means no-cost access to:
2
• Blood pressure, diabetes, and cholesterol tests
• Breast, cervical, prostate, and colorectal cancer screenings
• Osteoporosis screening
• Counseling from your health care provider on topics including quitting tobacco, losing weight,
eating healthy, treating depression, and reducing alcohol use
• Prescription tobacco cessation products
• Vaccines for children and adults
• Flu and pneumonia shots
• Screening for obesity and counseling from your doctor and other health professionals to promote
sustained weight loss, including dietary counseling from your doctor
• Screening for conditions that can harm pregnant women or their babies, including iron deficiency,
hepatitis B, a pregnancy related immune condition called Rh incompatibility, and a bacterial
infection called bacteriuria
• Special, pregnancy-tailored counseling from a doctor to help pregnant women quit smoking and
avoid alcohol use
• Counseling to support breast-feeding and help nursing mothers
See the HealthChoice website at www.sib.ok.gov or www.healthchoiceok.com for more details.
HealthChoice High, High Alternative, and USA Plans
♦♦ HealthChoice is implementing a family out-of-pocket limit for the HealthChoice High, High Alternative,
and USA Plans. The family out-of-pocket limit for the High and USA Plans will be $8,400 when using
a Network Provider and $9,900 when using a non-Network Provider. The family out-of-pocket limit
for the High Alternative Plan will be $9,150 when using a Network Provider and $10,650 when using a
non-Network provider.
HealthChoice S-Account Plan
♦♦ The out-of-pocket limits are being lowered to $3,000/individual and $6,000/family.
♦♦ Proof of a Health Savings Account (HSA) is not required to enroll.
♦♦ HealthChoice has contracted with American Fidelity Health Services Administrator to make establishing
and keeping a Health Savings Account easier and more convenient for S-Account members. HSA
deposits are invested in a money market account and all interest is applied to your account. The monthly
maintenance fee is waived as long as you continue to participate through OSEEGIB. See pages 7-8 for
more information.
HealthChoice Pharmacy Benefit
♦♦ Two 90-day courses of certain prescription tobacco cessation products will be covered at 100% with no
cost to members.
♦♦ HealthChoice is introducing a mail order pharmacy benefit and changing the quantity of medication you
can get per copay. A 30-day supply of medication will be covered, when purchased at a retail pharmacy,
for one copay. A 90-day supply of a maintenance medication will be covered for one copay when
purchased through Medco’s mail order service or one of the Network Retail Maintenance Pharmacies.
See the Comparison of Benefits for Health Plans for copay amounts.
Plan changes are indicated by bold text in the Comparison of Benefits charts.
HMOs
CommunityCare Wellness Alternative Plus, GlobalHealth Wellness Alternative Plus, and
UnitedHealthcare Wellness Alternative Plus HMO Plans
♦♦ To be eligible for one of the Wellness Alternative Plus plans, you must complete the Health Risk
Assessment (HRA) available at www.sib.ok.gov or www.healthchoiceok.com. If you completed the
HRA as a HealthChoice member after July 1, 2011, you do not have to complete it again.
♦♦ HMO service areas have changed. See the HMO ZIP Code List on pages 12-14 to check your eligibility.
Vision Plan Changes
Superior Vision Plan
♦♦ For in-Network services, there is a $25 fitting fee copay for standard and specialty fitting of contact
lenses. The Plan then pays 100% for standard fitting and up to $50 for specialty fitting. The fitting fee is
not a covered benefit when out-of-network.
UnitedHealthcare Vision
♦♦ UV coating and tinting will be covered in full when using in-Network providers.
Vision Service Plan (VSP)
♦♦ After a copay of up to $60, a contact lens exam is covered in full when using in-Network providers.
3
There are no dental plan changes for 2012.
INTRO DUCTION
The Oklahoma State and Education Employees Group Insurance Board (OSEEGIB), a division of the Office
of State Finance, produced this Benefit Options Guide to help you select your benefits. It is a summary of the
available plans for the following members who are not yet eligible for Medicare:
♦♦ Former employees and their dependents
♦♦ Surviving dependents
♦♦ COBRA participants
See the Monthly Premium Chart and Comparison of Benefits charts to determine your costs under each plan.
Helpful Hints For Option Period
♦♦ Review the upper right-hand section of your pre-printed Option Period Enrollment/Change Form. This
is the coverage you will have effective January 1, 2012, if you do not make changes during Option
Period and you are not automatically enrolled in one of the HealthChoice alternative plans.
♦♦ Review the premium rates and plan changes for 2012. Premium rates are listed at the front of this Guide
and plan changes are listed on pages 1-3 of this Guide.
♦♦ Use the following resources to help you decide on coverage for yourself and your dependents:
• This Guide
• Plan Websites
• Customer Service Telephone Numbers
• Provider Directories
• OSEEGIB Member Services
♦♦ Check the appropriate box(es) of your Option Period Enrollment/Change Form for the coverage
changes you wish to make effective January 1.
♦♦ Complete your Option Period Enrollment/Change Form and return it to OSEEGIB by December 7,
2011.
♦♦ Review your Confirmation Statement when you receive it in the mail to verify your coverage is correct.
♦♦ Contact OSEEGIB Member Services right away if your Confirmation Statement is incorrect.
♦♦ If you do not make changes to your coverage and you are not automatically enrolled in one of the
HealthChoice alternative palns, you will not receive a Confirmation Statement from OSEEGIB. Keep
your Option Period Enrollment/Change Form as verification of your coverage.
Once enrolled in any of the plans, it is your responsibility to review your benefits carefully so you know
what is covered, as well as the plan’s policies and procedures, before you use your benefits.
Don’t miss out on important mailings!
Keep your address information up-to-date. You can use the Change of Address Form available on the
HealthChoice website or write a letter informing HealthChoice of your new address including the date of the
change, your ID number, and signature.
Mail your completed Change of Address Form or letter to:
OSEGIB
3545 N.W. 58th Street, Suite 110
Oklahoma City, OK 73112
4
HEALTH PLANS
There are 15 health plans available:
• HealthChoice High and High Alternative
Plans
• CommunityCare Standard, Alternative, and
Wellness Alternative Plus HMO
• HealthChoice Basic and Basic Alternative
Plans
• GlobalHealth Standard, Alternative, and Wellness
Alternative Plus HMO
• HealthChoice S-Account Plan • UnitedHealthcare Standard, Alternative, and
• HealthChoice USA Plan* Wellness Alternative Plus HMO
See Comparison of Benefits for Health Plans on pages 16-23 for specific benefit information.
♦♦ There are no preexisting condition exclusions or limitations applied to any of the health plans.
♦�� To be eligible for the HealthChoice High or Basic Plan, you must complete the tobacco-free Attestation
located on the OSEEGIB website or complete and return the Attestation included with your Option
Period form.
♦♦ You must live within an HMO’s ZIP Code service area to be eligible. Post Office Box addresses cannot
be used to determine your HMO eligibility. See pages 12-14 for the HMO ZIP Code List.
♦♦ If you select an HMO, you must use the provider network designated by your plan for Oklahoma.
♦♦ You must complete the HRA through the OSEEGIB website to enroll in an HMO Wellness Alternative
Plus plan.
♦♦ All health plans coordinate benefits with other group insurance plans you have in force. For more
information, check with each health plan.
♦♦ All plans have toll-free numbers for customer service. See Help Lines on page 28.
♦♦ Check with the individual health plan if you have benefit questions.
*Pre-Medicare retirees who live outside of Oklahoma and Arkansas are eligible to enroll in HealthChoice
USA which includes a national provider network. Call HealthChoice for details. See Help Lines on page 28 for
contact information.
DENTA L PLANS
There are eight dental plans available:
• HealthChoice Dental • CIGNA Dental Care Plan (Prepaid)
• Assurant Freedom Preferred • Delta Dental PPO
• Assurant Heritage Plus with SBA (Prepaid) • Delta Dental Premier
• Assurant Heritage Secure (Prepaid) • Delta Dental PPO – Choice
See Comparison of Benefits for Dental Plans on pages 24-25 for specific benefit information.
♦♦ All dental plans have toll-free numbers for customer service. See Help Lines on page 28.
♦♦ Check with the individual dental plan if you have benefit questions.
5
VISION PLANS
There are five vision plans available:
• Humana/CompBenefits VisionCare Plan • UnitedHealthcare Vision
• Primary Vision Care Services (PVCS) • Vision Service Plan (VSP)
• Superior Vision Plan
See Comparison of Benefits for Vision Plans on pages 26-27 for specific benefit information.
♦♦ Verify your vision provider participates in a vision plan’s network by contacting the plan, visiting the
plan’s website, or calling your provider.
♦♦ All vision plans have limited coverage for services provided by out-of-network providers.
♦♦ All plans have toll-free numbers for customer service. See Help Lines on page 28.
♦♦ Check with the individual vision plan if you have benefit questions.
