Guide to pre-Medicare health plans : plan year ...

              E 3610.5 H677g 2011 c.1
OSEEGIB Oklahoma State and Education
"" Employees Group Insurance Board
Plan Guide for Pre-Medicare Members
Plan Year 2011
January 1 through December 31,2011
Health
Dental
Vision
Notice of Creditable Coverage
If you're a former employee who is already eligible or who 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 the Oklahoma State and Education Employees Group
Insurance Board (OSEEGIB) also 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 pages 23-24 of this Guide.
Provider Networks
HMO Plans
Be aware that even though some of the HMO plans have nationwide provider networks,
the plans offered through OSEEGIB allow access only to the HMO plans' Oklahoma provider
networks.
HealthChoice High Option, Basic, and S-Account Plans
These HealthChoice plans give you access to one of the largest Provider networks in
Oklahoma.
HealthChoice USA Plan
The HealthChoice USA Plan is available to members who live outside of Oklahoma and
Arkansas. The USA Plan provides access to a nationwide provider network.
For directions on how to access each health, dental, and vision plan's provider network, see
pages 21-22. If your provider leaves your health, dental, or vision plan, you cannot change
plans until the next annual Option Period; however, you may change providers within your
plan as needed.
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. 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
This publication was printed by the Oklahoma State and Education Employees Group Insurance Board as authorized by
74 O.S. Section 1301, et seq. 275 copies have been printed at a cost of $0.084 each. Copies have been deposited with the
Publications Clearinghouse of the Oklahoma Department of Libraries.
TABLE OF CONTENTS
Notice of Creditable Coverage .Inside front cover
Premium Chart.................................................................................................. 1
Introduction....................................................................................................... 2
Health Plans....................................................................................................... 2
Dental and Vision Plans.................................................................................... 3
Important Information About Becoming Eligible for Medicare....................... 4
HMO ZIP Code List. 5
Summary of Health Plan Deductibles and Out-of-Pocket LimitslMaximums... 8
Comparison of Benefits for Health Plans................ 9
Comparison of Benefits for Dental Plans......................................................... 17
Comparison of Benefits for Vision Plans......................................................... 19
How to Access the Online Provider Networks 21
Help Lines.......................................................................... 23
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.
Oklahoma State and Education Employees Group Insurance Board
Monthly Premiums for Former Employees and Surviving Dependents
Plan Year January 1, 2011 - December 31, 2011
HEALTH PLANS MEMBER SPOUSE CHILD CHILDREN
HealthChoice High Option $449.48 $ 682.74 $228.20 $352.08
HealthChoice Basic $391.64 $ 598.48 $201.82 $310.80
HealthChoice S-Account $382.56 $ 562.74 $190.18 $291.90
HealthChoice USA $688.82 $ 688.82 $226.22 $348.86
CommunityCare Standard HMO $772.34 $1,104.42 $386.16 $617.86
CommunityCare Alternative HMO $532.66 $ 761.68 $266.34 $426.12
GlobalHealth Standard HMO $366.56 $ 601.22 $193.12 $307.96
GlobalHealth Alternative HMO $333.26 $ 546.58 $175.62 $279.98
PacifiCare Standard HMO $686.42 $ 986.94 $342.96 $548.86
PacifiCare Alternative HMO $473.39 $ 680.63 $236.51 $378.51
DENTAL PLANS MEMBER SPOUSE CHILD CHILDREN
HealthChoice Dental $29.84 $29.84 $24.88 $64.56
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 $31.14 $31.14 $27.10 $68.56
Delta Dental Premier $35.52 $35.52 $30.90 $78.20
Delta Dental PPO - Choice $13.94 $31.64 $31.90 $77.42
VISION PLANS MEMBER SPOUSE CHILD CHILDREN
Humana/CompBenefits VisionCare Plan $6.76 $5.06 $3.57 $ 4.46
Primary Vision Care Services (PVCS) $9.25 $8.00 $8.50 $10.75
Superior Vision Plan $6.98 $6.90 $6.60 $ 6.60
UnitedHealthcare Vision $8.18 $5.79 $4.59 $ 6.98
Vision Service Plan (VSP) $8.76 $5.87 $5.62 $12.64
These rates do not reflect any retirement system contribution
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 FAQ section of the HealthChoice website
and search for blended rates.
1
INTRODUCTION
The Oklahoma State and Education Employees Group Insurance Board (OSEEGIB) produced
this 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
Helpful Hints
• Review the premium rates listed on the previous page.
• 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
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:
OSEEGIB
3545 N.W. 58th Street, Suite 110
Oklahoma City, OK 73112
HEALTH PLANS
There are 10 health plans available:
• HealthChoice High Option Plan
• HealthChoice Basic Plan
• HealthChoice S-Account Plan
• HealthChoice USA Plan*
See Comparison of Benefits for Health Plans on pages 9-16 for specific benefit information.
• CommunityCare Standard and Alternative HMO
• GlobalHealth Standard and Alternative HMO
• PacifiCare Standard and Alternative HMO
*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 pages 23-24 of this Guide.
2
• There are no preexisting condition exclusions or limitations applied to any of the health plans.
• You must live within the HMO's ZIP Code service area to be eligible. Post Office Box addresses
cannot be used to determine your HMO eligibility. See pages 5-7 for the HMO ZIP Code List.
• To enroll in the HealthChoice S-Account Plan, you must provide OSEEGIB with proof you have
a Health Savings Account at a bank or other financial institution. Without proof, your health plan
will default to the HealthChoice Basic 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 pages 23-24 of this
Guide.
• Check with each health plan if you have benefit questions.
3
DENTAL 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 17-18 for specific benefit information.
• All dental plans have toll-free numbers for customer service. SeeHelp Lines on pages 23-24 of this
Guide.
• Check with the individual dental plan if you have benefit questions.
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 19-20 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 by calling your provider.
• All vision plans have limited coverage for services received from out-of-network providers.
