Download Report

3140
Employees Group Insurance Division
Office of Management and Enterprise Services
Monthly Premiums for Current Employees Plan Year Jan. 1 through Dec. 31, 2015
HEALTH PLANS
MEMBER
HealthChoice High
HealthChoice High Alternative
HealthChoice Basic
HealthChoice Basic Alternative
HealthChoice High Deductible Health Plan (HDHP)
HealthChoice USA
CommunityCare HMO
GlobalHealth HMO
$ 499.42
$ 499.42
$ 391.52
$ 391.52
$ 338.02
$ 764.44
$ 711.34
$ 469.02
DISABILITY (Employee only)
SPOUSE
CHILD
$ 676.28
$ 676.28
$ 501.74
$ 501.74
$ 430.60
$ 764.44
$ 1,036.16
$ 769.22
$ 253.56
$ 253.56
$ 215.94
$ 215.94
$ 186.80
$ 251.06
$ 362.30
$ 247.18
CHILDREN
$ 391.20
$ 391.20
$ 342.74
$ 342.74
$ 295.24
$ 387.16
$ 579.68
$ 394.04
$9.10 (Limited county participation only)
DENTAL PLANS
MEMBER SPOUSE
HealthChoice Dental
Assurant Freedom Preferred
Assurant Heritage Plus with SBA (Prepaid)
Assurant Heritage Secure (Prepaid)
Cigna Dental Care Plan (Prepaid)
Delta Dental PPO
Delta Dental PPO Plus Premier
Delta Dental PPO — Choice
$ 32.00
$ 28.82
$ 11.74
$ 7.20
$ 9.26
$ 33.64
$ 47.98
$ 15.06
VISION PLANS
$ 32.00
$ 28.66
$ 8.86
$ 5.98
$ 6.06
$ 33.62
$ 47.98
$ 34.18
MEMBER SPOUSE
Humana/CompBenefits VisionCare Plan
Primary Vision Care Services (PVCS)
Superior Vision
UnitedHealthcare Vision
Vision Care Direct
Vision Service Plan (VSP)
$ 7.14
$ 9.00
$ 7.40
$ 8.18
$ 14.16
$ 9.50
LIFE
HealthChoice Basic Life ($20,000) $4.00
$ 12.46
$ 8.00
$ 7.36
$ 5.78
$ 8.50
$ 6.36
CHILD
$ 27.40
$ 21.50
$ 7.60
$ 5.20
$ 7.08
$ 29.26
$ 41.76
$ 34.44
CHILD
$ 10.90
$ 8.00
$ 6.96
$ 4.58
$ 8.50
$ 6.12
CHILDREN
$ 68.20
$ 57.80
$ 15.20
$ 10.38
$ 15.32
$ 74.04
$ 105.66
$ 83.60
CHILDREN
$ 11.84
$ 11.00
$ 14.30
$ 6.98
$ 12.00
$ 13.72
First $20,000 of Supplemental Life $4.00
SUPPLEMENTAL LIFE — Age Rated Cost Per $20,000 Unit
< 30 -------- $ 0.80
40 - 44 ---- $ 1.20
55 - 59 ---- $ 6.00
70 - 74 ---- $19.20
DEPENDENT LIFE
Spouse
Child (live birth to age 26)
30 - 34
45 - 49
60 - 64
75+
Low Option $2.60
$6,000 of coverage
$3,000 of coverage
-------------
$ 0.80
$ 2.00
$ 6.80
$29.60
Standard Option $4.32
$10,000 of coverage
$ 5,000 of coverage
Dependent Life does not include Accidental Death and Dismemberment (AD&D).
35 - 39 ---- $ 0.80
50 - 54 ---- $ 4.00
65 - 69 ---- $11.20
Premier Option $8.64
$20,000 of coverage
$10,000 of coverage
EGID Mission, Vision, Values and Behaviors Statements
Mission Statement
In an ever-changing environment, we are committed to serving the State of Oklahoma by providing,
with the highest degree of efficiency, a wide range of quality insurance benefits that are competitively
priced and uniquely designed to meet the needs of our defined population.
Vision Statement
To protect the participant’s health, wellness and financial futures by leveraging technology and
industry best practices to administer innovated insurance plans.
Values and Behaviors
Customer Service
To provide prompt and professional interaction with each individual and entity and require the
same for each contracted vendor.
Confidentiality
To protect confidential information.
Teamwork
To encourage a collaborative effort throughout the Division to achieve common goals.
Continuous Improvement
Keeping competitive by improving skills, innovative technology, and utilizing creative approaches.
Communication
Striving for transparency, accuracy and clarity in all communications.
This publication was printed by the Office of Management and Enterprise Services as authorized by Title 62, Section 34. 20,000 copies have
been printed at a cost of $13,630.75. A copy has been submitted to Documents.OK.gov in accordance with the Oklahoma State Government
Open Documents Initiative (62 O.S. 2012, § 34.11.3). This work is licensed under a Creative Attribution-NonCommercial-NoDerivs 3.0
Unported License.
A fully accessible version of this guide is available on the EGID website at www.sib.ok.gov or www.healthchoiceok.com.
TABLE OF CONTENTS
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i
2015 Plan Changes and Important Reminders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
General Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Health Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Dental Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Vision Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
HealthChoice Life Insurance Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
HealthChoice Disability Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
American Fidelity Health Savings Account . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Oklahoma Tobacco Helpline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Enrollment Periods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
HMO ZIP Code Lists . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Comparison of Network Benefits for Health Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Comparison of Benefits for Dental Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . .24
Comparison of Benefits for Vision Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26
Contact Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29
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 documents, insurance contracts, handbooks and Administrative Rules of the Employees
Group Insurance Division of the Office of Management and Enterprise Services. The rules of the Oklahoma
Administrative Code, Title 260, 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 healthchoiceok.com
INTRODUCTION
The Office of Management and Enterprise Services Employees Group Insurance Division (EGID) produced this guide
as a summary of the benefits offered by the health, dental, vision, life and disability plans available for eligible new and
current education and local government employees.
Refer to the Monthly Premium Chart and Comparison of Benefits charts to determine your costs under each plan.
Helpful Hints for Option Period
♦ Review Section B of your pre-printed Option Period Enrollment/Change Form listing your most current
coverage.
♦ Contact your Insurance Coordinator (IC) if you have questions about your current coverage.
♦ Review the plan changes for 2015 beginning on page 1 of this guide.
♦ Ask your IC if you should return your form even if you are not making changes.
♦ Use the following additional resources to help you choose coverage for next year:
● Plan provider directories;
● Summaries of Benefits and Coverage;
● Your Insurance Coordinator; and
● Contact Information on page 29
♦ Complete your Option Period Enrollment/Change Form and return it to your IC by the deadline set by your
Insurance Coordinator.
♦ Review your Confirmation Statement (CS) when you receive it in the mail to verify your coverage is correct.
♦ Contact your IC right away if your CS is incorrect. If you do not make changes to your coverage and you
are not automatically enrolled in one of the HealthChoice Alternative Plans (refer to page 1), you will not
receive a CS from EGID. Keep a copy of your Option Period Enrollment/Change Form as verification of your
insurance coverage.