HEALTHCHOICE LIFE INSURANCE PLANS
Please take time this Option Period to consider your life insurance needs. Former employees and
surviving dependents have the following life insurance options:
♦♦ Keep your current amount of life insurance
♦♦ Reduce your amount of life insurance
♦♦ Reduce your amount of dependent life insurance, if enrolled
♦♦ Change beneficiaries (not limited to Option Period)
Your Option Period Enrollment/Change Form will indicate the amounts and types of life insurance
you currently carry. Please take time to evaluate your coverage. Keep in mind that as a former employee or
surviving dependent, you cannot reinstate any life insurance that you decrease or terminate.
Beneficiary Designation
Benefits are paid to your beneficiary in a lump sum. Your beneficiary designation can be changed at any
time. For a Beneficiary Designation Form or more information, contact HealthChoice Member Services. See
Help Lines on page 28 of this Guide. This form is also available on the HealthChoice website at www.sib.
ok.gov or www.healthchoiceok.com. Be aware that life insurance benefits for covered dependents are always
paid to the member.
6
7
HEALTH SAVINGS ACCOUNTS
A Health Savings Account (HSA) is an individually owned savings account that allows you to set aside money
for health care tax-free whenever you select an HSA qualified High Deductible Health Plan (HDHP). Money left in
the account can accumulate interest tax-free and money used to pay for qualified medical expenses can be paid tax-free.
Through your employer’s Section 125 plan, you can make HSA contributions on a pre-tax basis up to the yearly
maximum allowed.
SOME HIGHLIGHTS OF HSAs
♦♦ HSA contributions are tax-free.
♦♦ Interest accrues tax-free.
♦♦ Interest earned is applied to your account starting with the first dollar contribution.
♦♦ Withdrawals are not taxed when funds are used for qualified medical expenses.
♦♦ You decide when and how to use your money.
♦♦ No “use it or lose it” requirement meaning whatever deposits you make each year can be left in the HSA to earn
interest and to be available to pay for future medical expenses.
♦♦ You can pay for qualified medical expenses on yourself, your spouse, or your tax dependents regardless of
whether or not they are covered by your health plan.
♦♦ No matter where you go, your account follows you. Even if you change jobs, change medical coverage, become
unemployed, move to another state, or change your marital status, your HSA goes with you. You own it!
♦♦ If you do not remain a qualified individual, you can continue to earn interest and pay for qualified medical
expenses as long as there are funds in your account.
CONTRIBUTIONS
You can contribute up to the annual maximum amount allowed by law in any given tax-year. The IRS establishes
the maximum amounts on an annual basis. The 2011 maximum allowable is $3,050 for an individual or $6,150 for a
family. Effective January 1st 2012 the maximum allowable will increase to $3,100 for an individual or $6,250 for a
family. If your HDHP is effective on a date other than January 1 and you wish to make the maximum contribution, you
must meet certain requirements. Visit www.afhsa.com for more information.
If you are age 55 and older, you are eligible to make an additional catch-up contribution of $1,000 per year. An
HSA is owned by one individual, so if you and your spouse are covered under the family HDHP and both of you
are age 55 or older, only you as the owner of the account can make the catch up contribution. Your spouse would be
required to establish his or her own HSA to make catch-up contributions.
QUA LIFIED MEDICAL EXPENSES
There are many expenses that qualify for tax-free distributions. For a listing, you can refer to the HSA Eligible
Expenses listed on www.afhsa.com. If you use funds for any expenses that are not eligible, then the funds withdrawn
are subject to income taxes and a 20% additional tax penalty. The non-qualified distributions must be reported on your
annual income tax return.
Additional information on eligible expenses can be found in IRS Publication 502 at www.irs.gov. Even though
Publication 502 is a valuable resource on what qualifies as a medical expense, it addresses only what expenses are
deductible.
MAKING WITHDRAWALS FROM YOUR HSA
You can withdraw funds from your account in three ways:
1. HSA Debit Card
2. On-Line Distribution Request
3. Distribution Form
SB-22136(State of Oklahoma)-0811
8
You can use the money from your HSA as follows:
1. You can only use the funds that have been deposited.
2. You can withdraw funds for qualified medical expenses incurred after the date your account is established.
3. You may elect to make withdrawals from your HSA when expenses are incurred, or you may make
withdrawals for these expenses anytime in the future. There is no time limit.
In order to receive the tax benefit, the IRS requires that you keep records to prove that your HSA funds were used
to pay for qualified medical expenses and that the qualified expense was not reimbursed from another source. Although
you are not required to send your receipts with your tax returns, keeping your receipts with your tax information is an
excellent way to ensure proper documentation. You will receive two forms each year as a result of having an HSA: 1) a
1099-SA which shows the total distributions from your account will be mailed by January 31, and 2) a 5498-SA which
shows total contributions to your account will be mailed by May 31. Each of these forms will also be sent to the IRS.
ELIGIBILITY REQUIREMENTS
To be eligible to establish and contribute to an HSA, you must meet the following requirements:
1. You must be covered by an HSA-qualified HDHP.
2. You cannot be claimed as a dependent on anyone else’s tax return.
3. You cannot be covered under a non-HDHP coverage other than “permitted coverage” or “permitted
insurance” and/or preventative care. Products such as Cancer, Accident, Long Term Care, and Disability
Income are usually considered permitted coverage/insurance. Check with your employer or visit www.irs.
gov to be sure.
4. You cannot have a general purpose Health FSA-Medical Reimbursement Account. However, you can have a
Limited Purpose Health FSA which allows for dental and vision reimbursement only should your employer
offer this benefit. Note: If you are covered under your spouse’s general purpose Health FSA, then you are not
eligible to establish and contribute to an HSA.
5. You cannot be enrolled in Medicare.
INTEREST & ACCOUNT FEES
HSA deposits are invested in a money market account and all interest is applied to your account. The monthly
maintenance fee is waived as long as you continue to be employed by the State of Oklahoma. This fee covers unlimited
account withdrawals, the debit card, and other investment funds for balances above the minimum $2,500 required in the
money market account. A $15 fee will also apply for an additional or replacement debit card.
SUMARY
HSAs give you the savings potential, flexibility, portability, and tax savings unlike any other savings account.
By enrolling in a qualified HDHP, you save on premiums. By investing those savings into an HSA, you can save for
medical expenses in the future.
Individuals who elect an HSA with us will receive a welcome packet outlining all the information associated with
the account. This flyer is meant to provide you high level information on HSAs. For more information on HSAs visit
our website at www.afhsa.com. There you will find an overview specific to employees/individuals along with other
helpful information. You can also find additional information about HSAs in the IRS Publication 969 at www.irs.gov.
CONTA CT INFORMATION
American Fidelity Health Services Administration Toll-Free - 1-866-326-3600
2000 N. Classen Blvd, Suite G16 Fax - (405) 523-5072
Oklahoma City, OK 73125 Web site - www.afhsa.com
(405) 523-5699 – Local Number email - HSA-Suppost@af-group.com
American Fidelity Health Services Administration and its affiliates do not provide legal or tax advice. The information provided here is general in nature and
should not be considered legal or tax advice. We recommend you consult with your tax or legal counsel about your personal situation.
SB-22136(State of Oklahoma)-0811
INSTRU CTIONS AND ELIGIBILITY
Former employees (retired, vested, and non-vested), COBRA participants, and surviving dependents can make
certain changes during Option Period:
Former employees and surviving dependents can:
♦♦ Change health and/or dental plans that are currently in place
♦♦ Drop coverage and/or dependents
♦♦ Decrease life insurance coverage
♦♦ Enroll in or change vision plans
COBRA participants can:
♦♦ Add eligible dependents up to age 26
♦♦ Add or change coverage (health, dental, and/or vision) as long as your former employer participates in that
benefit
♦♦ Drop benefits and/or dependents
The benefits you select will be in effect from January 1, 2012, through December 31, 2012. After enrollment, the
plans you have selected will provide more information about your benefits.
Once enrolled in any of the plans, it is your responsibility to review your benefits carefully so you know what
is covered, as well as the plan’s policies and procedures, before you use your benefits.
Dependents
If one eligible dependent is covered, all eligible dependents must be covered. You can choose not to cover
dependents who do not reside with you, are married, are not financially dependent on you for support, have other group
coverage, or are eligible for Indian or military health benefits. Eligible dependents include:
• Your legal spouse (including common-law).
• Your daughter, son, stepdaughter, stepson, eligible foster child, adopted child, or child legally placed with
you for adoption up to age 26, whether married or unmarried.
• A dependent, regardless of age, who is incapable of self-support due to a disability that was diagnosed prior
to age 26. Subject to medical review and approval.
• Other unmarried dependent children up to age 26, upon completion of an Application for Coverage for
Other Dependent Children. Guardianship papers or a tax return showing dependency may be provided in
lieu of the application.
♦♦ If your spouse is enrolled separately in one of the OSEEGIB plans, your dependents can be covered under one
parent’s health, dental, and/or vision plan (but not both); however, both parents can cover dependents under
Dependent Life insurance.