• All plans have toll-free numbers for customer service. See Help Lines on pages 23-24 of this
Guide.
• Check with the individual vision plan if you have benefit questions.
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 becomes
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 sends you a
letter that explains the Medicare plan options available to you. The letter also provides instructions on
how to enroll with a Medicare supplement or MA-PD plan.
If you are enrolled in HealthChoice, you are automatically 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 one of the Medicare Supplement or MA-PD plans 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.
4
HMo
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HMO ZIP Code List
C = CommunityCare G = GlobalHealth* P = PacifiCare
73001 G 73042 G 73086 G 73129 CGP 73179 CGP 73463 G
73002 GP 73043 G 73089 GP 73130 CGP 73180 CP 73481 G
73003 CGP 73044 CGP 73090 CGP 73131 CGP 73184 CGP 73487 G
73004 GP 73045 CGP 73092 GP 73132 CGP 73185 CGP 73488 G
73005 G 73047 G 73093 GP 73134 CGP 73189 CGP 73491 G
73006 G 73048 G 73094 G 73135 CGP 73190 CGP 73501 G
73007 CGP 73049 CGP 73095 GP 73136 CGP 73193 CP 73502 G
73008 CGP 73050 CGP 73096 G 73137 CGP 73194 CGP 73503 G
73009 G 73051 CGP 73097 CGP 73139 CGP 73195 CGP 73505 G
73010 GP 73052 G 73098 G 73140 CGP 73196 CGP 73506 G
73011 GP 73053 G 73099 CGP 73141 CGP 73197 CP 73507 G
73012 CGP 73054 CGP 73100 C 73142 CGP 73198 CGP 73520 G
73013 CGP 73055 G 73101 CGP 73143 CGP 73199 CP 73521 G
73014 CGP 73056 CGP 73102 CGP 73144 CGP 73401 G 73522 G
73015 G 73057 GP 73103 CGP 73145 CGP 73402 G 73523 G
73016 GP 73058 CGP 73104 CGP 73146 CGP 73403 G 73526 G
73017 G 73059 GP 73105 CGP 73147 CGP 73425 G 73527 G
73018 GP 73061 CG 73106 CGP 73148 CGP 73430 G 73528 G
73019 CGP 73062 G 73107 CGP 73149 CGP 73432 G 73529 G
73020 CGP 73063 CGP 73108 CGP 73150 CGP 73433 G 73530 G
73021 G 73064 CGP 73109 CGP 73151 CGP 73434 G 73532 G
73022 CGP 73065 GP 73110 CGP 73152 CGP 73435 G 73533 G
73023 G 73066 CGP 731II CGP 73153 CGP 73436 G 73534 G
73024 G 73067 GP 73112 CGP 73154 CGP 73437 G 73536 G
73025 CGP 73068 CGP 73113 CGP 73155 CGP 73438 G 73537 G
73026 CGP 73069 CGP 73114 CGP 73156 CGP 73441 G 73538 G
73027 CGP 73070 CGP 73115 CGP 73157 CGP 73442 G 73539 G
73028 CGP 73071 CGP 73116 CGP 73159 CGP 73443 G 73540 G
73029 G 73072 CGP 73117 CGP 73160 CGP 73444 G 73541 G
73030 G 73073 CGP 73118 CGP 73162 CGP 73447 G 73542 G
73031 GP 73074 G 73119 CGP 73163 CGP 73448 G 73543 G
73032 G 73075 G 73120 CGP 73164 CGP 73449 G 73544 G
73033 G 73077 CG 73121 CGP 73165 CGP 73450 G 73546 G
73034 CGP 73078 CGP 73122 CGP 73167 CGP 73453 G 73548 G
73036 CGP 73079 GP 73123 CGP 73169 CGP 73455 G 73549 G
73037 CP 73080 GP 73124 CGP 73170 CGP 73456 G 73550 G
73038 G 73082 G 73125 CGP 73172 CGP 73458 G 73551 G
73039 G 73083 CGP 73126 CGP 73173 CGP 73459 G 73552 G
73040 G 73084 CGP 73127 CGP 73177 CP 73460 G 73553 G
73041 G 73085 CGP 73128 CGP 73178 CGP 73461 G 73555 G
*GlobalHealth may be available in more areas than indicated in the above list. Please contact GlobalHealth
for complete service area information. See Help Lines on pages 23-24.