Helpful Hints for New Employees
♦
♦
♦
♦
Use the above additional resources to help you choose coverage.
Complete your Insurance Enrollment Form and return it to your IC.
Review your CS when you receive it in the mail to verify your coverage is correct.
Contact your IC right away if your CS is incorrect.
i
2015 PLAN CHANGES AND IMPORTANT REMINDERS
Plan changes are indicated by bold text in the Comparison of Benefits charts.
HealthChoice Basic Plans
♦ The calendar year deductible for the HealthChoice Basic Plan is increasing from $500 to $1,000 for an
individual and from $1,000 to $1,500 for a family. The out-of-pocket maximum is decreasing from $5,500 to
$4,000 for an individual and from $11,000 to $9,000 for a family.
♦ The calendar year deductible for the HealthChoice Basic Alternative Plan is increasing from $750 to $1,250 for
an individual and from $1,500 to $1,750 for a family. The out-of-pocket maximum is decreasing from $5,750 to
$4,000 for an individual and from $11,500 to $9,000 for a family.
HealthChoice High Deductible Health Plan (formerly S-Account)
♦ The name of the HealthChoice S-Account is changing to the HealthChoice High Deductible Health Plan.
♦ The annual maximum contribution amounts are changing from $3,300 to $3,350 for an individual and from
$6,550 to $6,650 for a family.
CommunityCare HMO
♦ CommunityCare has made changes to the network of providers available for state, education and local
government members in 2015. Please review the updated provider directory on the website at state.ccok.com to
confirm the status of your provider(s).
Reminder – All Health Plans
♦ Review your plan’s 2015 formulary, excluded medications list, and any prior authorization or quantity limit lists
by visiting the plan’s website.
Reminder
To complete your HealthChoice tobacco-free Attestation, log on to HealthConnect at https://gateway.sib.ok.gov/
Attestation. The Attestation is open from Aug. 1, 2014, through Nov. 14, 2014, and is required for all members who
are tobacco-free starting their second plan year on the HealthChoice High or Basic Plan (first plan year is waived). If
you cannot complete the tobacco-free Attestation because you or your covered dependents are not tobacco-free, you can
still qualify for the HealthChoice High or Basic Plan if you can provide one of the following Reasonable Alternatives:
♦ Show proof of an attempt to quit using tobacco by enrolling in the quit tobacco program available through the
Oklahoma Tobacco Helpline and Alere Wellbeing AND completing three coaching calls by Nov. 14, 2014; or
♦ Provide a letter from your doctor by Nov. 14, 2014, indicating it is not medically advisable for you or your
covered dependents to quit tobacco.
If you do not complete the tobacco-free Attestation or complete one of the Reasonable Alternatives as defined above,
you will automatically be enrolled in the HealthChoice High Alternative or Basic Alternative Plan, and your annual
deductible and out-of-pocket maximum will be $250 higher. For more information on tobacco cessation products and
resources to help you quit, go to http://www.ok.gov/sib/Tobacco_Free.html.
1
If you have questions about any of the
plan changes or need additional
information, please contact the plan
directly. Refer to Contact Information on
page 29.
2
GENERAL INFORMATION
Your employer determines which benefits are available to you and may not participate in all the benefits explained in
this guide. Ask your IC which benefits are available to you.
The benefits you select will be in effect Jan. 1, 2015, or for new employees, the effective date of your coverage,
through Dec. 31, 2015, or your termination date if earlier.
After enrollment, the plans you selected will provide more information about your benefits. Contact the plan directly
with your benefit questions.
Once enrolled in any of the plans, it is your responsibility to review your benefits carefully so you know what is
covered, as well as the plan’s policies and procedures, before you use your benefits.
HEALTH PLANS
There are eight health plans available:
♦ HealthChoice High and High Alternative Plans
♦ HealthChoice USA Plan
♦ HealthChoice Basic and Basic Alternative Plans
♦ CommunityCare HMO
♦ HealthChoice HDHP
♦ GlobalHealth HMO
Refer to the Comparison of Network Benefits for Health Plans on pages 16-23 for specific benefit
information.
♦ There are no preexisting condition exclusions or limitations applied to any of the health plans.
♦ You can become tobacco-free at any time, but HealthChoice High or Basic Plan enrollees must complete the
Attestation or a Reasonable Alternative during Option Period, unless the grace period applies to you. Visit
www.sib.ok.gov or www.healthchoiceok.com.
♦ The HealthChoice USA Plan is designed for employees who receive a work assignment of 90 or more
consecutive days outside of Oklahoma and Arkansas.
♦ HealthChoice contracts with American Fidelity Health Services Administration to make establishing and
keeping a health savings account (HSA) easier and more convenient for HealthChoice HDHP members. For
more information about HSAs, refer to page 6.
♦ You must live or work within an HMO’s ZIP code service area to be eligible. Post office box addresses cannot
be used to determine your HMO eligibility. Refer to pages 12-15 for the HMO ZIP Code Lists.
♦ If you select an HMO, you must use the provider network designated by that plan for Oklahoma.
♦ All health plans coordinate benefits with other group insurance plans you have in force.
DENTAL PLANS
There are eight dental plans available:
♦ Assurant Freedom Preferred
♦ Delta Dental PPO
♦ Assurant Heritage Plus with SBA (Prepaid)
♦ Delta Dental PPO Plus Premier
♦ Assurant Heritage Secure (Prepaid)
♦ Delta Dental PPO – Choice
♦ CIGNA Dental Care Plan (Prepaid)
♦ HealthChoice Dental
Refer to the Comparison of Benefits for Dental Plans on pages 24-25 for specific benefit information.
3
VISION PLANS
There are six vision plans available:
♦ Humana/CompBenefits VisionCare Plan
♦ Primary Vision Care Services (PVCS)
♦ Superior Vision
♦ UnitedHealthcare Vision
♦ Vision Care Direct
♦ Vision Service Plan (VSP)
Refer to the Comparison of Benefits for Vision Plans on pages 26-27 for specific benefit information.
♦ Verify your vision provider participates in a vision plan’s network by contacting the plan, visiting the plan’s
website or calling your provider.
♦ All vision plans have limited coverage for services provided by out-of-network providers.
If your provider leaves your health, dental or vision plan, you cannot change plans until the next annual Option
Period; however, you can change providers within your plan’s network as needed.
Retiring and Changing Plans
If you are retiring on or before Jan. 1, 2015, go to www.sib.ok.gov or www.healthchoiceok.com for the appropriate
Option Period materials. Select the Option Period button, then select according to your status as of Jan. 1 –
Pre-Medicare or Medicare. Your Insurance Coordinator can assist you and must also provide you the required
Application for Retiree/Vested/Non-Vest/Defer Insurance. If you and/or your dependent(s) will be Medicare eligible
by Jan. 1, an additional form will be required for Part D. You can also call EGID Member Services. Refer to Contact
Information on page 29.
HEALTHCHOICE LIFE INSURANCE PLAN
♦ As a new employee, you can elect life insurance coverage within 30 days of your employment or initial
eligibility date. You can enroll in Guaranteed Issue, in addition to Basic Life, without a Life Insurance
Application. Guaranteed Issue is two times your annual salary rounded up to the nearest $20,000. All requests
for supplemental coverage above Guaranteed Issue require an approved Life Insurance Application.