♦♦ Dependents can only be enrolled in the same types of coverage and in the same plans you have.
♦♦ To enroll your newborn, a letter requesting coverage of the newborn must be sent to OSEEGIB within 30 days
of the birth. If you are a former employee or surviving spouse and do not enroll your newborn during this 30-
day period, you cannot do so at a later date. If you are a COBRA participant and do not enroll your newborn
during this 30-day period, you will not be able to do so until the next annual Option Period. Direct notification
to a plan will not enroll your newborn or any other dependents. The newborn’s Social Security number is not
required at the time of initial enrollment, but must be provided once it is received from the Social Security
Administration. Insurance premiums for the month the child was born must be paid. Under the HealthChoice
plans, a separate deductible and coinsurance may apply.
♦♦ Without enrollment, newborns are covered only for the first 48 hours following a vaginal birth or the first 96
9
hours following a cesarean section birth. Deductible and coinsurance may apply.
Excluding Dependents From Coverage
♦♦ You can exclude your spouse from health and/or dental coverage while covering other dependents on these
benefits. Your spouse must sign the Spouse Exclusion Certification section of the Option Period Enrollment/
Change Form.
♦♦ You can exclude your spouse or other dependents who do not reside with you, are married, are not financially
dependent on you for support, have other group coverage, or are eligible for Indian or military health benefits.
Note: Your spouse cannot be excluded from vision coverage if your other dependents are covered unless your spouse
has proof of other group vision coverage.
COBRA Coverage
COBRA coverage may be available to dependents who become ineligible. Examples of COBRA qualifying
events for dependents include:
♦♦ Reaching age 26 (applies only to dependent children)
♦♦ Divorce of a spouse
♦♦ Death of the covered employee
10
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Important Information About Becoming Eligible for Medicare
Eligible for Medicare Prior to Turning 65
If you are under age 65 and become eligible for Medicare, you must notify OSEEGIB to begin the enrollment
process into a Medicare supplement or Medicare Advantage Prescription Drug (MA-PD) plan. You will be asked
to provide your Medicare ID number as it appears on your Medicare card. Depending on the plan you’re enrolled in,
you may have different options for your Medicare supplement or MA-PD coverage. Your Medicare supplement or
MA-PD coverage will become effective the date you become eligible for Medicare or the first of the month after you
complete the enrollment process, whichever is later.
Aging into Medicare
About two months before you or one of your eligible dependents turn 65, OSEEGIB will send you a letter that
explains the Medicare plan options available to you. The letter will also provide instructions on how to enroll with a
Medicare supplement or MA-PD plan.
If you are enrolled in HealthChoice, you will automatically be enrolled in the HealthChoice Employer PDP High
Option Medicare Supplement Plan With Part D. If you are enrolled in an HMO, you can enroll in either its Medicare
supplement (if available) or MA-PD Plan (if available in your service area). If you or one of your dependents will soon
become Medicare eligible, watch your mail for this important enrollment information.
All Medicare Eligible Members
OSEEGIB Rules state that all covered individuals who are eligible for Medicare, except current employees, must
be enrolled in a Medicare supplement or MA-PD plan offered through OSEEGIB, regardless of age. To maximize your
benefits, you need to enroll in Medicare Part B. The HealthChoice Medicare Supplement plans do not require you to
be enrolled in Part B, but pay as though you are enrolled in Part B. All other Medicare supplement plans and MA-PD
plans offered through OSEEGIB require you to have both Medicare Part A and Part B.
Notice of Creditable Coverage
If you’re a former employee who is already eligible or will soon become eligible for Medicare, you may be hearing
a lot about Medicare Part D prescription drug plans and Creditable Coverage.
The term Creditable Coverage as it applies to Medicare Part D simply means that the prescription drug benefits of
an insurance plan meet certain standards that have been set by the Centers for Medicare and Medicaid Services (CMS).
All HealthChoice prescription drug benefits meet or exceed the standards set by CMS; therefore, the HealthChoice
plans provide our members with Creditable Coverage. Additionally, all other health plans offered through OSEEGIB
provide Creditable Coverage.
Since you have Creditable Coverage through one of the plans offered through OSEEGIB, you will not be subject
to Medicare’s late enrollment penalty for Part D if you decide to drop your coverage through OSEEGIB and enroll in
another Medicare Part D prescription drug plan.
For more information about Creditable Coverage for Part D, contact HealthChoice Member Services. See Help
Lines on page 28.
12
HMO ZIP Code List
C = CommunityCare G = GlobalHealth U = UnitedHealthcare
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72761 C G 73039 G U 73079 G U 73118 C G U 73160 C G U 73437 G U 73528 G U
73001 G U 73040 G U 73080 G U 73119 C G U 73162 C G U 73438 G U 73529 G U
73002 G U 73041 G U 73081 G U 73120 C G U 73163 C G U 73439 G U 73530 G U
73003 C G U 73042 G U 73082 G U 73121 C G U 73164 C G U 73440 G U 73531 G U
73004 G U 73043 G U 73083 C G U 73122 C G U 73165 C G U 73441 G U 73532 G U
73005 G U 73044 C G U 73084 C G U 73123 C G U 73167 C G U 73442 G U 73533 G U
73006 G U 73045 C G U 73085 C G U 73124 C G U 73169 C G U 73443 G U 73534 G U
73007 C G U 73046 G U 73086 G U 73125 C G U 73170 C G U 73444 G U 73536 G U
73008 C G U 73047 G U 73087 G U 73126 C G U 73172 C G U 73446 G U 73537 G U
73009 G U 73048 G U 73088 G U 73127 C G U 73173 C G U 73447 G U 73538 G U
73010 G U 73049 C G U 73089 G U 73128 C G U 73175 G 73448 G U 73539 G U
73011 G U 73050 C G U 73090 C G U 73129 C G U 73177 C G U 73449 G U 73540 G U
73012 G U 73051 C G U 73091 G U 73130 C G U 73178 C G U 73450 G U 73541 G U
73013 C G U 73052 G U 73092 G U 73131 C G U 73179 C G U 73451 G 73542 G U
73014 C G U 73053 G U 73093 G U 73132 C G U 73180 C G U 73453 G U 73543 G U
73015 G U 73054 C G U 73094 G U 73134 C G U 73184 C G U 73455 G U 73544 G U
73016 G U 73055 G U 73095 G U 73135 C G U 73185 C G U 73456 G U 73546 G U
73017 G U 73056 C G U 73096 G U 73136 C G U 73189 C G U 73458 G U 73547 G U
73018 G U 73057 G U 73097 C G U 73137 C G U 73190 C G U 73459 G U 73548 G U
73019 C G U 73058 C G U 73098 G U 73139 C G U 73193 C G U 73460 G U 73549 G U
73020 C G U 73059 G U 73099 C G U 73140 C G U 73194 C G U 73461 G U 73550 G U
73021 G U 73061 C G U 73100 G U 73141 C G U 73195 C G U 73463 G U 73551 G U
73022 C G U 73062 G U 73101 C G U 73142 C G U 73196 C G U 73476 G U 73552 G U
73023 G U 73063 C G U 73102 C G U 73143 C G U 73197 C G U 73481 G U 73553 G U
73024 G U 73064 C G U 73103 C G U 73144 C G U 73198 C G U 73487 G U 73554 G U
73025 G U 73065 G U 73104 C G U 73145 C G U 73199 C G U 73488 G U 73555 G U
73026 C G U 73066 C G U 73105 C G U 73146 C G U 73210 G 73491 G U 73556 G U
73027 C G U 73067 G U 73106 C G U 73147 C G U 73251 G 73501 G U 73557 G U
73028 C G U 73068 C G U 73107 C G U 73148 C G U 73401 G U 73502 G U 73558 G U
73029 G U 73069 C G U 73108 C G U 73149 C G U 73402 G U 73503 G U 73559 G U
73030 G U 73070 C G U 73109 C G U 73150 C G U 73403 G U 73505 G U 73560 G U
73031 G U 73071 C G U 73110 C G U 73151 C G U 73422 G 73506 G U 73561 G U
73032 G U 73072 C G U 73111 C G U 73152 C G U 73425 G U 73507 G U 73562 G U
73033 G U 73073 C G U 73112 C G U 73153 C G U 73430 G U 73520 G U 73564 G U
73034 C G U 73074 G U 73113 C G U 73154 C G U 73432 G U 73521 G U 73565 G U
73035 G U 73075 G U 73114 C G U 73155 C G U 73433 G U 73522 G U 73566 G U
73036 C G U 73076 G U 73115 C G U 73156 C G U 73434 G U 73523 G U 73567 G U