5 continued on next page
continued from previous page
HMO ZIP Code List
C = CommunityCare G = GlobalHealth* P = PacifiCare
73556 G 73718 G 73901 G 74038 CGP 74084 CG 74153 CGP
73557 G 73720 G 73939 G 74039 CGP 74085 CGP 74155 CGP
73558 G 73724 G 73942 G 74041 CGP 74100 C 74156 CGP
73559 G 73727 G 73944 G 74042 CG 74101 CGP 74157 CGP
73560 G 73729 G 73945 G 74043 CGP 74102 CGP 74158 CGP
73561 G 73730 G 73951 G 74044 CGP 74103 CGP 74159 CGP
73564 G 73733 G 74001 CG 74045 CG 74104 CGP 74169 CGP
73565 G 73734 G 74002 CGP 74046 CGP 74105 CGP 74170 CGP
73566 G 73735 G 74003 CG 74047 CGP 74106 CGP 74171 CGP
73567 G 73736 G 74004 CG 74048 CG 74107 CGP 74172 CGP
73569 G 73737 G 74005 CG 74050 CGP 74108 CGP 74182 CGP
73570 G 73738 G 74006 CG 74051 CG 74110 CGP 74183 CP
73571 G 73742 G 74008 CGP 74052 CGP 74112 CGP 74184 C
73573 G 73743 G 74009 C 74053 CGP 74114 CGP 74186 CGP
73601 G 73744 G 74010 CGP 74054 CGP 74115 CGP 74187 CGP
73620 G 73747 G 74011 CGP 74055 CGP 74116 CGP 74189 CP
73622 G 73750 G 74012 CGP 74056 CG 74117 CGP 74192 CGP
73624 G 73753 G 74013 CGP 74058 CG 74119 CGP 74193 CGP
73625 G 73754 G 74014 CGP 74059 CGP 74120 CGP 74194 CP
73626 G 73755 G 74015 CGP 74060 CGP 74121 CGP 74301 CGP
73627 G 73756 G 74016 CGP 74061 CGP 74126 CGP 74330 CGP
73632 G 73757 CG 74017 CGP 74062 CGP 74127 CGP 74331 CG
73639 G 73758 G 74018 CGP 74063 CGP 74128 CGP 74332 CG
73641 G 73759 G 74019 CGP 74066 CGP 74129 CGP 74333 CG
73644 G 73760 G 74020 CGP 74067 CGP 74130 CGP 74335 CG
73645 G 73761 G 74021 CGP 74068 CGP 74131 CGP 74337 CGP
73647 G 73762 GP 74022 CG 74070 CGP 74132 CGP 74338 CG
73648 G 73763 G 74023 CGP 74071 CGP 74133 CGP 74339 CG
73651 G 73764 G 74026 GP 74072 CG 74134 CGP 74340 CGP
73655 G 73766 G 74027 CG 74073 CGP 74135 CGP 74342 CG
73661 G 73768 G 74028 CGP 74074 CGP 74136 CGP 74343 CG
73662 G 73770 G 74029 CG 74075 CGP 74137 CGP 74344 CG
73664 G 73771 G 74030 CGP 74076 CGP 74141 CGP 74345 CG
73668 G 73772 G 74031 CGP 74077 CG 74145 CGP 74346 CG
73669 G 73773 G 74032 CGP 74078 CG 74146 CGP 74347 CG
73701 G 73834 G 74033 CGP 74079 GP 74147 CGP 74349 CGP
73702 G 73838 G 74034 CG 74080 CGP 74148 CGP 74350 CGP
73703 G 73848 G 74035 CGP 74081 CGP 74149 CGP 74352 CGP
73705 G 73851 G 74036 CGP 74082 CGP 74150 CGP 74353 CP
73706 G 73855 G 74037 CGP 74083 CG 74152 CGP 74354 CG
*GlobalHealth may be available in more areas than indicated in the above list. Please contact GlobalHealth
for complete service area information. See Help Lines on pages 23-24.
6 continued on next page
H
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HMo
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continued from previous page
HMO ZIP Code List
C = CommunityCare G = GlobalHealth* P = PacifiCare
74355 CG 74447 CGP 74549 CG 74720 G 74824 GP 74873 GP
74358 CG 74450 CG 74552 CG 74721 G 74825 G 74875 GP
74359 CG 74451 CG 74553 CG 74722 G 74826 GP 74878 GP
74360 CG 74452 CG 74554 CG 74723 G 74827 G 74880 CGP
74361 CGP 74454 CGP 74557 CG 74724 G 74829 GP 74881 GP
74362 CGP 74455 CG 74558 CG 74726 G 74830 CGP 74882 P
74363 CG 74456 CGP 74559 C 74727 CG 74831 GP 74883 G
74364 CGP 74457 CG 74560 CG 74728 G 74832 GP 74884 CGP
74365 CGP 74458 CGP 74561 CG 74729 G 74833 GP 74901 CG
74366 CGP 74459 CG 74562 CG 74730 G 74834 GPP 74902 CG
74367 CGP 74460 CGP 74563 C 74731 G 74835 P 74930 CG
74368 CG 74461 CG 74565 CG 74733 G 74836 G 74931 CG
74369 CG 74462 CG 74567 CG 74734 G 74837 CGP 74932 CG
74370 CG 74463 CG 74570 CG 74735 CG 74838 P 74935 CG
74401 CG 74464 CG 74571 C 74736 G 74839 G 74936 CG
74402 CG 74465 CG 74574 CG 74737 G 74840 GP 74937 CG
74403 CG 74466 CP 74576 CG 74738 CG 74842 G 74939 CG
74421 CGP 74467 CGP 74577 CG 74740 G 74843 G 74940 CG
74422 CGP 74468 CG 74578 C 74741 G 74844 G 74941 CG
74423 CG 74469 CG 74601 G 74743 CG 74845 CG 74942 CG
74425 CG 74470 CG 74602 G 74745 G 74848 G 74943 CG
74426 CG 74471 CG 74604 CG 74747 G 74849 CGP 74944 CG
74427 CG 74472 CG 74630 CG 74748 G 74850 G 74945 CG
74428 CG 74477 CGP 74631 G 74750 G 74851 GP 74946 CG
74429 CGP 74501 CG 74632 G 74752 G 74852 GP 74947 CG
74430 CG 74502 CG 74633 CG 74753 G 74854 GP 74948 CG
74431 CGP 74521 CG 74636 G 74754 G 74855 GP 74949 CG
74432 CG 74522 CG 74637 CG 74755 G 74856 G 74951 CG
74434 CG 74523 CG 74640 G 74756 CG 74857 GP 74953 CG
74435 CG 74526 C 74641 G 74759 CG 74859 GP 74954 CG
74436 CGP 74528 CG 74643 G 74760 CG 74860 GP 74955 CG
74437 CGP 74529 CG 74644 CG 74761 CG 74862 P 74956 CG
74438 CG 74530 G 74646 G 74764 G 74864 GP 74957 G
74439 CG 74531 G 74647 G 74766 G 74865 G 74959 CG
74440 CG 74536 CG 74650 CG 74801 GP 74866 GP 74960 CG
74441 CG 74543 CG 74651 CG 74802 GP 74867 CGP 74962 CG
74442 CG 74545 C 74652 CG 74804 GP 74868 GP 74963 G
74444 CG 74546 CG 74653 G 74818 CGP 74869 GP 74964 CG
74445 CGP 74547 CG 74701 G 74820 G 74871 G 74965 CG
74446 CGP 74548 C 74702 G 74821 G 74872 G 74966 CG
*GlobalHealth may be available in more areas than indicated in the above list. Please contact GlobalHealth
for complete service area information. See Help Lines on pages 23-24.