♦ As a current employee, if you did not enroll when first eligible, you can enroll with an approved Life Insurance
Application:
● During the annual Option Period (enroll in or increase life coverage); or
● Within 30 days of a midyear qualifying event, such as birth of a child or marriage.
As a current employee, you can enroll in life insurance coverage within 30 days of the loss of other group life coverage.
You are eligible to enroll in the amount of coverage you lost rounded up to the next $20,000 unit without an approved
Life Insurance Application. Proof of loss is required.
Basic Life Insurance. . . For You
♦ Basic Life pays a benefit of $20,000 to your beneficiary in the event of your death.
♦ Basic Life includes Accidental Death and Dismemberment (AD&D) coverage, which pays an additional
$20,000 to your beneficiary if your death is due to an accident. It also pays benefits if you lose your sight or a
limb due to an accident.
Supplemental Life Insurance . . . For You
♦ You can enroll in Supplemental Life in units of $20,000. The maximum amount of Supplemental Life coverage
available is $500,000. You must complete a Life Insurance Application to apply for coverage.
♦ The first $20,000 of Supplemental Life provides an additional $20,000 of AD&D coverage.
4
Beneficiary Designation
For Basic and Supplemental Life benefits, you must name your beneficiary(ies) when you enroll. Your designation
can be changed at any time. For a Beneficiary Designation Form or more information, contact your IC. This form is
also available at www.healthchoiceok.com or www.sib.ok.gov. Life insurance benefits are paid according to the
information on file.
Dependent Life Insurance . . . For Your Eligible Dependents
♦ If you are enrolled in Basic Life insurance, you can elect Dependent Life for your spouse and other eligible
dependents during your initial enrollment, the annual Option Period, or within 30 days of the loss of other group
life insurance or other midyear qualifying event without a Life Insurance Application.
♦ Each eligible dependent must be enrolled in Dependent Life. Regardless of the number of dependents, the
monthly premium is a flat amount. Benefits are paid only to the member. Below are the three levels of coverage:
DEPENDENT
LOW OPTION
STANDARD OPTION
Spouse
$6,000 of coverage
Child (live birth to age 26)
$3,000 of coverage
Dependent Life does not include AD&D coverage.
$10,000 of coverage
$ 5,000 of coverage
PREMIER OPTION
$20,000 of coverage
$10,000 of coverage
HEALTHCHOICE DISABILITY PLAN
The HealthChoice Disability Plan provides partial replacement income if you are unable to work due to an illness or
injury. Disability coverage is not available to dependents.
Eligibility
Enrollment in the Disability Plan begins the first day of the month following your employment date or the date you
become eligible. You become eligible for disability benefits after 31 consecutive days of employment. During that time,
you must continuously perform all of the material duties of your regular occupation. Any claim for disability benefits
must be filed within one year of the date your disability began.
5
HEALTH SAVINGS ACCOUNTS
A Health Savings Account (HSA) is an individually owned savings account that allows you to set aside money for
health care tax-free whenever you select an HSA qualified High Deductible Health Plan (HDHP). Money left in the
account can accumulate interest tax-free and money used to pay for qualified medical expenses can be made tax-free.
Through your employers Section 125 plan, you can contribute pre-tax amounts up to the yearly maximum allowed.
SOME HIGHLIGHTS OF HSAs
HSA contributions are tax-free.
Interest may be tax-free.
Interest earned is applied to your account starting with first dollar contribution.
Withdrawals are not taxed when funds are used for qualified medical expenses.
You decide when and how to use your money.
No “use it or lose it” requirement meaning whatever deposits you make each year can be left on deposit to earn
interest and to be available to pay for future medical expenses.
♦ You can pay for qualified medical expenses on yourself, and your spouse or your tax dependents regardless of
whether or not they are on your health plan.
♦ No matter where you go, your account follows you. Even if you change jobs, change medical coverage, become
unemployed, move to another state, or change your marital status, your HSA goes with you. You own it!
♦ If you do not remain a qualified individual, you can continue to earn interest and pay for qualified medical
expenses as long as there are funds in your account.
♦
♦
♦
♦
♦
♦
CONTRIBUTIONS
You can contribute up to the annual maximum amount allowed by law in any given tax-year. The IRS establishes
the maximum amounts on an annual basis. The 2014 maximum allowable is $3,300 for an individual or $6,550 for a
family. The 2015 maximum allowable contribution is $3,350 for an individual or $6,650 for a family. If your HDHP is
effective other than January 1 and you wish to make the maximum contribution, you must meet certain requirements.
Go to www.afhsa.com for more information.
If you are age 55 and older, you are eligible to make a catch-up contribution of $1,000. HSAs are owned by one
individual, so if you and your spouse are covered under the family HDHP and both of you are age 55 or older, only you
as the owner of the account can make the catch up contribution. Your spouse would be required to establish his or her
own HSA to make catch-up contributions.
QUALIFIED MEDICAL EXPENSES
There are many expenses that qualify for tax-free distributions. For a listing, you can refer to the HSA Eligible
Expenses listed on www.afhsa.com. If you use funds for any expenses that are not eligible, then the funds withdrawn
are subject to income taxes and a 20% additional tax penalty. The non-qualified distributions must be reported on your
annual income tax return.
Additional information on eligible expenses can be found in IRS Publication 502 at www.irs.gov. Even though
Publication 502 is a valuable resource on what qualifies as a medical expense, it addresses only what expenses are
deductible. It does not describe the different rules for reimbursing medical expenses under an HSA.
MAKING WITHDRAWALS FROM YOUR HSA
You can withdraw funds from your account in three ways: 1. HSA Debit Card; 2. On-Line Distribution Request; 3.
Distribution Form. You can use the money from your HSA as follows:
1. You can only use the funds that have been deposited.
2. You can withdraw funds for qualified medical expenses incurred after the date your account is established.
3. You may elect to make withdrawals from your HSA when the expenses are incurred, or you may make
withdrawals for these expenses anytime in the future. There is no time limit.
SB-22136 0512(State of Oklahoma)-513
6
The IRS requires that you keep receipts to prove that your HSA funds were used to pay for qualified medical expenses
in order to receive the tax benefit. Although you are not required to send your receipts with your tax returns, keeping
your receipts with your tax information is an excellent way to ensure proper documentation. You will receive two forms
each year as a result of having an HSA: 1) a 1099-SA which shows the total distributions from your account will be
mailed by January 31, and 2) a 5498-SA which shows total contributions to your account will be mailed by May 31.
Each of these forms will be sent to the IRS.
ELIGIBILITY REQUIREMENTS
To be eligible to establish and contribute to an HSA, you must meet the following requirements:
♦ You must have an HSA qualified HDHP.
♦ You cannot be claimed as a dependent on anyone else’s tax return.
♦ You cannot be covered under a non-HDHP coverage other than “permitted coverage” or “permitted insurance”
and/or preventative care. Products such as Cancer, Accident, Long Term Care, and Disability Income are usually
considered permitted coverage/insurance. Check with your employer or the insurance provider to be sure.
