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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 Z I P coDE LIST 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 Mo Z I P coDE L IST HMo Z I P co DE LIST 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 24
Object Description
Description
Title | Pre-Medicare members plan guide 2011 |
OkDocs Class# | E3610.5 H677g 2011 |
Digital Format | PDF, Adobe Reader required |
ODL electronic copy | Deposited by agency in print; scanned by Oklahoma Department of Libraries 8/2011 |
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 | 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 Z I P coDE LIST 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 Mo Z I P coDE L IST HMo Z I P co DE LIST 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 24 |
Date created | 2011-08-11 |
Date modified | 2011-10-28 |