7
Summary of Health Plan Deductibles and
Out-of-Pocket Limits/Maximums
Health Plans CHaD(leNeeaednltutdwhcaotrPirbYlkale)enar LimCOaiutlste-/noMdfa-aPxroimYcekuaemrt s
$2,800/Individual- Network
$500/Individual
$3,300/Individual-
Non-Network + amounts
HealthChoice High above Allowed Charges
$1,500IFamily No Family
(3 or more members) Out-of-Pocket Limit
$500/Individual $5,500/Individual
HealthChoice Basic
$1,OOO/Family $11,OOOlFamily
(2 or more members) (2 or more members)
$1,500/Individual (medical
$4,OOO/Individual
HealthChoice and pharmacy combined)
S-Account* $3,OOO/Family (medical and
$8,OOOlFamily
pharmacy combined)
$O/Individual $2,500/Individual
All Standard
HMO Plans
$OlFamily $5,OOOlFamily
$O/Individual
All Alternative See the Comparison of Benefits
HMO Plans for Health Plans on
$OlFamily the next page
* Individual or family deductible must be met before benefits are paid. Also, the
individual or family out-of-pocket limit must be met before the plan pays 1000/0of
Allowed Charges for the rest of the calendar year.
8
COMPARISON OF BENEFITS FOR HEALTH PLANS
*HealthChoice members do not need to designate a primary care physician and can change physicians at
any time.
PLAN YEAR 2011 COMPARISON CHART 9
COMPARISON OF BENEFITS FOR HEALTH PLANS
COMMUNITyCARE GLOBALHEALTH PACIFICARE
YOUR COSTS
HMO STANDARD
FOR NETWORK
OPTION ALTERNATIVE HMO ALTERNATIVE HMO ALTERNATIVE HMO
SERVICES
No deductible No deductible No deductible No deductible
CALENDAR YEAR
DEDUCTIBLES
$2,500 individual $3,000 individual $3,000 individual $2,500 individual
$5,000 family $6,000 family $5,000 family $5,000 family
CALENDAR YEAR
OUT-OF-POCKET
MAxIMuM
$30 copay/PCP $35 copaylPCP $25 copaylPCP $35 copaylPCP
$40 copay/specialist $50 copay/specialist $50 copay/specialist $50 copay/specialist OFFICE VISIT
(PROFESSIONAL
SERVICES)
No copay for laboratory No additional copay for $0 copay $0 copay for standard
services or outpatient laboratory services or $250 copay per MRI, lab and radiology
radiology outpatient radiology MRA, PET, CAT, or $200 copay per MRI, DIAGNOSTIC X-RAY
$150 copay per MRI, $200 copay per MRI, nuclear scan MRA, PET, or CAT AND LAB
CAT, MRA, or PET CAT, MRA, or PET scan
scan scan
$350 copay $500 copay $250 copay per day $1,000 copay/admission
Preauthorization Preauthorization $750 maximum per
required required admission HOSPITAL
Preauthorization INPATIENT
required ADMISSION
$250 copay $300 copay $250 copay $500 copay
Preauthorization Preauthorization
required required HOSPITAL
OUTPATIENT
VISIT
$0 copay $0 copay $0 copay ages 0 - 21 $0 copay
WELL CHILD
CARE VISIT
$0 copay ages birth $0 copay ages birth $0 copay $0 copay ages birth
through age 18 through age 18 years Office visit copay may through age 18 (if
$0 copay/ages 19 and $0 copay ages 19 and apply no other service is
over over rendered) IMMUNIZATIONS
When medically $0 copay ages 19 and
necessary over
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 pages 23-24 for contact information.
10 PLAN YEAR 2011 COMPARISON CHART
COMPARISON OF BENEFITS FOR HEALTH PLANS
20% of Allowed Charges after
deductible
Limit: 30 days per year*
20% of Allowed Charges after
deductible
Limit: 30 days per year*
YOUR COSTS
HEALTHCHOICE HEALTH CHOICE HEALTHCHOICE
FOR NETWORK HIGH OPTION BASIC PLAN S-ACCOUNT PLAN
SERVICES
$0 copay for one preventive One preventive service office $0 copay for one preventive
service office visit per visit per calendar year for service office visit per
PERIODIC HEALTH
calendar year for members and members and dependents age 20 calendar year for members and
dependents age 20 and older and older covered at 100% dependents age 20 and older
EXAMS One mammogram per year at no One mammogram per year at no
charge for women age 40 and One mammogram per year at no charge for women age 40 and
older charge for women age 40 and older
20% of Allowed Charges after over 20% of Allowed Charges after
ALLERGY
deductible deductible
Limit: 60 tests every 24 months ·Copays do not apply Limit: 60 tests every 24 months
TREATMENT AND
TESTING -All services, benefits,
exceptions, limitations, and
conditions are identical to the
EMERGENCY
20% of Allowed Charges after HealthChoice High Option Plan 20% of Allowed Charges after
deductible deductible
HEALTH CARE Additional $100 ER deductible For Network services: Additional $100 ER deductible
FACILITY - waived if admitted ·$0 the first $500 ofAllowed - waived if admitted
VISIT Charges
20% of Allowed Charges after ·100% of the next $500 of 20% of Allowed Charges after
deductible Allowed Charges (deductible) deductible
AFTER HoURS Only Allowed Charges apply to
URGENT CARE the deductible'
MENTAL HEALTH OR
SUBSTANCE ABUSE
INPATIENT
ADMISSION
·$0 of Allowed Charges over
$5,500/individual or $11,0001
family
MENTAL HEALTH OR
SUBSTANCE ABUSE
OUTPATIENT
VISIT
20% of Allowed Charges after
deductible
Limit: 26 visits per year*
-You may use non-Network
providers, but it will be more
costly
20% of Allowed Charges after
deductible
Limit: 26 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
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 pages 23-24 for contact information.