♦ You cannot have a general purpose Health FSA-Medical Reimbursement Account or a general purpose Health
Reimbursement Account (HRA). However, you can have a Limited Purpose Health FSA or HRA which allows
for dental and vision reimbursement only should your employer offer this benefit. Note: If you are covered
under your spouse’s general purpose Health FSA or HRA, then you are not eligible to establish and contribute
to an HSA. In addition, your eligibility may be affected if you have access to the following: Employer’s on-site
clinic, VA benefits, Tri-Care or an Indian Clinic.
♦ You cannot be enrolled in Medicare.
INTEREST & ACCOUNT FEES
HSA funds are deposited into an interest bearing FDIC insured account. The more you save the more you earn.
Monthly maintenance and transaction fees may apply and will be deducted from your account. Check with your
employer for the interest/fee schedule.
If you seek higher returns or value security, we do not charge transaction fees or broker commissions when we give
you access to investment fund options that cover the spectrum of investment risks. (Fees associated with certain mutual
funds may be incurred. Review the mutual funds prospectus for additional information when you are ready to invest.)
SUMMARY
HSAs give you the savings potential, flexibility, portability, and tax savings unlike any other savings account. By
enrolling in a qualified HDHP, you save on premiums. By investing those savings into an HSA, you can save for
medical expenses in the future.
Individuals who elect an HSA with us will receive a welcome packet outlining all the information associated with the
account. This flyer is meant to provide you high level information on HSAs. For more information on HSAs visit our
website at www.afhsa.com. There you will find an overview specific to employees/individuals along with other helpful
information.
CONTACT INFORMATION
American Fidelity Health Services Administration
2000 N. Classen Blvd., Suite 7E
Oklahoma City, OK 73106
(405) 523-5699 Local Number
Toll-free 1-866-326-3600
Fax (405) 523-5072
Web site - www.afhsa.com
Email - HSA-Support@af-group.com
American Fidelity Health Services Administration and its affiliates do not provide legal or tax advice and the information provided is general in nature and
should not be considered legal or tax advice. You should consult with an attorney or tax professional regarding legal or tax advice.
7
SB-22136 0512(State of Oklahoma)-513
What is the Oklahoma Tobacco Helpline?
The Helpline is a highly effective tobacco cessation program that provides a series of one-on-one
coaching sessions over the telephone. Once enrolled in the program, most participants also receive
nicotine replacement products such as patches, gum or lozenges. The Helpline has been proven to
work for Oklahomans, and similar Helplines have been proven to work for people all over the country.
How does telephone coaching work?
Identify yourself as a HealthChoice participant when you call the Helpline at 1-800-QUIT-NOW.
You’ll speak with a helpful registration assistant who will gather basic contact information and ask
a few questions about your reason for calling. Then, a Helpline Quit Coach™ will work with you to
determine your readiness to quit, discuss your options for using nicotine replacement products or other
cessation aids, and assist you in developing a quit plan that is right for you. The Quit Coach will also
schedule up to four follow-up sessions throughout your quitting process and you can call in to speak
with a coach as needed between scheduled calls.
Who is eligible to receive Helpline services?
Anyone living in Oklahoma age 13 or older can call the Helpline and receive services at no charge up
to twice per year. Helpline specialists assist tobacco users, health care professionals, and concerned
family members and friends. The level of services available will depend on an individual’s age and
insurance status.
Do HealthChoice participants have to be tobacco-free?
To remain enrolled in the HealthChoice High or HealthChoice Basic Plan, participants must attest that
they and their covered dependents are tobacco-free. For participants who can’t complete the tobaccofree Attestation and would like to remain on the HealthChoice High or Basic Plan, they can still
qualify by completing one of the following Reasonable Alternative options:
1. Enrolling in the quit tobacco program as mentioned on this flyer and completing three coaching
calls prior to the deadline within the calendar year of their Option Period.
2. Providing a letter from their physician prior to the deadline.
What are the Oklahoma Tobacco Helpline hours?
The Helpline is available 24 hours a day, 7 days a week.
Do HealthChoice members receive additional Helpline benefits?
HealthChoice members enrolled in the Helpline program can receive up to 12 weeks of nicotine
replacement products up to twice per year with no copay or deductible. The products are mailed
directly to your home.
8
ENROLLMENT PERIODS
Option Period Enrollment – Coverage effective Jan. 1, 2015
This is the time when eligible employees can:
● Enroll in coverage;
● Change plans or drop coverage;
● Increase or decrease life coverage; or
● Add or drop eligible dependents from coverage.
♦ You can enroll in health, dental, life and/or vision coverage for yourself and/or your dependent(s) during the annual
Option Period, as long as you have not dropped that coverage within the past 12 months. If you have dropped
coverage within the past 12 months without a midyear qualifying event, limitations and/or exceptions may apply.
♦ Keep a copy of your Option Period Enrollment/Change Form for your records.
Initial Enrollment – Coverage effective the first of the month following your
employment date or the date set by your employer
This is the time when new employees are eligible to:
● Enroll in coverage;
● Enroll eligible dependents; and
● Enroll in Guaranteed Issue life or apply for greater coverage by submitting a Life Insurance
Application.
As a new employee, you have 30 days from your employment or eligibility date to enroll in coverage. If you do not
enroll within 30 days, you cannot enroll until the next annual Option Period, unless you experience a qualifying event.
Check with your IC for more information.
You have 30 days following your eligibility date to make changes to your original enrollment.
Keep a copy of your Insurance Enrollment Form for your records.
Midyear Changes – Coverage generally effective the first of the month
following a qualifying event
Midyear plan changes are allowed only when a qualifying event, such as birth, marriage or loss of other group
coverage, occurs. You must complete an Insurance Change Form within 30 days of the event. Your IC has more
information.
ELIGIBILITY
Members
♦ Your employer must participate in the plans offered through EGID.
♦ You must be a current education employee eligible to participate in the Oklahoma Teachers Retirement System
working a minimum of four hours per day or 20 hours per week, or a current local government employee
regularly scheduled to work at least 1,000 hours a year, and not classified as temporary or seasonal.
♦ You must be enrolled in a group health plan to enroll in dental and/or life insurance.
9
Dependents
♦ If one eligible dependent is covered, all eligible dependents must be covered. Exceptions apply (refer to
Excluding Dependents from Coverage below).
♦ Eligible dependents include:
● Your legal spouse (including common-law);
● Your daughter, son, stepdaughter, stepson, eligible foster child, adopted child or child legally placed
with you for adoption up to age 26, whether married or unmarried;
● A dependent, regardless of age, who is incapable of self-support due to a disability that was
diagnosed prior to age 26. Subject to medical review and approval; and
● Other unmarried dependent children up to age 26, upon completion and approval of an Application
for Coverage for Other Dependent Children. Guardianship papers or a tax return showing
dependency can be provided in lieu of the application.
♦ If your spouse is enrolled separately in one of the EGID plans, your dependents can be covered under either
parent’s health, dental and/or vision plan (but not both); however, both parents can cover dependents under
Dependent Life.
♦ Dependents who are not enrolled within 30 days of your eligibility date cannot be enrolled until the next
annual Option Period, unless a qualifying event such as birth, marriage or loss of other group coverage occurs.