73037 C G 73077 C G U 73116 C G U 73157 C G U 73435 G U 73526 G U 73568 G U
73038 G U 73078 C G U 73117 C G U 73159 C G U 73436 G U 73527 G U 73569 G U
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73570 G U 73666 G U 73750 G U 73858 G U 74023 C G U 74070 C G U 74131 C G U
73571 G U 73667 G U 73753 G U 73859 G U 74026 G U 74071 C G U 74132 C G U
73572 G U 73668 G U 73754 G U 73860 G U 74027 C G U 74072 C G U 74133 C G U
73573 G U 73669 G U 73755 G U 73901 G U 74028 C G U 74073 C G U 74134 C G U
73575 G U 73673 G U 73756 G U 73931 G U 74029 C G U 74074 C G U 74135 C G U
73589 G 73701 G U 73757 C G U 73932 G U 74030 C G U 74075 C G U 74136 C G U
73601 G U 73702 G U 73758 G U 73933 G U 74031 C G U 74076 C G U 74137 C G U
73597 G 73703 G U 73759 G U 73937 G U 74032 C G U 74077 C G U 74138 G
73620 G U 73705 G U 73760 G U 73938 G U 74033 C G U 74078 C G U 74141 C G U
73622 G U 73707 G 73761 G U 73939 G U 74034 C G U 74079 G U 74145 C G U
73624 G U 73706 G U 73762 G U 73942 G U 74035 C G U 74080 C G U 74146 C G U
73625 G U 73716 G U 73763 G U 73944 G U 74036 C G U 74081 C G U 74147 C G U
73626 G U 73717 G U 73764 G U 73945 G U 74037 C G U 74082 C G U 74148 C G U
73627 G U 73718 G U 73766 G U 73946 G U 74038 C G U 74083 C G U 74149 C G U
73628 G U 73719 G U 73768 G U 73947 G U 74039 C G U 74084 C G U 74150 C G U
73632 G U 73720 G U 73770 G U 73949 G U 74041 C G U 74085 C G U 74152 C G U
73637 G 73722 G U 73771 G U 73950 G U 74042 C G U 74100 G U 74153 C G U
73638 G U 73724 G U 73772 G U 73951 G U 74043 C G U 74101 C G U 74155 C G U
73639 G U 73725 GU 73773 G U 74001 C G U 74044 C G U 74102 C G U 74156 C G U
73641 G U 73726 G U 73801 G U 74002 C G U 74045 C G U 74103 C G U 74157 C G U
73642 G U 73727 G U 73802 G U 74003 C G U 74046 C G U 74104 C G U 74158 C G U
73644 G U 73728 G U 73820 G 74004 C G U 74047 C G U 74105 C G U 74159 C G U
73645 G U 73729 G U 73832 G U 74005 C G U 74048 C G U 74106 C G U 74169 C G U
73646 G U 73730 G U 73834 G U 74006 C G U 74050 C G U 74107 C G U 74170 C G U
73647 G U 73731 G U 73835 G U 74008 C G U 74051 C G U 74108 C G U 74171 C G U
73648 G U 73733 G U 73838 G U 74009 C G U 74052 C G U 74110 C G U 74172 C G U
73650 G U 73734 G U 73840 G U 74010 C G U 74053 C G U 74112 C G U 74182 C G U
73651 G U 73735 G U 73841 G U 74011 C G U 74054 C G U 74114 C G U 74183 C G U
73654 G U 73736 G U 73842 G U 74012 C G U 74055 C G U 74115 C G U 74184 C G U
73655 G U 73737 G U 73843 G U 74013 C G U 74056 C G U 74116 C G U 74186 C G U
73656 G U 73738 G U 73844 G U 74014 C G U 74058 C G U 74117 C G U 74187 C G U
73657 G 73739 G U 73847 G U 74015 C G U 74059 C G U 74119 C G U 74189 C G U
73658 G U 73741 G U 73848 G U 74016 C G U 74060 C G U 74120 C G U 74192 C G U
73659 G U 73742 G U 73849 G U 74017 C G U 74061 C G U 74121 C G U 74193 C G U
73660 G U 73743 G U 73851 G U 74018 C G U 74062 C G U 74126 C G U 74194 C G U
73661 G U 73744 G U 73852 G U 74019 C G U 74063 C G U 74127 C G U 74301 C G U
73662 G U 73746 G U 73853 G U 74020 C G U 74066 C G U 74128 C G U 74306 G
73663 G U 73747 G U 73855 G U 74021 C G U 74067 C G U 74129 C G U 74317 G
73664 G U 73749 G U 73857 G U 74022 C G U 74068 C G U 74130 C G U 74330 C G U
HMO ZIP Code List
C = CommunityCare G = GlobalHealth U = UnitedHealthcare
14
continued from previous page
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74331 G U 74421 C G U 74466 C G U 74559 C G U 74722 G U 74825 G U 74877 C G
74332 C G U 74422 C G U 74467 C G U 74560 C G U 74723 G U 74826 C G U 74878 C G U
74333 C G U 74423 C G U 74468 C G U 74561 C G U 74724 G U 74827 G U 74880 C G U
74335 C G U 74425 C G U 74469 C G U 74562 C G U 74726 G U 74829 G U 74881 G U
74336 C G 74426 C G U 74470 C G U 74563 C G U 74727 C G U 74830 C G U 74883 G U
74337 C G U 74427 C G U 74471 C G U 74565 C G U 74728 G U 74831 G U 74884 C G U
74338 C G 74428 C G U 74472 C G U 74567 C G U 74729 G U 74832 G U 74901 C G
74339 C G U 74429 C G U 74477 C G U 74569 G U 74730 G U 74833 G U 74902 C G
74340 C G U 74430 C G U 74501 C G U 74570 C G U 74731 G U 74834 G U 74930 C G
74342 C G 74431 C G U 74502 C G U 74571 C G U 74733 G U 74836 G U 74931 C G
74343 C G U 74432 C G U 74521 C G U 74572 G U 74734 G U 74837 C G U 74932 C G
74344 C G 74434 C G U 74522 C G U 74574 C G U 74735 C G U 74838 C G 74935 C G
74345 G 74435 C G 74523 C G U 74576 C G U 74736 G U 74839 G U 74936 C G
74346 C G 74436 C G U 74525 G U 74577 C G 74737 G U 74840 C G U 74937 C G
74347 C G 74437 C G U 74526 C G U 74578 C G U 74738 C G U 74842 G U 74939 C G
74349 C G U 74438 C G U 74528 C G U 74601 G U 74740 G U 74843 G U 74940 C G
74350 C G U 74439 G U 74529 C G U 74602 G U 74741 G U 74844 G U 74941 C G U
74352 C G U 74440 C G U 74530 G U 74603 G U 74743 C G U 74845 C G U 74942 C G
74353 C G U 74441 C G U 74531 G U 74604 G U 74745 G U 74848 G U 74943 C G U
74354 C G U 74442 C G U 74533 G U 74630 C G U 74747 G U 74849 C G U 74944 C G U
74355 C G U 74444 C G U 74534 G U 74631 G U 74748 G U 74850 G U 74945 C G
74358 C G U 74445 C G U 74535 G U 74632 G U 74750 G U 74851 C G U 74946 C G
74359 C G 74446 C G U 74536 C G U 74633 C G U 74752 G U 74852 C G U 74947 C G
74360 C G U 74447 C G U 74538 G U 74636 G U 74753 G U 74854 C G U 74948 C G
74361 C G U 74450 C G U 74540 G U 74637 C G U 74754 G U 74855 G U 74949 C G
74362 C G U 74451 C G U 74542 G U 74640 G U 74755 G U 74856 G U 74951 C G
74363 C G U 74452 C G U 74543 C G U 74641 G U 74756 G C U 74857 C G U 74953 C G
74364 C G U 74454 C G U 74545 C G U 74643 G U 74759 C G U 74859 G U 74954 C G
74365 C G U 74455 C G U 74546 C G U 74644 C G U 74760 C G U 74860 G U 74955 C G
74366 C G U 74456 C G U 74547 C G U 74646 G U 74761 C G U 74864 G U 74956 C G
74367 C G U 74457 C G 74548 C G U 74647 G U 74764 G U 74865 G U 74957 C G U
74368 C G 74458 C G U 74549 C G 74650 C G U 74766 G U 74866 C G U 74959 C G
74369 C G U 74459 C G U 74552 C G U 74651 C G U 74801 C G U 74867 C G U 74960 C G
74370 C G U 74460 C G U 74553 C G U 74652 C G U 74802 C G U 74868 C G U 74962 C G
74401 C G U 74461 C G U 74554 C G U 74653 C G U 74804 C G U 74869 G U 74963 G U
74402 C G U 74462 C G U 74555 G U 74701 G U 74818 C G U 74871 G U 74964 C G
74403 C G U 74463 C G U 74556 G U 74702 G U 74820 G U 74872 G U 74965 C G
74406 G 74464 C G U 74557 C G U 74720 G U 74821 G U 74873 C G U 74966 C G
74408 G 74465 C G U 74558 C G U 74721 G U 74824 G U 74875 G U
HMO ZIP Code List
C = CommunityCare G = GlobalHealth U = UnitedHealthcare
Health Plans
Calendar Year Health
Plan Deductible
(Network)
Calendar Year
Out-of-Pocket Limit
HealthChoice High
$500/Individual
$2,800/Individual – Network
$3,300/Individual –
Non-Network + amounts above Allowed
Charges
$1,500/Family
(3 or more members)
$8,400/Family – Network
$9,900/Family non-Network + amounts
above Allowed Charges
HealthChoice High
Alternative
$750/Individual
$3,050/Individual – Network
$3,550/Individual –
Non-Network + amounts above Allowed
Charges
$2,250/Family
(3 or more members)
$9,150/Family – Network
$10,650/Family non-Network + amounts
above Allowed Charges
HealthChoice Basic
$500/Individual $5,500/Individual
$1,000/Family
(2 or more members)
$11,000/Family
(2 or more members)
HealthChoice Basic
Alternative
$750/Individual $5,750/Individual
$1,500/Family
(2 or more members)
$11,500/Family
(2 or more members)
HealthChoice
S-Account*
$1,500/Individual (applies to
medical and pharmacy) $3,000/Individual
$3,000/Family (applies to medical
and pharmacy) $6,000/Family
All Standard
HMO Plans
$0/Individual $2,500/Individual
$0/Family $5,000/Family
All Alternative
HMO Plans
$0/Individual See the Comparison of Benefits for Health
$0/Family Plans on the next page
All HMO Wellness
Alternative Plus Plans
$0/Individual See the Comparison of Benefits for Health
Plans on the next page
$0/Family
Summary of Health Plan Deductibles and
Out-of-Pocket Limits
*Individual or family deductible must be met before benefits are paid. Also, the individual or family out-of-pocket
maximum must be met before the plan pays 100% of Allowed Charges for the rest of the calendar year.