PLAN YEAR 2011 COMPARISON CHART
*MENTAL HEALTH PARITY PROVIDES THAT CERTAIN BIOLOGICAL CONDITIONS FOR SEVERE MENTAL ILLNESS ARE NOT
LIMITED AS OTHER MENTAL HEALTH CONDITIONS. THIS DOES NOT APPLY TO SUBSTANCE ABUSE.
11
COMPARISON OF BENEFITS FOR HEALTH PLANS
$0 copay per visit for
routine physicals
$0 copaylPCP
$50 copay/specialist
HMO STANDARD
OPTION
COMMUNITyCARE GLOBALHEALTH P ACIFICARE
ALTERNATIVE HMO ALTERNATIVE HMO ALTERNATIVE HMO
YOUR COSTS
FOR NETWORK
SERVICES
$0 copay $0 copaylPCP
Limit: One per year
PERIODIC HEALTH
EXAMS
$30 copaylPCP $35 copaylPCP $25 copaylPCP $35 copaylPCP
$40 copay/specialist $50 copay/specialist $50 copay/specialist $50 copay/specialist
$30 serum and shots $30 serum and shots $30 serum and shots $35 serum and shots ALLERGY
including a 6-week including a 6-week including a 6-week including a 6-week TREATMENT AND
supply of antigen supply of antigen supply of antigen supply of antigen TESTING
$150 copay; waived if $200 copay; waived if $150 copay; waived if $200 copay; waived if
admitted admitted admitted admitted EMERGENCY
HEALTH CARE
FACILITY
VISIT
$40 copay per visit $50 copay per visit $25 copaylPCP $50 copay per visit
Preauthorization $50 copay/all others
required Must use Network AFTER HoURS
facilities URGENT CARE
$350 copay $500 copay $250 per day $1,000 copay per
Must be preauthorized $750 maximum per admission MENTAL HEALTH OR
and approved through admission SUBSTANCE ABUSE
CCOK Behavioral Must be preauthorized INPATIENT
Health Services ADMISSION
$30 copaylPCP $35 copaylPCP $25 copay $35 copaylPCP
$40 copay/specialist $50 copay/specialist Must be preauthorized $50 copay/specialist
Must be preauthorized MENTAL HEALTH OR
and approved through SUBSTANCE ABUSE
CCOK Behavioral OUTPATIENT
Health Services VISIT
20% coinsurance initial 20% coinsurance initial 20% coinsurance 20% coinsurance
device device
20% coinsurance repair 20% coinsurance repair
and replacement and replacement 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 pages 23-24 for contact information.
12 PLAN YEAR 2011 COMPARISON CHART
COMPARISON OF BENEFITS FOR HEALTH PLANS
YOUR COSTS
HEALTHCHOICE HEALTHCHOICE HEALTH CHOICE
FOR NETWORK HIGH OPTION BASIC PLAN S-ACCOUNT PLAN
SERVICES
20% of Allowed Charges after -Copays do not apply 20% of Allowed Charges after
deductible deductible
For each service -All services, benefits, For each service
OCCUPATIONAL AND Limit: 20 visits per year without exceptions, limitations, and Limit: 20 visits per year without
SPEECH THERAPY certification conditions are identical to the certification
VISITS Maximum of 60 visits per year HealthChoice High Option Plan Maximum of 60 visits per year
For Network services:
-$0 the first $500 ofAllowed
20% of Allowed Charges after Charges 20% of Allowed Charges after
deductible deductible
PHYSICAL THERAPY/ Limit: 20 visits per year without -100% of the next $500 of Limit: 20 visits per year without
certification Allowed Charges (deductible) certification
PHYSICAL MEDICINE Maximum of 60 visits per year Only Allowed Charges apply to Maximum of 60 visits per year
VISIT the deductible
-50% of the next $10,000 of
Chiropractic services:
Allowed Charges
Chiropractic services:
20% of Allowed Charges after -$0 of Allowed Charges over 20% of Allowed Charges after
deductible $5,500/individual or $11,0001 deductible
Limit: 20 visits per year without family Limit: 20 visits per year without
CHIROPRACTIC AND certification certification
MANIPULATIVE
Maximum of 60 visits per year -You may use non-Network Maximum of 60 visits per year
THERAPY Manipulative therapy: see
providers, but it will be more
Manipulative therapy: see
VISIT Physical TherapylPhysical
costly
Physical TherapylPhysical
Medicine 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 He.anng 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
*HealthChoice members do not need to designate a primary care physician and can change physicians at
any time.
PLAN YEAR 2011 COMPARISON CHART 13
COMPARISON OF BENEFITS FOR HEALTH PLANS
HMO STANDARD
OPTION
COMMUNITyCARE GLOBALHEALTH PACIFICARE
ALTERNATIVE HMO ALTERNATIVE HMO ALTERNATIVE HMO
YOUR COSTS
FOR NETWORK
SERVICES
No copay inpatient
$30 copay/PCP
$40 copay/specialist
Limit: 60 treatment
days per illness
No copay inpatient
$30 copaylPCP
$40 copay/specialist
Limit: 60 treatment
days per illness
$40 copay
Limit: 15 visits per
year
PCP referral required
No copay inpatient
$50 copay outpatient
therapy
Limit: 60 days per
illness
No copay inpatient
$50 copay outpatient
therapy
Limit: 60 days per
illness
$50 copay
Limit: 15 visits per
year
PCP referral required
No copay inpatient
$50 copay per
outpatient therapy
Limit: 60 consecutive
days per illness
No copay inpatient
$50 copay per
outpatient visit
Limit: 60 consecutive
days per illness
$50 copay
Must be preauthorized
$0 copay inpatient
$35 copaylPCP
$50 copay/specialist
Limit: 60 days per
illness
$0 copay inpatient
$35 copaylPCP
$50 copay/specialist
Limit: 60 days per
illness
$50 copay
Limit: 15 visits per
year - referral required
Limited to treatment
of neurological and
orthopedic conditions
$30 copay for initial $35 copay for initial $25 copay for initial $35 copaylPCP
visit visit visit only $50 copay/specialist
$350 copay per hospital $500 copay per hospital $250 copay per hospital for initial visit once
admission admission admission per day diagnosis of pregnancy
$750 maximum per is confirmed
admission $1,000 copay per
hospital admission
$0 copay children birth $0 copay $0 copay children birth $0 copay/PCP
- age 21 Limit: One per year - age 21
$30 copay age 22 and $25 copay age 22 and Hearing aids - covered
over Hearing aids - 20% over for children up to age
Limit: One per year coinsurance for children Limit: One per year 18
up to age 18
Hearing aids - 20% Hearing aids - 20%
coinsurance for children coinsurance
up to age 18 Covered for children up
to age 18
OCCUPATIONAL OR
SPEECH THERAPY
VISIT
PHYSICAL THERAPY/
PHYSICAL MEDICINE
VISIT
CHIROPRACTIC AND
MANIPULATIVE
THERAPY
VISIT
MATERNITY
PRE AND POST
NATAL CARE
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 pages 23-24 for contact information. .