Dependents can be dropped midyear with a qualifying event. Otherwise, the 12-month requirement applies
before reinstatement is possible during the next annual Option Period.
♦ Dependents can be enrolled only in the same types of coverage and in the same plans you elect.
♦ To enroll your newborn, an Insurance Change Form must be provided to your IC within 30 days of the birth.
This coverage is effective the first of the birth month. If you do not enroll your newborn during this 30-day
period, you cannot do so until the next annual Option Period. Direct notification to a plan will not enroll your
newborn or any other dependents. The newborn’s Social Security number is not required at the time of initial
enrollment, but must be provided once it is received from Social Security. Insurance premiums for the month
the child was born must be paid. Under the HealthChoice Plans, a separate deductible and coinsurance applies.
♦ Without enrollment, newborns are covered only for the first 48 hours following a vaginal birth or the first 96
hours following a cesarean section birth under HealthChoice. Deductible and coinsurance may apply.
♦ CommunityCare and GlobalHealth HMO - A newborn is covered for 31 days without an additional premium.
Excluding Dependents from Coverage
♦ You can exclude your spouse from health and/or dental coverage while covering other dependents on these
benefits. Your spouse must sign the Spouse Exclusion Certification section of the enrollment or change form.
♦ You can exclude dependents who do not reside with you, are married, are not financially dependent on you for
support, have other group coverage or are eligible for Indian or military health benefits.
Note: Your spouse cannot be excluded from vision coverage if your other dependents are covered unless your spouse
has proof of other group vision coverage. You must always provide proof of other group coverage to your Insurance
Coordinator when excluding a dependent for that reason.
Confirmation Statement (CS)
♦ You are mailed a CS when you enroll or make changes to your coverage. Your CS lists the coverage you are
enrolled in, the effective date of your coverage and the premium amounts.
♦ Always review your CS to verify your coverage is correct. Corrections to your coverage must be submitted to
your IC within 60 days of your election. Corrections reported after 60 days are effective the first of the month
following notification.
10
♦ Section B of your Option Period Enrollment/Change Form lists your most current coverage. If you don’t make
changes and you are not automatically enrolled in one of the HealthChoice Alternative Plans, you will not
receive a CS from EGID. Keep a copy of your Option Period Enrollment/Change Form as verification of your
coverage.
Transfer Employee
♦ You can keep your coverage continuous when you move from one participating employer to another as long as
there is no break in coverage that lasts longer than 30 days. Premiums must be paid upon reporting to work.
♦ Benefit options vary from employer to employer. Changes to your coverage must be made within the first 30
days of your transfer. Your IC has more information.
Termination of Coverage
♦ Coverage will end the last day of the month in which a termination event occurs. such as:
● Loss of employment;
● Reduction in hours;
● Loss of dependent eligibility;
● Non-payment of premiums; or
● Death.
COBRA – Temporary Continuation of Coverage
♦ The Consolidated Omnibus Budget Reconciliation Act (COBRA) allows you and/or your dependents to
continue health, dental and/or vision insurance coverage after your employment terminates or after your
dependent loses eligibility. Certain time limits apply to enrollment. Contact your IC immediately upon
termination of your employment, or when changes to your family status occur, to find out more about your
COBRA rights. Be aware, dropping dependent coverage during Option Period is not a COBRA qualifying
event.
11
CommunityCare ZIP Code List
2
0
1
5
H
M
O
Z
I
P
C
O
D
E
L
I
S
T
S
74001
74009
74016
74023
74033
74041
74048
74056
74066
74074
74082
74104
74114
74126
74133
74146
74155
74171
74189
74332
74342
74352
74361
74368
74422
74430
74438
74447
74457
74464
74471
74523
74546
74557
74565
74633
74738
74880
74936
74944
74953
74962
74002
74010
74017
74027
74034
74042
74050
74058
74067
74075
74083
74105
74115
74127
74134
74147
74156
74172
74192
74333
74343
74353
74362
74369
74423
74431
74440
74450
74458
74465
74472
74526
74547
74558
74567
74637
74743
74901
74937
74945
74954
74964
74003
74011
74018
74028
74035
74043
74051
74059
74068
74076
74084
74106
74116
74128
74135
74148
74157
74182
74193
74335
74344
74354
74363
74370
74425
74432
74441
74451
74459
74466
74477
74528
74548
74559
74570
74650
74756
74902
74939
74946
74955
74965
74004
74012
74019
74029
74036
74044
74052
74060
74070
74077
74085
74107
74117
74129
74136
74149
74158
74183
74194
74337
74346
74355
74364
74401
74426
74434
74442
74452
74460
74467
74501
74529
74549
74560
74571
74652
74759
74930
74940
74947
74956
74966
12
74005
74013
74020
74030
74037
74045
74053
74061
74071
74078
74101
74108
74119
74130
74137
74150
74159
74184
74301
74338
74347
74358
74365
74402
74427
74435
74444
74454
74461
74468
74502
74536
74552
74561
74574
74653
74760
74931
74941
74948
74957
74006
74014
74021
74031
74038
74046
74054
74062
74072
74080
74102
74110
74120
74131
74141
74152
74169
74186
74330
74339
74349
74359
74366
74403
74428
74436
74445
74455
74462
74469
74521
74543
74553
74562
74577
74727
74761
74932
74942
74949
74959
74008
74015
74022
74032
74039
74047
74055
74063
74073
74081
74103
74112
74121
74132
74145
74153
74170
74187
74331
74340
74350
74360
74367
74421
74429
74437
74446
74456
74463
74470
74522
74545
74554
74563
74578
74735
74845
74935
74943
74951
74960
GlobalHealth ZIP Code List
73001
73008
73015
73022
73029
73037
73045
73053
73061
73068
73075
73084
73095
73103
73110
73117
73124
73131
73140
73147
73154
73163
73173
73190
73425
73437
73444
73455
73481
73505
73526
73533
73541
73549
73556
73564
73571
73625
73641
73650
73661
73669
73002
73009
73016
73023
73030
73038
73047
73054
73062
73069
73077
73085
73096
73104
73111
73118
73125
73132
73141
73148
73155
73164
73177
73194
73430
73438
73446
73456
73487
73506
73527
73534
73542
73550
73557
73565
73572
73626
73642
73651
73662
73673
73003
73010
73017
73024
73031
73040
73048
73055
73063
73070
73078
73086
73097
73105
73112
73119
73126
73134
73142
73149
73156
73165
73178
73195
73432
73439
73447
73458
73488
73507
73528
73536
73543
73551
73558
73566
73573
73627
73644
73654
73663
73701
73004
73011
73018
73025
73032
73041
73049
73056
73064
73071
73079
73089
73098
73106
73113
73120
73127
73135
73143
73150
73157
73167
73179
73196
73433
73440
73448
73459
73491
73520
73529
73537
73544
73552
73559
73567
73601
73628
73645
73655
73664
73702
73005
73012
73019
73026
73033
73042
73050
73057
73065
73072
73080
73090
73099