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Plan Year 2012 Comparison Chart 16
COMPARISON OF BENEFITS FOR HEALTH PLANS
*The $30 copay applies to general practioners, internal medicine physicians, OB/GYNs, pediatricians, physician assistants,
and nurse practitioners. Plan changes are indicated by bold text.
Your Costs
for Network
Services
HealthChoice
High, High Alternative,
and USA Plans
HealthChoice
Basic and Basic
Alternative Plans
HealthChoice
S-Account Plan
Calendar Year
Deductibles
High and USA Plans
$500 individual
$1,500 family
Basic Plan
$500 individual
$1,000 family
Applies after Plan pays first $500
of Allowed Charges
$1,500 individual
$3,000 family
The combined medical and
pharmacy deductible must be
High Alternative Plan met before benefits are paid
$750 individual
$2,250 family
Basic Alternative Plan
$750 individual
$1,500 family
Applies after Plan pays first
$250 of Allowed Charges
Calendar Year
Out-of-Pocket
Limit
High and USA Plans
$2,800 Network individual
$8,400 Network family
$3,300 non-Network individual
$9,900 non-Network family, plus
amounts over Allowed Charges
Basic Plan
$5,500 individual
$11,000 family
$3,000 individual
$6,000 family
Non-Network charges do not
apply
High Alternative Plan
$3,050 Network individual
$9,150 Network family
$3,550 non-Network individual
$10,650 non-Network family, plus
amounts over Allowed Charges
Basic Alternative Plan
$5,750 individual
$11,500 family
Office Visit
(Professional
Services)
$30 copay/physician office visit*
$50 copay/specialist office visit
•Copays do not apply
•All services, benefits, exceptions,
limitations, and conditions are
identical to the HealthChoice
High Plan
Basic Plan
•$0 the first $500 of Allowed
Charges
•100% of the next $500 of
Allowed Charges (deductible)
Only Allowed Charges apply to
the deductible
Basic Alternative Plan
•$0 the first $250 of Allowed
Charges
•100% of the next $750 of
Allowed Charges (deductible)
Only Allowed Charges apply to
the deductible
Both Basic Plans
•50% of the next $10,000 of
Allowed Charges
•$0 of Allowed Charges over the
individual or family out-of-pocket
limit
•No deductible for well child
care visit.
•You may use non-Network
providers, but it will be more
costly*
You pay 100% of Allowed
Charges until deductible is met
$50 office visit copay applies
after deductible
Diagnostic X-ray
and Lab
20% of Allowed Charges after
deductible
20% of Allowed Charges after
deductible
Hospital
Inpatient
Admission
20% of Allowed Charges after
deductible
Additional $300 deductible per
non-Network admission
20% of Allowed Charges after
deductible
Additional $300 deductible
per non-Network admission
Hospital
Outpatient Visit
20% of Allowed Charges after
deductible
20% of Allowed Charges after
deductible
Well Child
Care Visit
$0 copay; no deductible $0 copay; no deductible
applies
Immunizations
No charge for well child and adult
immunizations
$30/$50 office visit copay and/or
administration fee may apply
No charge for well child and
adult immunizations
$50 office visit copay and/or
administration fee may apply
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17 Plan Year 2012 Comparison Chart
COMPARISON OF BENEFITS FOR HEALTH PLANS
HMO Standard
Option
CommunityCare
Alternative
& Wellness
Alternative Plus
HMO
GlobalHealth
Alternative
and Wellness
Alternative Plus
HMO
UnitedHealthcare
Alternative
and Wellness
Alternative Plus
HMO
Your Costs
for Network
Services
No deductible No deductible No deductible No deductible
Calendar Year
Deductibles
Wellness Alternative
Plus
To be eligible for
this Plan, you must
complete a Health
Risk Assessment For
instructions, see page
2
Wellness Alternative
Plus
To be eligible for
this Plan, you must
complete a Health
Risk Assessment. For
instructions, see page
2
Wellness Alternative
Plus
To be eligible for
this Plan, you must
complete a Health
Risk Assessment. For
instructions, see page
2
$2,500 individual
$5,000 family
$3,000 individual
$6,000 family
$3,000 individual
$5,000 family
$2,500 individual
$5,000 family
Calendar Year
Out-of-Pocket
Limit
$30 copay/PCP
$40 copay/specialist
$35 copay/PCP
$50 copay/specialist
$25 copay/PCP
$50 copay/specialist
$35 copay/PCP
$50 copay/specialist Office Visit
(Professional
Services)
No copay for laboratory
services or outpatient
radiology
$150 copay per MRI,
CAT, MRA, or PET
scan
No additional copay for
laboratory services or
outpatient radiology
$200 copay per MRI,
CAT, MRA, or PET
scan
$0 copay
$250 copay per MRI,
MRA, PET, CAT, or
nuclear scan
$0 copay for standard
lab and radiology
$200 copay per MRI,
MRA, PET, CAT, or
nuclear scan
Diagnostic X-ray
and Lab
$350 copay
Preauthorization
required
$500 copay
Preauthorization
required
$250 copay per day
$750 maximum per
admission
Preauthorization
required
$1,000 copay/admission
Hospital
Inpatient
Admission
$250 copay
Preauthorization
required
$300 copay $250 copay
Preauthorization
required
$500 copay Hospital
Outpatient Visit
$0 copay $0 copay $0 copay ages 0 – 21 $0 copay
Well Child
Care Visit
$0 copay ages birth
through age 18
$0 copay ages 19 and
over
$0 copay ages birth
through age 18 years
$0 copay ages 19 and
over
When medically
necessary
$0 copay
Office visit copay may
apply
$0 copay
In accordance with the
US Preventive Services
Task Force and other
health organizations
required guidelines
Immunizations
Plan changes are indicated by bold text.
This is only a sample of the services covered by each plan. For services that are not listed in this comparison
chart, contact each plan. See Help Lines on page 28 of this guide for contact information.
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Plan Year 2012 Comparison Chart 18
COMPARISON OF BENEFITS FOR HEALTH PLANS
This is only a sample of the services covered by each plan. For services that are not listed in this comparison
chart, contact the plan. See Help Lines on page 28 of this guide for contact information.
Plan changes are indicated by bold text.