14 PLAN YEAR 2011 COMPARISON CHART
HEALTHCHOICE HIGH OPTION
AND
HEALTHCHOICE BASIC PLAN
NETWORK:
Generic Mandate
Preferred Medication:
-If the cost of medication is $100 or less - You pay
up to $30 or actual cost if less
-If the cost of medication is more than $100 - You
pay 25% up to a $60 maximum
-Out-of-pocket maximum - $2,500 per person
using Preferred products at Network pharmacies,
then you pay $0
Non-Preferred Medication:
-If the cost of medication is $100 or less - You pay
up to $60 or actual cost if less
-If the cost of medication is more than $100 - You
pay 50% up to a $120 maximum
-Out-of-pocket maximum does not apply to
non-Preferred medications
NOTE:
• Pharmacy benefits may cover up to a 34-day
supply or 100 units, whichever is greater
• Some medications may have a limit on
quantity and/or duration of therapy
• Some medications require prior authorization
• Specialty medications are covered when
ordered through Accredo Health Group
If you choose a brand-name medication when a
generic is available, you will be responsible for
the difference in cost, plus the copay
NON-NETWORK:
Preferred Medication:
-You pay the cost of medication up to a $75
maximum plus a dispensing fee
Non-Preferred Medication:
-You pay the cost of medication up to a $125
maximum plus a dispensing fee
COMPARISON OF BENEFITS FOR HEALTH PLANS
YOUR COSTS
FOR NETWORK
SERVICES
PHARMACY
BENEFITS
$5 copay per fill for certain
prescription tobacco cessation products
HEALTHCHOICE
S-ACCOUNT PLAN
PLAN YEAR 2011 COMPARISON CHART 15
After the combined medical and pharmacy
deductible ($1,500 individuaV$3,000 family) has
been met, the pharmacy benefits are:
NETWORK:
Generic Mandate
Preferred Medication:
-If the cost of medication is $100 or less - You pay
up to $30 or actual cost if less
-If the cost of medication is more than $100 - You
pay 25% up to a $60 maximum
Non-Preferred Medication:
-If the cost of medication is $100 or less - You pay
up to $60 or actual cost if less
-If the cost of medication is more than $100 - You
pay 50% up to a $120 maximum
NOTE:
• Pharmacy benefits may cover up to a 34-day
supply or 100 units, whichever is greater
• Some medications have a limit on
quantity and/or duration of therapy
• Some medications require prior authorization
• Specialty medications are covered when
ordered through Accredo Health Group
If you choose a brand-name medication when a
generic is available, you will be responsible for
the difference in cost, plus the copay
NON-NETWORK:
Preferred Medication:
-You pay the cost of medication up to a $75
maximum plus a dispensing fee
Non-Preferred Medication:
-You pay the cost of medication up to a $125
maximum plus a dispensing fee
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 pages 23-24 for contact information.
COMPARISON OF BENEFITS FOR HEALTH PLANS
HMO STANDARD
OPTION
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
COMMUNlTyCARE GLOBALHEALTH PACIFICARE
ALTERNATIVE HMO ALTERNATIVE HMO ALTERNATIVE HMO
Tier 1: $10
Tier 2: $40
Tier 3: $65
$0 copay for selected
generics
Up to $65 non-formulary
30-day supply
Certain medications
have restricted
quantities.
Tier 1: $10
Tier 2: $50
Tier3: $75
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
YOUR COSTS
FOR NETWORK
SERVICES
PHARMACY
BENEFITS
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 pages 23-24 for contact information.