73107
73114
73121
73128
73136
73144
73151
73159
73169
73184
73401
73434
73441
73449
73460
73501
73521
73530
73538
73546
73553
73560
73568
73620
73632
73646
73658
73666
73703
13
73006
73013
73020
73027
73034
73043
73051
73058
73066
73073
73082
73092
73101
73108
73115
73122
73129
73137
73145
73152
73160
73170
73185
73402
73435
73442
73450
73461
73502
73522
73531
73539
73547
73554
73561
73569
73622
73638
73647
73659
73667
73705
73007
73014
73021
73028
73036
73044
73052
73059
73067
73074
73083
73093
73102
73109
73116
73123
73130
73139
73146
73153
73162
73172
73189
73403
73436
73443
73453
73463
73503
73523
73532
73540
73548
73555
73562
73570
73624
73639
73648
73660
73668
73706
2
0
1
5
H
M
O
Z
I
P
C
O
D
E
L
I
S
T
S
GlobalHealth ZIP Code List
2
0
1
5
H
M
O
Z
I
P
C
O
D
E
L
I
S
T
S
73716
73726
73734
73742
73753
73760
73770
73834
73844
73858
73937
73947
74004
74013
74020
74029
74036
74044
74052
74060
74070
74077
74084
74106
74116
74128
74135
74148
74157
74182
74331
74340
74349
74360
74367
74421
74429
74437
74445
74455
74462
74470
74525
73717
73727
73735
73743
73754
73761
73771
73835
73848
73859
73938
73949
74005
74014
74021
74030
74037
74045
74053
74061
74071
74078
74085
74107
74117
74129
74136
74149
74158
74186
74332
74342
74350
74361
74368
74422
74430
74438
74446
74456
74463
74471
74528
73718
73728
73736
73744
73755
73762
73772
73838
73851
73860
73939
73950
74006
74015
74022
74031
74038
74046
74054
74062
74072
74079
74101
74108
74119
74130
74137
74150
74159
74187
74333
74343
74352
74362
74369
74423
74431
74439
74447
74457
74464
74477
74529
73719
73729
73737
73746
73756
73763
73773
73840
73852
73901
73942
73951
74008
74016
74023
74032
74039
74047
74055
74063
74073
74080
74102
74110
74120
74131
74141
74150
74169
74192
74335
74344
74354
74363
74370
74425
74432
74440
74450
74458
74465
74501
74530
14
73720
73730
73738
73747
73757
73764
73801
73841
73853
73931
73944
74001
74010
74017
74026
74033
74041
74048
74056
74066
74074
74081
74103
74112
74121
74132
74145
74153
74170
74193
74337
74345
74355
74364
74401
74426
74434
74441
74451
74459
74467
74521
74531
73722
73731
73739
73749
73758
73766
73802
73842
73855
73932
73945
74002
74011
74018
74027
74034
74042
74050
74058
74067
74075
74082
74104
74114
74126
74133
74146
74155
74171
74301
74338
74346
74358
74365
74402
74427
74435
74442
74452
74460
74468
74522
74533
73724
73733
73741
73750
73759
73768
73832
73843
73857
73933
73946
74003
74012
74019
74028
74035
74043
74051
74059
74068
74076
74083
74105
74115
74127
74134
74147
74156
74172
74330
74339
74347
74359
74366
74403
74428
74436
74444
74454
74461
74469
74523
74534
GlobalHealth ZIP Code List
74535
74547
74557
74565
74576
74631
74643
74653
74724
74733
74741
74753
74764
74821
74831
74840
74850
74859
74869
74881
74932
74942
74949
74959
74536
74549
74558
74567
74577
74632
74644
74701
74726
74734
74743
74754
74766
74824
74832
74842
74851
74860
74871
74883
74935
74943
74951
74960
74538
74552
74559
74569
74578
74633
74646
74702
74727
74735
74745
74755
74801
74825
74833
74843
74852
74864
74872
74884
74936
74944
74953
74962
74540
74553
74560
74570
74601
74636
74647
74720
74728
74736
74747
74756
74802
74826
74834
74844
74854
74865
74873
74901
74937
74945
74954
74963
74543
74554
74561
74571
74602
74637
74650
74721
74729
74737
74748
74759
74804
74827
74836
74845
74855
74866
74875
74902
74939
74946
74955
74964
74545
74555
74562
74572
74604
74640
74651
74722
74730
74738
74750
74760
74818
74829
74837
74848
74856
74867
74878
74930
74940
74947
74956
74965
74546
74556
74563
74574
74630
74641
74652
74723
74731
74740
74752
74761
74820
74830
74839
74849
74857
74868
74880
74931
74941
74948
74957
74966
2
0
1
5
H
M
O
Z
I
P
C
O
D
E
L
I
S
T
S
15
2
0
1
5
H
E
A
L
T
H
P
L
A
N
C
O
M
P
A
R
I
S
O
N
COMPARISON OF NETWORK BENEFITS FOR HEALTH PLANS
HealthChoice
Your Costs for
High, High Alternative and
Network Services
USA Plans
High and USA Plans
$500 individual
$1,500 family
Calendar Year
Deductible
High Alternative Plan
$750 individual
$2,250 family
Calendar Year
Out-of-Pocket
Maximum
High and USA Plans*
Copays apply
$3,300 Network individual
$8,400 Network family
$3,800 non-Network individual
$9,900 non-Network family,
plus amounts over Allowed
Charges
High Alternative Plan*
Copays apply
$3,550 Network individual
$8,400 Network family
$4,050 non-Network individual
$9,900 non-Network family,
plus amounts over Allowed
Charges
HealthChoice
Basic and Basic
Alternative Plans
HealthChoice
HDHP
Basic Plan
$1,000 individual
$1,500 family
Applies after Plan pays first $500 of
Allowed Charges
Basic Alternative Plan
$1,250 individual
$1,750 family
Applies after Plan pays first $250 of
Allowed Charges
$1,500 individual
$3,000 family
The individual deductible
does not apply if two or
more family members are
covered
The combined medical and
pharmacy deductible must
be met before benefits are
paid
Basic Plan
$4,000 individual
$9,000 family
$3,000 individual
$6,000 family
Pharmacy copays apply
Non-Network charges do
not apply
Basic Alternative Plan
$4,000 individual
$9,000 family
Copays do not apply
$30 copay/physician office
All covered services, benefits,
visit**
$50 copay/specialist office visit exceptions, limitations and conditions
are identical to the HealthChoice High
Plan
Basic Plan
$0 of the first $500 of Allowed
Diagnostic X-Ray 20% of Allowed Charges after Charges
deductible
and Lab
100% of the next $1,000 of Allowed
20% of Allowed Charges after Charges (deductible). Only Allowed
Charges count toward the deductible
deductible
Hospital
50% of the next $6,000 of Allowed
Additional $300 copay per
Inpatient
non-Network admission (does Charges
Basic Alternative Plan
Admission
not apply to out-of-pocket
$0 of the first $250 of Allowed
maximum)
Charges
100% of the next $1,250 of Allowed
20%
of
Allowed
Charges
after
Hospital
Charges (deductible). Only Allowed
deductible
Outpatient Visit
Charges count toward the deductible
$0 copay; no deductible (Refer 50% of the next $5,500 of Allowed
Well Child
Charges
to Preventive Services list for
Both Basic Plans
Care Visit
more information)
$0 of Allowed Charges over the
individual or family out-of-pocket
No charge for well child and
maximum
adult immunizations and
No deductible for well child care visit
Immunizations administration
$30/$50 office visit copay may You can use non-Network providers,
but it will be more costly
apply
Office Visit
(Professional
Services)
You pay 100% of Allowed
Charges until deductible is
met
$30/$50** office visit copay
applies after deductible
20% of Allowed Charges
after deductible
20% of Allowed Charges
after deductible
Additional $300 copay per
non-Network admission
20% of Allowed Charges
after deductible
$0 copay; no deductible
applies
No charge for well child and
adult immunizations and
administration
$30/$50 office visit copay
may apply
*Emergency room and office visit copays apply. Coinsurance applies until the out-of-pocket maximum is met.