Your Costs
for Network
Services
HealthChoice
High, High Alternative
and USA Plans
HealthChoice
Basic and Basic
Alternative Plans
HealthChoice
S-Account Plan
Periodic Health
Exams
$0 copay for one preventive
service office visit per
calendar year for members and
dependents age 20 and older
One mammogram per year at no
charge for women age 40 and
older
$0 copay for one preventive
service office visit per calendar
year for members and
dependents age 20 and older
One mammogram per year at no
charge for women age 40 and
over
•Copays do not apply
•All services, benefits,
exceptions, limitations, and
conditions are identical to the
HealthChoice High Plan
Basic Plan
•$0 the first $500 of Allowed
Charges
•100% of the next $500 of
Allowed Charges (deductible)
Only Allowed Charges apply to
the deductible
Basic Alternative Plan
•$0 the first $250 of Allowed
Charges
•100% of the next $750 of
Allowed Charges (deductible)
Only Allowed Charges apply to
the deductible
Both Basic Plans
•50% of the next $10,000 of
Allowed Charges
•$0 of Allowed Charges over
the individual or family out-of-pocket
limit
•You may use non-Network
providers, but it will be more
costly
$0 copay for one preventive
service office visit per calendar
year for members and
dependents age 20 and older
One mammogram per year at no
charge for women age 40 and
older
Allergy
Treatment and
Testing
20% of Allowed Charges after
deductible
Limit: 60 tests every 24 months
20% of Allowed Charges after
deductible
Limit: 60 tests every 24 months
Emergency
Health Care
Facility
Visit
20% of Allowed Charges after
deductible
Additional $100 ER deductible
– waived if admitted
20% of Allowed Charges after
deductible
Additional $100 ER deductible
– waived if admitted
After Hours
Urgent Care
20% of Allowed Charges after
deductible
20% of Allowed Charges after
deductible
Mental Health or
Substance Abuse
Inpatient
Admission
20% of Allowed Charges after
deductible
No limit on the number of
days per year
20% of Allowed Charges after
deductible
No limit on the number of
days per year
Mental Health or
Substance Abuse
Outpatient
Visit
20% of Allowed Charges after
deductible
No limit on the number of
visits per year
20% of Allowed Charges after
deductible
No limit on the number of
visits per year
Durable Medical
Equipment (DME)
20% of Allowed Charges after
deductible for purchase, rental,
repair, or replacement
20% of Allowed Charges after
deductible for purchase, rental,
repair, or replacement
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19 Plan Year 2012 Comparison Chart
COMPARISON OF BENEFITS FOR HEALTH PLANS
HMO Standard
Option
CommunityCare
Alternative
& Wellness
Alternative Plus
HMO
GlobalHealth
Alternative
and Wellness
Alternative Plus
HMO
UnitedHealthcare
Alternative
and Wellness
Alternative Plus
HMO
Your Costs
for Network
Services
$0 copay per visit for
routine physicals
$0 copay $0 copay/PCP
Limit: One per year
$0 copay
In accordance with the
US Preventive Services
Task Force and other
health organizations
required guidelines
Periodic Health
Exams
$30 copay/PCP
$40 copay/specialist
$30 serum and shots
including a 6-week
supply of antigen
$35 copay/PCP
$50 copay/specialist
$30 serum and shots
including a 6-week
supply of antigen
$25 copay/PCP
$50 copay/specialist
$30 serum and shots
including a 6-week
supply of antigen
$35 copay/PCP
$50 copay/specialist
$35 serum and shots
including a 6-week
supply of antigen
Allergy
Treatment and
Testing
$150 copay; waived if
admitted
$200 copay; waived if
admitted
$150 copay; waived if
admitted
$200 copay; waived if
admitted Emergency
Health Care
Facility
Visit
$40 copay per visit $50 copay per visit
Preauthorization
required
$25 copay/PCP
$50 copay/all others
Must use Network
facilities
$50 copay per visit
After Hours
Urgent Care
$350 copay $500 copay
Must be preauthorized
and approved through
CCOK Behavioral
Health Services
$250 per day
$750 maximum per
admission
Must be preauthorized
$1,000 copay per
admission Mental Health or
Substance Abuse
Inpatient
Admission
$30 copay/PCP
$40 copay/specialist
$35 copay/PCP
$50 copay/specialist
Must be preauthorized
and approved through
CCOK Behavioral
Health Services
$25 copay
Must be preauthorized
$35 copay/PCP and
specialist Mental Health or
Substance Abuse
Outpatient
Visit
20% coinsurance initial
device
20% coinsurance repair
and replacement
20% coinsurance initial
device
20% coinsurance repair
and replacement
20% coinsurance 20% coinsurance
$10,000 maximum
benefit per calendar
year
Durable Medical
Equipment (DME)
This is only a sample of the services covered by each plan. For services that are not listed in this comparison
chart, contact the plan. See Help Lines on page 28 of this guide for contact information.
Plan changes are indicated by bold text.
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Plan Year 2012 Comparison Chart 20
COMPARISON OF BENEFITS FOR HEALTH PLANS
Plan changes are indicated by bold text.
Your Costs
for Network
Services
HealthChoice
High, High Alternative,
and USA Plans
HealthChoice
Basic and Basic
Alternative Plans
HealthChoice
S-Account Plan
Occupational and
Speech Therapy
Visits
20% of Allowed Charges after
deductible
Occupational therapy*
Limit: 20 visits per year without
certification
Speech therapy*
Certification not required for
age 18 and older
*Maximum of 60 visits per year
•Copays do not apply
•All services, benefits,
exceptions, limitations, and
conditions are identical to the
HealthChoice High Plan
Basic Plan
•$0 the first $500 of Allowed
Charges
•100% of the next $500 of
Allowed Charges (deductible)
Only Allowed Charges apply to
the deductible
Basic Alternative Plan
•$0 the first $250 of Allowed
Charges
•100% of the next $750 of
Allowed Charges (deductible)
Only Allowed Charges apply to
the deductible
Both Basic Plans
•50% of the next $10,000 of
Allowed Charges
•$0 of Allowed Charges over
the individual or family out-of-pocket
limit
•You may use non-Network
providers, but it will be more
costly*
20% of Allowed Charges after
deductible
Occupational therapy*
Limit: 20 visits per year without
certification
Speech therapy*
Certification not required for
age 18 and older
*Maximum of 60 visits per year
Physical Therapy/
Physical Medicine
Visit
20% of Allowed Charges after
deductible
Limit: 20 visits per year without
certification
Maximum of 60 visits per year
20% of Allowed Charges after
deductible
Limit: 20 visits per year without
certification
Maximum of 60 visits per year
Chiropractic and
Manipulative
Therapy
Visit
Chiropractic services:
20% of Allowed Charges after
deductible
Limit: 20 visits per year without
certification
Maximum of 60 visits per year
Manipulative therapy: see
Physical Therapy/Physical
Medicine
Chiropractic services:
20% of Allowed Charges after
deductible
Limit: 20 visits per year without
certification
Maximum of 60 visits per year
Manipulative therapy: see
Physical Therapy/Physical
Medicine
Maternity
Pre and Post
Natal Care
20% of Allowed Charges after
deductible
Includes one postpartum home
visit - criteria must be met
20% of Allowed Charges after
deductible
Includes one postpartum home
visit - criteria must be met
Hearing
Screening and
Hearing Aids
$50 copay/specialist
$30 copay/primary care
physician**
Basic hearing screening
Limit: one per year
Hearing aids are covered as
durable medical equipment for
children up to age 18
$50 copay after deductible
Basic hearing screening
Limit: one per year
Hearing aids are covered as
durable medical equipment for
children up to age 18
**The $30 copay applies to general practioners, internal medicine physicians, OB/GYNs, pediatricians, physician
assistants, and nurse practitioners.
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21 Plan Year 2012 Comparison Chart
COMPARISON OF BENEFITS FOR HEALTH PLANS
HMO Standard
Option
CommunityCare
Alternative
& Wellness
Alternative Plus
HMO
GlobalHealth
Alternative
and Wellness
Alternative Plus
HMO
UnitedHealthcare
Alternative
and Wellness
Alternative Plus
HMO
Your Costs
for Network
Services
No copay inpatient
$30 copay/PCP
$40 copay/specialist
Limit: 60 treatment
days per illness
No copay inpatient
$50 copay outpatient
therapy
Limit: 60 days per
illness
No copay inpatient
$50 copay per
outpatient therapy
Limit: 60 consecutive
days per illness
$0 copay inpatient
$35 copay/PCP
$50 copay/specialist
Limit: 60 days per
medical episode
Occupational or
Speech Therapy
Visit
No copay inpatient
$30 copay/PCP
$40 copay/specialist
Limit: 60 treatment
days per illness
No copay inpatient
$50 copay outpatient
therapy
Limit: 60 days per
illness
No copay inpatient
$50 copay per
outpatient visit
Limit: 60 consecutive
days per illness
$0 copay inpatient
$35 copay/PCP
$50 copay/specialist
Limit: 60 days per
medical episode
Physical Therapy/
Physical Medicine
Visit
$40 copay
Limit: 15 visits per
year
PCP referral required
$50 copay
Limit: 15 visits per
year
PCP referral required
$50 copay
Must be preauthorized
$50 copay
Limit: 15 visits per
year - referral required
Limited to treatment
of neurological and
orthopedic conditions
Chiropractic and
Manipulative
Therapy
Visit
$30 copay for initial
visit
$350 copay per hospital
admission
$35 copay for initial
visit
$500 copay per hospital
admission
$25 copay for initial
visit only
$250 copay per hospital
admission per day
$750 maximum per
admission
$35 copay/PCP
$50 copay/specialist
for initial visit once
diagnosis of pregnancy
is confirmed
$1,000 copay per
hospital admission
Maternity
Pre and Post
Natal Care
$0 copay children birth
– age 21
$30 copay age 22 and
over
Limit: One per year
Hearing aids – 20%
coinsurance for children
up to age 18
$0 copay
Limit: One per year
Hearing aids – 20%
coinsurance for children
up to age 18
$0 copay children birth
– age 21
$25 copay age 22 and
over
Limit: One per year
Hearing aids – 20%
coinsurance
For children up to age
18
$0 copay/PCP ages 0-17
20% coinsurance ages
18 and over
Limited to a single
hearing aid every 3
years – maximum
benefit of $5,000 per
calendar year
Hearing
Screening and
Hearing Aids
This is only a sample of the services covered by each plan. For services that are not listed in this comparison
chart, contact each plan. See Help Lines on page 28 of this guide for contact information.
