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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 11 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 H M O Z I P C O D E L I S T 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 13 H M O Z I P C O D E L I S T continued on next page 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 H M O Z I P C O D E L I S T 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. 15 H E A L T H P L A N C O M P A R I S O N 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 H E A L T H P L A N C O M P A R I S O N 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. H E A L T H P L A N C O M P A R I S O N 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 H E A L T H P L A N C O M P A R I S O N 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. H E A L T H P L A N C O M P A R I S O N 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. H E A L T H P L A N C O M P A R I S O N 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. P H A R M A C Y 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 H A R M A C Y 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 D E N T A L P L A N C O M P A R I S O N 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 D E N T A L P L A N C O M P A R I S O N 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 V I S I O N P L A N C O M P A R I S O N 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 I S I O N P L A N C O M P A R I S O N 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
Object Description
Description
Title | Pre-Medicare, former employees 2012 |
Notes | #2557 |
OkDocs Class# | E3610.5 H677f 2012 |
Digital Format | PDF, Adobe Reader required |
ODL electronic copy | Downloaded from agency website: http://www.ok.gov/sib/documents/FOG_PY_2012.pdf |
Rights and Permissions | This Oklahoma state government publication is provided for educational purposes under U.S. copyright law. Other usage requires permission of copyright holders. |
Language | English |
Full text | 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 11 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 H M O Z I P C O D E L I S T 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 13 H M O Z I P C O D E L I S T continued on next page 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 H M O Z I P C O D E L I S T 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. 15 H E A L T H P L A N C O M P A R I S O N 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 H E A L T H P L A N C O M P A R I S O N 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. H E A L T H P L A N C O M P A R I S O N 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 H E A L T H P L A N C O M P A R I S O N 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. H E A L T H P L A N C O M P A R I S O N 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. H E A L T H P L A N C O M P A R I S O N 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. P H A R M A C Y 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 H A R M A C Y 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 D E N T A L P L A N C O M P A R I S O N 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 D E N T A L P L A N C O M P A R I S O N 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 V I S I O N P L A N C O M P A R I S O N 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 I S I O N P L A N C O M P A R I S O N 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 |
Date created | 2011-10-07 |
Date modified | 2011-10-27 |