**The $30 copay applies to general practitioners, internal medicine physicians, OB/GYNs, pediatricians, physician
assistants and nurse practitioners. Plan changes are indicated by bold text.
16
COMPARISON OF NETWORK BENEFITS FOR HEALTH PLANS
Your Costs for
Network Services
CommunityCare HMO
GlobalHealth HMO
No deductible
No deductible
Calendar Year
Deductible
$4,000 individual
$8,000 family
Includes all paid medical and pharmacy copays
and coinsurance for covered services
Calendar Year
Out-of-Pocket
Maximum
Office Visit
(Professional
Services)
$35 copay/PCP
$50 copay/specialist
and Lab
Hospital
Outpatient Visit
Well Child
Care Visit
Immunizations
Includes all copays and coinsurance paid on
covered services, prescriptions and durable
medical equipment
$25 copay/PCP
$50 copay/specialist
No additional copay for laboratory services or
outpatient radiology
Diagnostic X-Ray $200 copay per MRI, CAT, MRA or PET scan
Hospital
Inpatient
Admission
$3,000 individual
$5,000 family
$0 copay for x-ray and lab
$250 copay per scan in a free-standing/low-cost
facility
$750 per scan in a hospital facility
Specialty scans: MRI, MRA, PET, CAT and
nuclear scans
$750 copay
Preauthorization required
$250 copay per day
$750 maximum per admission
Preauthorization required
$500 copay
$250 copay in a free-standing/low-cost facility
$750 copay in a hospital facility
$0 copay
$0 copay ages 0 – 21
$0 copay ages birth through age 18 years
$0 copay ages 19 and over
When medically necessary
$0 copay birth through age 18 years
$0 copay ages 19 and over when appropriate
following the recommendation of ACIP
Office visit copay may apply
Plan changes are indicated by bold text.
This is only a sample of the services covered by each plan. For services that are not listed in this comparison chart, contact
each plan. Refer to Contact Information on page 29 .
17
2
0
1
5
H
E
A
L
T
H
P
L
A
N
C
O
M
P
A
R
I
S
O
N
2
0
1
5
H
E
A
L
T
H
P
L
A
N
C
O
M
P
A
R
I
S
O
N
COMPARISON OF NETWORK BENEFITS FOR HEALTH PLANS
HealthChoice
Your Costs for
High, High Alternative and
Network Services
USA Plans
$0 copay for one preventive
service office visit per
calendar year for members and
dependents ages 20 and older
HealthChoice
Basic and Basic
Alternative Plans
$0 copay for one preventive service
office visit per calendar year for
members and dependents ages 20
and older
Periodic Health
Exams
One mammogram per year at no One mammogram per year at no
charge for women ages 40 and
charge for women ages 40 and older
older
Copays do not apply
All covered services, benefits,
exceptions, limitations and
conditions are identical to the
20% of Allowed Charges after
HealthChoice High Plan
deductible
Basic Plan
Allergy
$0 of the first $500 of Allowed
Treatment and Limit of 60 tests every 24
Charges
Testing
months
100% of the next $1,000 of Allowed
Charges (deductible). Only Allowed
Charges count toward the deductible
20% of Allowed Charges after
50% of the next $6,000 of Allowed
deductible
Emergency
Charges
Health Care
Basic Alternative Plan
Additional $100 ER copay –
$0 of the first $250 of Allowed
Facility Visit
waived if admitted
Charges
100% of the next $1,250 of Allowed
20% of Allowed Charges after
Charges (deductible). Only Allowed
deductible
Charges count toward the deductible
After Hours
50% of the next $5,500 of Allowed
Urgent Care
$30/$50 office visit copay may Charges
apply
Both Basic Plans
$0 of Allowed Charges over the
20% of Allowed Charges after
individual or family out-of-pocket
Mental Health or deductible
maximum
Substance Abuse
No deductible for well child care
Inpatient
No limit on the number of days visit.
Admission
per year
You can use non-Network providers,
but it will be more costly.
20% of Allowed Charges after
deductible
Mental Health or
Substance Abuse Limit of 15 services per
Outpatient Visit calendar year without
HealthChoice
HDHP
$0 copay for one preventive
service office visit per
calendar year for members
and dependents ages 20 and
older
One mammogram per year
at no charge for women
ages 40 and older
20% of Allowed Charges
after deductible
Limit of 60 tests every 24
months
20% of Allowed Charges
after deductible
Additional $100 ER copay
– waived if admitted
20% of Allowed Charges
after deductible
20% of Allowed Charges
after deductible
No limit on the number of
days per year
20% of Allowed Charges
after deductible
Limit of 15 services per
calendar year without
certification
certification
20% of Allowed Charges after
deductible for purchase, rental,
Durable Medical repair or replacement
20% of Allowed Charges
after deductible for
purchase, rental, repair or
replacement
Equipment
(DME)
Plan changes are indicated by bold text.
This is only a sample of the services covered by each plan. For services that are not listed in this comparison chart, contact
each plan. Refer to Contact Information on page 29.
18
COMPARISON OF NETWORK BENEFITS FOR HEALTH PLANS
Your Costs for
Network Services
CommunityCare HMO
GlobalHealth HMO
$0 copay/PCP
$0 copay/PCP/routine physical exam
Limit of one per year
$0 copay well-woman exam and preventive
services
Periodic Health
Exams
Allergy
Treatment and
Testing
Emergency
Health Care
Facility Visit
$35 copay/PCP
$50 copay/specialist
$30 serum and shots including a 6-week supply
of antigen
$25 copay/PCP
$50 copay/specialist
$30 serum and shots including a 6-week supply
of antigen and administration
$200 copay; waived if admitted
$300 copay; waived if admitted
$50 copay per visit
$50 copay
$750 copay
$250 per day
$750 maximum per admission
Must be preauthorized by MHNet
After Hours
Urgent Care
Mental Health or
Substance Abuse
Inpatient
Admission
$35 copay/PCP/specialist
$25 copay
Must be preauthorized by MHNet
20% coinsurance initial device
20% coinsurance repair and replacement
20% coinsurance for purchase, rental, repair or
replacement
Must be preauthorized and obtained from
network provider
Mental Health or
Substance Abuse
Outpatient Visit
Durable Medical
Equipment
(DME)
Plan changes are indicated by bold text.
This is only a sample of the services covered by each plan. For services that are not listed in this comparison chart, contact
each plan. Refer to Contact Information on page 29.