Plan changes are indicated by bold text.
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Plan Year 2012 Comparison Chart 22
COMPARISON OF BENEFITS FOR HEALTH PLANS
Plan changes are indicated by bold text.
Your Costs
for Network
Services
HealthChoice High, High Alternative,
Basic, Basic Alternative, and USA
Plans
HealthChoice
S-Account Plan
Pharmacy
Benefits
NETWORK
Retail Pharmacy
•Up to a 30-day supply
•Generic medication – $10 copay or cost of
medication if less
•Preferred brand-name medication – cost of
medication up to $15 or a maximum copay of
$30
•Non-preferred brand-name medication – cost
of medication up to $30 or a maximum copay
of $60
•Maintenance medication – 50% of ingredient
cost plus dispensing fee for fourth and all
subsequent fills; minimum copay of $10 for
generics, $15 for Preferred brand-name, and
$30 for non-Preferred brand-name medication
Mail Order and
Retail Maintenance Pharmacies
•Up to a 90-day supply
•Generic medication – $25 or cost of
medication if less
•Preferred brand-name medication – cost of
medication up to $30 or a maximum copay of
$60
•Non-preferred brand-name medication – cost
of medication up to $60 or a maximum copay
of $120
•Specialty medication covered only when
ordered through Accredo Health Group
• Preferred medication $60 per 30-day
supply
• Non-Preferred $120 per 30-day supply
Pharmacy out-of-pocket maximum - $2,500
per person using Preferred products at Network
pharmacies, then you pay $0
After combined medical and pharmacy
deductible ($1,500 individual/$3,000 family)
has been met, the pharmacy benefits are:
NETWORK
Retail Pharmacy:
•Up to a 30-day supply
•Generic medication – $10 copay or cost of
medication if less
•Preferred brand-name medication – cost of
medication up to $15 or a maximum copay of
$30
•Non-preferred brand-name medication – cost
of medication up to $30 or a maximum copay
of $60
•Maintenance medication – 50% of ingredient
cost plus dispensing fee for fourth and all
subsequent fills; minimum copay of $10 for
generics, $15 for Preferred brand-name, and
$30 for non-Preferred brand-name medication
Mail Order and
Retail Maintenance Pharmacies
•Up to a 90-day supply
•Generic medication – $25 or cost of
medication if less
•Preferred brand-name medication – cost of
medication up to $30 or a maximum copay of
$60
•Non-preferred brand-name medication – cost
of medication up to $60 or a maximum copay
of $120
•Specialty medication covered only when
ordered through Accredo Health Group
• Preferred medication $60 per 30-day
supply
• Non-Preferred $120 per 30-day supply
23 Plan Year 2012 Comparison Chart
COMPARISON OF BENEFITS FOR HEALTH PLANS
P
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HMO Standard
Option
CommunityCare
Alternative
& Wellness
Alternative Plus
HMO
GlobalHealth
Alternative
and Wellness
Alternative Plus
HMO
UnitedHealthcare
Alternative
and Wellness
Alternative Plus
HMO
Your Costs
for Network
Services
Up to $5 generic
formulary
Up to $30 brand
formulary (when no
generic is available)
Up to $60 brand
formulary (when
generic is available)
30-day supply
Certain medications
have restricted
quantities
Mail order may be
available, contact Plans
for details
Please note: Tier
categories will be
determined by each
HMO based on its
formulary design
Tier 1: $10
Tier 2: $40
Tier 3: $65
$0 copay for selected
generics
Up to $65 non-formulary
(non-
Preferred)
These copays do not
apply to the maximum
out-of-pocket
30-day supply
Certain medications
have restricted
quantities
Convenient mail-order
is available. Contact
Plan for details
Tier 1: $10
Tier 2: $50
Tier 3: $75
$4 copay for selected
generics
30-day supply
Certain medications
may have restricted
quantities
These copays do not
apply to the maximum
out-of-pocket
$5 copay for formulary
generic drugs
$30 copay for formulary
brand-name drugs
$60 copay non-formulary
generic and
non-formulary brand
drugs
Lesser of a 30-day
supply or 100 units
Certain medications
have restricted
quantities
Pharmacy
Benefits
Plan changes are indicated by bold text.
COMPARISON OF BENEFITS FOR DENTA L PLANS
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Plan Year 2012 Comparison Chart 24
Your Costs
for Network
Services
HealthChoice
Dental
CIGNA Dental Care
Plan (Prepaid)
Assurant
Freedom
Preferred
Annual
Deductible
Network: $25 Basic and
Major services combined
Non-Network: $25
Preventive, Basic, and Major
services combined plus
amounts above Allowed
Charges
No deductible or plan
maximum
$5 office copay applies
$25 per person, per year,
waived for preventive services
in-network
Preventive
Care
ex: cleaning,
routine oral exam
Allowed Charges
apply
Network: $0
Non-Network: $0 of Allowed
Charges after deductible
Sealant: $15 per tooth
No charge for routine cleaning
once every 6 months
No charge for topical fluoride
application (through age 18)
No charge for periodic oral
evaluations
$0 with no deductible when
in-network
Basic Care
ex: extractions,
oral surgery
Allowed Charges
apply
Network: 15%
Non-Network: 30% plus
amounts above Allowed
Charges
Deductible applies
Amalgam: One surface,
permanent teeth $21
Network: 15%
Non-Network: 30%
Plan pays 85% of usual and
customary when in-network
Deductible applies
Major Care
ex: dentures,
bridge work
Allowed Charges
apply
Network: 40%
Non-Network: 50% plus
amounts above Allowed
Charges
Deductible applies
Root canal, anterior: $355
Periodontal/scaling/root
planing 1-3 teeth (per
quadrant): $71
Network: 40%
Non-Network: 50%
Plan pays 60% of usual and
customary when in-network
Deductible applies
Orthodontic Care
Allowed Charges
apply
Network: 50%
Non-Network: 50% plus
amounts above Allowed
Charges
12-month waiting period may
apply
No lifetime maximum for
Network or non-Network
Covered for members under
age 19 and members age 19
and older with TMD
$2,280 out-of-pocket for
children through age 18
$3,120 out-of-pocket for adults
24-month treatment excludes
orthodontic treatment plan and
banding
Network: 40%
Non-Network: 50%
Up to $2,000 lifetime
maximum for members under
age 19
12-month waiting period may
apply
Plan Year
Maximum
Network and non-Network:
$2,000 per person per year
No maximum $2,000
Filing Claims
Network: No claims to file
Non-Network: You file claims
No claims to file Member/provider must file
claims
COMPARISON OF BENEFITS FOR DENTA L PLANS
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25 Plan Year 2012 Comparison Chart
Assurant Prepaid Plans
Heritage Plus with SBA
and Heritage Secure
Delta Dental PPO
In-Network and
Out-of-Network
Delta Dental Premier
In-Network and
Out-of-Network
Delta Dental
PPO – Choice
PPO Network
No deductibles $25 per person, per year,
applies to Basic and Major
Care only
$50 per person, per year,
applies to Diagnostic,
Preventive, Basic, and Major
Care
$100 per person, per year,
applies to Major Care only
(Level 4)
No charge for routine cleaning
(once every 6 months)
No charge for topical fluoride
application (up to age 18)
No charge for periodic oral
evaluations
$0 of allowable amounts
No deductible applies
Includes diagnostic
$0 of allowable amounts after
deductible
Includes diagnostic
Schedule of covered services
and copays
Copay examples:
Routine cleaning $5
Periodic oral evaluation $5
Topical fluoride application
(up to age 19) $5
Includes diagnostic
Fillings
Minor oral surgery
Refer to the copayment schedule
for each plan
15% of allowable amounts
after deductible
30% of allowable amounts
after deductible
Schedule of covered services
and copays
Copay example:
Amalgam - one surface,
primary or permanent tooth
$12
Root canal
Periodontal
Crowns
Refer to the copayment schedule
for each plan
40% of allowable amounts
after deductible
50% of allowable amounts
after deductible
Schedule of covered services
and copays
Copay examples:
Crown - porcelain/ceramic
substrate $241
Complete denture - maxillary
$320
25% discount
Adults and children
40% of allowable amounts,
up to lifetime maximum of
$2,000
No deductible
No waiting period
Orthodontic benefits are
available to the employee
and their lawful spouse and
eligible dependent children
40% of allowable amounts, up
to lifetime maximum of $2,000
No deductible
No waiting period
Orthodontic benefits are
available to the employee and
their lawful spouse and eligible
dependent children
You pay amounts in excess of
$50 per month
Lifetime maximum up to
$1,800
No deductible
No waiting period
Orthodontic benefits are
available to the employee and
their lawful spouse and eligible
dependent children
No annual maximum for general
dentist
$2,500 per person, per year $3,000 per person, per year $2,000 per person, per year
No claims to file Claims are filed by
participating dentists
Claims are filed by
participating dentists
Claims are filed by
participating dentists
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Plan Year 2012 Comparison Chart 26
COMPARISON OF BENEFITS FOR VISION PLANS
Humana/CompBenefits
VisionCare Plan
Primary Vision
Care Services, Inc.