16 PLAN YEAR 2011 COMPARISON CHART
COMPARISON OF BENEFITS FOR DENTAL PLANS
YOUR COSTS
FOR NETWORK
SERVICES
HEALTHCHOICE
DENTAL
CIGNA DENTAL CARE
PLAN (PREPAID)
ASSURANT
FREEDOM
PREFERRED
ANNUAL
DEDUCTIBLE
PREVENTIVE
CARE
EX: CLEANING,
ROUTINE ORAL EXAM
ALLOWED CHARGES
APPLY
BASIC CARE
EX: EXTRACTIONS,
ORAL SURGERY
ALLOWED CHARGES
APPLY
Network: $25 Basic and
Major services combined
Non-Network: $25
Preventive, Basic, and Major
services combined
Network: $0
Non-Network: $0 of Allowed
Charges after deductible
Network: 15%
Non-Network: 30%
Deductible applies
No deductible or plan
maximum
$5 office copay applies
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
Amalgam: One surface,
permanent teeth $21
$25 per person, per year,
waived for preventive services
in-network
$0 with no deductible when
in-Network
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
ALLOWED CHARGES
APPLY
PLAN YEAR
MAXIMUM
FILING CLAIMS
Network: 40%
Non-Network: 50%
Deductible applies
Network: 50%
Non-Network: 50%
12-month waiting period may
apply
No lifetime limit for Network
or non-Network
Covered for members under
age 19 and members age 19
and older with TMD
Network and non-Network:
$2,000 per person per year
Network: No claims to file
Non-Network: You file claims
PLAN YEAR 2011 COMPARISON CHART
Root canal, anterior: $355
Periodontal/scaling/root
planing 1-3 teeth (per
quadrant): $65
$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
No maximum
No claims to file
17
Network: 40%
Non-Network: 50%
Plan pays 60% of usual and
customary when in-network
Deductible applies
Network: 40%
Non-Network: 50%
Up to $2,000 lifetime
maximum for members under
age 19*
12-month waiting period may
apply
$2,000
Member/provider must file
claims
COMPARISON OF BENEFITS FOR DENTAL PLANS
ASSURANT PREPAID PLANS
HERITAGE PLus WITH SBA
ANDHERITAGE SECURE
DELTA DENTAL PREMIER
IN-NETWORK AND
OUT-oF-N ETWORK
DELTA DENTAL
PPO-CHOICE
PPONETWORK
DELTA DENTAL PPO
IN-NETWORK AND
OUT-oF-NETWORK
$100 per person, per year,
applies to Major Care only
(Level 4)
$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
No deductibles
No charge for routine cleaning $0 of allowable amounts $0 of allowable amounts after Schedule of covered services
(once every 6 months) No deductible applies deductible and copays
No charge for topical fluoride Copay examples:
application (up to age 18) Includes diagnostic Includes diagnostic Routine cleaning $5
No charge for periodic oral Periodic oral evaluation $5
evaluations Topical fluoride application
(up to age 19) $5
Includes diagnostic
Fillings 15% of allowable amounts 30% of allowable amounts Schedule of covered services
Minor oral surgery after deductible after deductible and copays
Refer to the copayrnent schedule Copay example:
for each plan Amalgam - One surface,
primary or permanent tooth
$12
Root canal 40% of allowable amounts 50% of allowable amounts Schedule of covered services
Periodontal after deductible after deductible and copays
Crowns Copay examples:
Refer to the copayrnent schedule Crown - porcelain/ceramic
for each plan substrate $241
Complete denture - maxillary
$320
25% discount 40% of allowable amounts, 40% of allowable amounts, up You pay amounts in excess of
Adults and children up to lifetime maximum of to lifetime maximum of $2,000 $50 per month
$2,000 No deductible Lifetime maximum up to
No deductible No waiting period $1,800
No waiting period No deductible
Orthodontic benefits are No waiting period
Orthodontic benefits are available to the employee
available to the employee and his/her lawful spouse and Orthodontic benefits are
and his/her lawful spouse eligible dependent children. available to the employee
and eligible dependent and his/her lawful spouse and
children. eligible dependent children.
No annual maximum for general $2,500 per person, per year $3,000 per person, per year $2,000 per person, per year
dentist
No claims to file Claims are filed by Claims are filed by Claims are filed by
participating dentists participating dentists participating dentists
18 PLAN YEAR 2011 COMPARISON CHART
COMPARISON OF BENEFITS FOR VISION PLANS
V HUMANAICOMPBENEFITS PRIMARY VISION
VISIONCARE PLAN CARE SERVICES, INC.
I COVERED SERVICES IN-NETWORK
OUT-OF-IN-
NETWORK
OUT-OF-S
NETWORK NETWORK*
$10 copay Copays do not apply $0 copay Plan pays up to $40
I EYE EXAMS One exam for Plan pays up to $35 No limit on exams per One exam per year
eyeglasses or contacts One exam per year year
per year 0 $25 material copay Plan pays up to: You pay wholesale You pay normal
applies to lenses and! $25 single cost with no limit on doctor's fee, N or frames (single, $40 bifocals number of pairs reimbursed up to $60
lined bifocal, trifocal, $60 trifocals for one set of lenses
lenticular are covered $100 lenticular and frames per year
LENSES EACH PAIR at 100%). A discount One pair of lenses per
p applies to progressive year
lenses
One pair of lenses per
L year
A $25 material copay $25 copay You pay wholesale You pay normal doctor
applies to lenses and! Plan pays up to $45 cost. No limit on fee, reimbursed up
N or frames One pair of frames per number of frames to $60 for one set of
$45 wholesale frame year lenses and frames per
FRAMES allowance year
One pair of frames per
year
C0
$130 allowance $130 allowance for You pay wholesale Limit of one set
for conventional or exam, contacts, and cost for an annual annually in lieu of
disposable contact fitting fee supply of contacts eyeglasses M lenses and fitting fee in lieu of all other $50 service fee applies You pay normal doctor
in lieu of all other benefits to all soft contact lens fees, reimbursed up to
P CONTACT LENSES benefits Medically necessary, fittings; $75 to rigid $60
Medically necessary, Plan pays $210 or gas permeable lens
Plan pays 100% One set of contacts fittings; $150 to hybrid A One set of contacts per per year contact lens fittings
year Replacement lenses do
R not have these fees
$895 copay No benefit Discount nationwide No benefit I conventional at The Laser Center
$1,295 copay custom (TLC)
S $1,895 copay custom
LASER VISION
plus bladeless when
0 CORRECTION
services are rendered
by a TLC Network
Provider N
Vision benefits apply from January 1 through
December 31,2011
For information on limitationsfexc1usions, please
contact PVCS. See Help Lines on pages 23-24.
*Out-of-Network limited to one eye exam and
one set of eyeglasses or contact lenses annually.
Cannot be used with In-Network services.
PLAN YEAR 2011 COMPARISON CHART 19
COMPARISON OF BENEFITS FOR VISION PLANS
SUPERIOR VISION PLAN UNITEDHEALTHCARE VISION
VISION SERVICE PLAN V (VSP)
IN-NETWORK
OUT-OF-IN-
NETWORK
OUT-OF-IN-
NETWORK
OUT-OF- I
NETWORK NETWORK NETWORK S $10 copay OD-$26 max $10 copay Plan pays up to $40 $10 copay $10 copay
One exam per year MD-$34 max One exam per year One exam per year Plan pays up to $35 I0
$25 copay Plan pays up to: $25 copay Plan pays up to: $25 copay* $25 copay*
One pair of lenses $26 single One pair of lenses $40 single One set of lenses Plan pays up to:
per year $39 bifocals per year $60 bifocals per year $25 single N $49 trifocals $80 trifocals Polycarbonate $40 bifocals
$78 lenticular $80 lenticular lenses covered in $55 trifocals
full for dependent $80 lenticular
Achvieldraregne 35-40% p
savings on non-covered
lens L options
$25 copay Plan pays up to $68 $25 copay Plan pays up to $45 $25 copay* $25 copay* A Plan pays up to $130 allowance $120 allowance Plan pays up to $45
$125 One pair of frames 20% off any out-of- One pair of frames per year pocket costs above N
per year the allowance
One pair of frames
per year
$0 copay
Plan pays up to
$120
Medically
necessary contacts
are covered in full
(in lieu of glasses)
$0 copay
Plan pays up to
$100
Medically
necessary contacts,
Plan pays up to
$210
(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
lens exam and the
contact lenses
15% discount on
contact lens exam
(in lieu of glasses)
$0 copay
Plan pays up to
$105 for disposable
or conventional
contact lenses
(in lieu of glasses)
20% off retail price No benefit Members No benefit
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
Vision benefits apply from January 1 through
December 31, 2011
*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.
20 PLAN YEAR 2011 COMPARISON CHART
coMPA
R
I
SoN
How to Access the Online Provider Networks
HealthChoice Health Plans
HealthChoice High Option, Basic, and S-Account
Visit www.healthchoiceok.com
Click on Find a Provider and follow the on-screen instructions
HealthChoice USA Plan
Visit www.choicecarenetwork.com
Click on ChoiceCare Physician Finder Plus under Provider Search
Select ChoiceCare Network PPO under Coverage and Network
Follow the on-screen instructions
CommunityCare Standard and Alternative HMO
Visit www.ccok.com
Click on Find a Provider
Select State, Education and Local Government Employees
HMO Plans
GlobalHealth Standard and Alternative HMO
Visit www.globalhealth.com
Click on STATE and choose State Employees and Educators
Click on PROVIDER LOOKUP under the Provider Search tab
PacifiC are Standard and Alternative HMO
Visit www.pacificare.com
Click on Find a Doctor
Select Plan or Service Type choose PacifiCare Signature Value (HMO)
Dental Plans
HealthChoice Dental
Visit www.healthchoiceok.com
Click on Find a Provider and follow the on-screen instructions
Assurant Freedom Preferred (Options for PPO)
Visit www.assurantemployeebenefits.com
Click on Find a Dentist
Select DHA Network
21
continued from previous page
Assurant Heritage Plus with SBA and Heritage Secure (Options-for Prepaid)
Visit www.assurantemployeebenefits.com
Click on Find a Dentist
Select The Heritage Series
CIGNA Dental
Visit www.cigna.com
Click on Provider Directory
Click Dentist for the type of provider
Select CIGNA Dental Care (HMO)
Delta Dental
Visit www.DeltaDentalOK.org
Click on Click here under Welcome State of Oklahoma Employees
Click here on the 3 NEW Dental Plans for 2011 and select your dental plan
(Delta Dental PPO, Delta Premier, and Delta Dental PPO - Choice)
Vision Plans
Humana/CompBenefits Vision Care Plan
Visit www.compbenefits.com/custom/stateofoklahoma
Click on Search for Providers
Primary Vision Care Services (PVCS)
Visit www.pvcs-usa.com
Click on Find a Doctor
Superior Vision Plan
Visit www.superiorvision.com
Click on Locate a Provider
UnitedHealthcare Vision
Visit www.myuhcvision.com
Click on Provider Locator
Vision Services Plan (VSP)
Visit www.vsp.com
Either click on Find the right doctor for you under the Members tab or click on Choose VSP through
your employer under Prospective Members tab
Click on Find a VSP Doctor
Select VSP Signature Network For assistance in locating the correct provider network, contact
each plan's customer service. See Help Lines on pages 23-24.
22
HealthChoice (OSEEGIB)
Help Lines
Health and Dental Claims, Benefits,
Verification of Coverage,
and 10 Cards
Oklahoma City Area 1-405-416-1800
All Other Areas 1-800-782-5218
TDD Oklahoma City 1-405-416-1525
Area
TDD All Other Areas 1-800-941-2160
Website www.sib.ok.gov or
www.healthchoiceok.com
Pharmacy Claims/Pharmacy 10 Cards
All Areas 1-800-903-8113
TDD All Areas 1-800-825-1230
Certification
All Areas 1-800-848-8121
TDD All Areas 1-877-267-6367
Member Services/Provider Directory
Oklahoma City Area 1-405-717-8780
All Other Areas 1-800-752-9475
TDD Oklahoma City 1-405-949-2281
Area
TDDAllAreas 1-866-447-0436
HealthChoice USA
Customer Service & 1-800-782-5218
Claims
Provider Information
TDD All Areas
1-877-877-0715
ext. 4059
1-800-941-2160
Website www.choicecarenetwork.com
HMO Plans' Help Lines
CommunityCare
1-800-777-4890
1-800-722-0353
All Areas
TDD All Areas
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
PacifiCare
1-800-825-9355
1-800-557-7595
All Areas
TDD All Areas
Website www.pacificare.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
Hearing Impaired Relay Svc 1-405-948-3303
Website www.cigna.com
Delta Dental
Oklahoma City Area 1-405-607-2100
All Other Areas 1-800-522-0188
Website www.DeltaDentalOK.org
23
Vision Plans' Help Lines
HumanalCompBenefits
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
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