Covered Services In-Network
Out-of-
Network
In-Network
Out-of-
Network*
Eye Exams
$10 copay
One exam for
eyeglasses or contacts
per year
Copays do not apply
Plan pays up to $35
One exam per year
$0 copay
No limit on exams per
year
Plan pays up to $40
One exam per year
Lenses Each Pair
$25 material copay
applies to lenses and/
or frames (single,
lined bifocal, trifocal,
lenticular are covered
at 100%)
A discount applies to
progressive lenses
One pair of lenses per
year
Plan pays up to:
$25 single
$40 bifocals
$60 trifocals
$100 lenticular
One pair of lenses per
year
You pay wholesale
cost with no limit on
number of pairs
You pay normal
doctor’s fee,
reimbursed up to $60
for one set of lenses
and frames per year
Frames
$25 material copay
applies to lenses and/
or frames
$45 wholesale frame
allowance
One pair of frames per
year
$25 copay
Plan pays up to $45
One pair of frames per
year
You pay wholesale
cost. No limit on
number of frames
You pay normal doctor
fee, reimbursed up
to $60 for one set of
lenses and frames per
year
Contact Lenses
$130 allowance
for conventional or
disposable contact
lenses and fitting fee
In lieu of all other
benefits
Medically necessary,
Plan pays 100%
One set of contacts per
year
$130 allowance for
exam, contacts, and
fitting fee
In lieu of all other
benefits
Medically necessary,
Plan pays $210
One set of contacts
per year
You pay wholesale
cost for an annual
supply of contacts
$50 service fee applies
to all soft contact lens
fittings; $75 to rigid
or gas permeable lens
fittings, $150 to hybrid
contact lens fittings
Replacement lenses do
not have these fees
Limit of one set
annually in lieu of
eyeglasses
You pay normal doctor
fees, reimbursed up to
$60
Laser Vision
Correction
$895 copay
conventional
$1,295 copay custom
$1,895 copay custom
plus bladeless when
services are rendered
by a TLC Network
Provider
No benefit Discount nationwide
at The Laser Center
(TLC)
No benefit
For information on limitations/exclusions,
please contact PVCS. See Help Lines on page 28
*Out-of-Network limited to one eye exam and
one set of eyeglasses or contact lenses annually.
Cannot be used with In-Network services.
Vision benefits apply from January 1 through
December 31, 2012
V
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27 Plan Year 2012 Comparison Chart
COMPARISON OF BENEFITS FOR VISION PLANS
Superior Vision Plan UnitedHealthcare Vision
Vision Service Plan
(VSP)
In-Network
Out-of-
Network
In-Network
Out-of-
Network
In-Network
Out-of-
Network
$10 copay
One exam per year
OD-$26 max
MD-$34 max
$10 copay
One exam per year
Plan pays up to $40 $10 copay
One exam per year
$10 copay
Plan pays up to $35
$25 copay
One pair of lenses
per year
Plan pays up to:
$26 single
$39 bifocals
$49 trifocals
$78 lenticular
$25 copay
One pair of lenses
per year
Lens options
covered in full:
•UV coating
•Tints
Plan pays up to:
$40 single
$60 bifocals
$80 trifocals
$80 lenticular
$25 copay*
One set of lenses
per year
Polycarbonate
lenses covered in
full for dependent
children
Average 35-40%
savings on non-covered
lens
options
$25 copay*
Plan pays up to:
$25 single
$40 bifocals
$55 trifocals
$80 lenticular
$25 copay
Plan pays up to
$125
One pair of frames
per year
Plan pays up to $68 $25 copay
$130 allowance
One pair of frames
per year
Plan pays up to $45 $25 copay*
$120 allowance
20% off any out-of-pocket
costs above
the allowance
One pair of frames
per year
$25 copay*
Plan pays up to $45
$25 fitting copay
for standard fitting
After copay, Plan
pays 100%
$25 fitting copay
for specialty fitting
After copay, Plan
pays up to $50
Plan pays up to
$120 for elective
contacts
Medically
necessary contacts
are covered in full
(in lieu of glasses)
Fitting fee is not a
covered benefit
Plan pays up to
$100 for elective
contacts
Plan pays up to
$210 for medically
necessary contacts
(in lieu of glasses)
$25 copay
covers fitting/
evaluation fees,
contacts (including
disposables), and
up to 2 follow-up
visits
(in lieu of glasses)
Plan pays up to
$150
For medically
necessary contacts,
Plan pays up to
$210
(in lieu of glasses)
$0 copay
$120 allowance
applied to the cost
of your contact
lenses (in lieu of
glasses)
Contact lens exam
is covered in full
after a copay up
to $60
$0 copay
Plan pays up to
$105 for disposable
or conventional
contact lenses
(in lieu of glasses)
20% to 50%
savings on LASIK
surgery
No benefit Members
have access
to discounted
refractive eye
surgery from
numerous
provider locations
throughout the U.S.
No benefit Laser vision
correction services
(PRK, LASIK, and
Custom LASIK)
are provided at
a reduced cost
through VSP’s
contracted laser
surgery centers
No benefit
*Benefit includes an annual $25 materials
copay for lenses or frames, but not both.
Contact VSP at 1-800-877-7195 for
additional information regarding in-network
added value discounts.
Vision benefits apply from January 1 through
December 31, 2012
28
HealthChoice (OSEGIB)
Help Lines
Health, Dental, and Life Claims, Benefits,
Verification of Coverage, and ID Cards
Oklahoma City Area 1-405-416-1800
All Other Areas 1-800-782-5218
TDD Oklahoma City Areas 1-405-416-1525
TDD All Other Areas 1-800-941-2160
Website www. sib.ok.gov or www.healthchoiceok.com
Pharmacy Claims/Pharmacy ID Cards
All Areas 1-800-903-8113
TDD All Areas 1-800-825-1230
Member Services/Provider Directory
Oklahoma City Area 1-405-717-8780
All Other Areas 1-800-752-9475
TDD 1-405-949-2281 or All Areas 1-866-447-0436
HealthChoice USA
Customer Service & Claims 1-800-782-5218
Provider Information 1-877-877-0715 ext. 4059
TDD All Areas 1-800-941-2160
Website www.choicecarenetwork.com
American Fidelity Health Services
Administration
Health Savings Account (HSA)
Oklahoma City Area 1-405-523-5699
All Areas 1-866-326-3600
Fax 1-405-523-5072
HMO Plans’ Help Lines
CommunityCare
All Areas 1-800-777-4890
TDD All Areas 1-800-722-0353
Website www.ccok.com
GlobalHealth, Inc.
Oklahoma City Area 1-405-280-5600
All Other Areas 1-877-280-5600
TDD All Areas 1-800-522-8506
Website www.globalhealth.com
UnitedHealthcare
All Areas 1-800-825-9355
TDD All Areas 1-800-557-7595
Website www.UHCwest.com
Dental Plans’ Help Lines
Assurant, Inc. Dental
Prepaid Plan 1-800-443-2995
Indemnity Plan 1-800-442-7742
Website www.assurantemployeebenefits.com
CIGNA Prepaid Dental
All Areas 1-800-244-6224
Toll-free Hearing Impaired Relay Svc 1-800-654-5988
Website www.cigna.com
Delta Dental
Oklahoma City Area 1-405-607-2100
All Other Areas 1-800-522-0188
Website www.DeltaDentalOK.org
Vision Plans’ Help Lines
Humana/CompBenefits
All Areas 1-800-865-3676
TDD All Areas 1-877-553-4327
Website www.compbenefits.com/custom/stateofoklahoma
Primary Vision Care Services (PVCS)
All Areas 1-888-357-6912
TDD All Areas 1-800-722-0353
Website www.pvcs-usa.com
Superior Vision Plan
All Areas 1-800-507-3800
TDD 1-916-852-2382
Website www.superiorvision.com
UnitedHealthcare Vision
All Areas 1-800-638-3120
TDD All Areas 1-800-524-3157
Website www.myuhcvision.com
Vision Service Plan (VSP)
All Areas 1-800-877-7195
TDD All Areas 1-800-428-4833
Website www.vsp.com
Presorted
Standard
U. S. Postage
PAID
Okla. City, OK
Permit #1067
HealthChoice
OPTION PERIOD Guide
PLAN YEAR 2012
Oklahoma State and Education
Employees Group Insurance Board
3545 NW 58 Street, Suite 110
Oklahoma City, OK 73112