19
2
0
1
5
H
E
A
L
T
H
P
L
A
N
C
O
M
P
A
R
I
S
O
N
2
0
1
5
H
E
A
L
T
H
P
L
A
N
C
O
M
P
A
R
I
S
O
N
COMPARISON OF NETWORK BENEFITS FOR HEALTH PLANS
HealthChoice
Your Costs for
High, High Alternative and
Network Services
USA Plans
Occupational
and Speech
Therapy Visits
20% of Allowed Charges after
deductible
Occupational therapy*
Limit of 20 visits per year
without certification
Speech therapy*
For ages 17 and younger,
certification required
For ages 18 and older,
certification not required
*Maximum of 60 visits per year
20% of Allowed Charges after
deductible
Physical
Limit of 20 visits per year
Therapy/Physical without certification
Medicine Visit Maximum of 60 visits per year
Chiropractic therapy
20% of Allowed Charges after
deductible
Limit of 20 visits per year
Chiropractic and without certification
Maximum of 60 visits per year
Manipulative
Manipulative therapy
Therapy Visit
Refer to Physical Therapy/
Physical Medicine above
Maternity
Pre and Post
Natal Care
Hearing
Screening and
Hearing Aid
HealthChoice
Basic and Basic
Alternative Plans
Copays do not apply
All covered services, benefits,
exceptions, limitations and
conditions are identical to the
HealthChoice High Plan
Basic Plan
$0 of the first $500 of Allowed
Charges
100% of the next $1,000 of Allowed
Charges (deductible). Only Allowed
Charges count toward the deductible
50% of the next $6,000 of Allowed
Charges
Basic Alternative Plan
$0 of the first $250 of Allowed
Charges
100% of the next $1,250 of Allowed
Charges (deductible). Only Allowed
Charges count toward the deductible
50% of the next $5,500 in Allowed
Charges
Both Basic Plans
$0 of Allowed Charges over the
individual or family out-of-pocket
maximum
No deductible for well child care
visit.
HealthChoice
HDHP
20% of Allowed Charges
after deductible
Occupational therapy*
Limit of 20 visits per year
without certification
Speech therapy*
For ages 17 and younger,
certification required
For ages 18 and older,
certification not required
*Maximum of 60 visits per
year
20% of Allowed Charges
after deductible
Limit of 20 visits per year
without certification
Maximum of 60 visits per
year
Chiropractic therapy
20% of Allowed Charges
after deductible
Limit of 20 visits per year
without certification
Maximum of 60 visits per
year
Manipulative therapy
Refer to Physical Therapy/
Physical Medicine above
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
$30 copay/primary care
physician**
$50 copay/specialist
Basic hearing screening
Limit of one per year
$30/$50** copay after
deductible
Basic hearing screening
Limit of one per year
Hearing aids are covered as
durable medical equipment
for children up to age 18
Certification required
Hearing aids are covered as
durable medical equipment
for children up to age 18
Certification required
Plan changes are indicated by bold text.
**The $30 copay applies to general practitioners, internal medicine physicians, OB/GYNs, pediatricians, physician assistants
and nurse practitioners.
20
COMPARISON OF NETWORK BENEFITS FOR HEALTH PLANS
Your Costs for
Network Services
CommunityCare HMO
GlobalHealth HMO
No copay inpatient
$50 copay outpatient therapy
Limit of 60 days per illness
No copay inpatient
$50 copay per outpatient therapy
Limit of 60 combined inpatient and outpatient
visits per acute illness or injury for physical,
occupational or speech therapy or any
combination of all three
Occupational
and Speech
Therapy Visits
Physical
Therapy/Physical
Medicine Visit
No copay inpatient
$50 copay outpatient therapy
Limit of 60 days per illness
No copay inpatient
$50 copay per outpatient visit
Limit of 60 combined inpatient and outpatient
visits per acute illness or injury for physical,
occupational or speech therapy or any
combination of all three
$50 copay
Limit of 15 visits per year
$20 copay
Must be preauthorized
$35 copay for initial visit
$750 copay per hospital admission
$0 copay for prenatal care
$25 copay for delivery and all postnatal care
$250 per day, $750 maximum per hospital
admission
Hearing screening
$0 copay
Limit of one per year
Hearing screening
$0 copay children birth – age 21
$25 copay ages 22 and over
Limit of one per year
Hearing aids
20% coinsurance for children up to age 18
Hearing aids
20% coinsurance
For children up to age 18
Chiropractic and
Manipulative
Therapy Visit
Maternity
Pre and Post
Natal Care
Hearing
Screening and
Hearing Aid
Plan changes are indicated by bold text.
This is only a sample of the services covered by each plan. For services that are not listed in this comparison chart, contact
each plan. Refer to Contact Information on page 29.
21
2
0
1
5
H
E
A
L
T
H
P
L
A
N
C
O
M
P
A
R
I
S
O
N
COMPARISON OF NETWORK BENEFITS FOR HEALTH PLANS
Your Costs
for Network Services
2
0
1
5
P
H
A
R
M
A
C
Y
HealthChoice High, High Alternative, Basic,
Basic Alternative, HDHP and USA Plans
Prescription Medications
30-Day Supply
31- to 90-Day Supply
Generic Drugs
Up to $10
Up to $25
Preferred Drugs
Up to $45
Up to $90
Non-Preferred Drugs
Up to $75
Up to $150
Specialty Drugs*
♦ Preferred drugs – $100 copay
♦ Non-Preferred drugs – $200 copay
Copays are up to a 30-day supply
*Specialty medications are covered only when ordered through Accredo Health.
Plan changes are indicated in bold text.
HEALTHCHOICE HIGH, HIGH ALTERNATIVE,
BASIC, BASIC ALTERNATIVE AND USA PLANS
Pharmacy out-of-pocket maximum – $2,500 per person ($4,000 family) using Preferred products at Network
Pharmacies, then you pay $0 for the rest of the calendar year.
HEALTHCHOICE HDHP
Pharmacy benefits are available only after the combined health and pharmacy deductible ($1,500
individual/$3,000 family) has been met.
ALL HEALTHCHOICE PLANS
All Plan provisions apply. Some medications are subject to prior authorization and/or quantity limits. If you
choose a brand-name medication when a generic is available, you are responsible for the difference in the cost in
addition to the copay.
HealthChoice covers tobacco cessation medications at 100% when filled at a Network Pharmacy. Visit the Be
Tobacco-Free page at www.healthchoiceok.com or www.sib.ok.gov for details.
CDC vaccinations, such as for Shingles, are covered at 100% when using a Network Pharmacy. (Note: These can
also be covered under the health benefit if provided by a Network recognized health provider, such as a physician
or health department.)
22
COMPARISON OF NETWORK BENEFITS FOR HEALTH PLANS
Your Costs
for Network Services
Pharmacy Benefits
CommunityCare HMO
GlobalHealth HMO
Tier 1: $10
Tier 2: $40
Tier 3: $65
Tier 1: $10
Tier 2: $50
Tier 3: $75
$0 copay for selected generics
$4 copay for selected generics
Up to $65 non-formulary (nonpreferred)
30-day supply
30-day supply
Certain medications may have
restricted quantities
Certain medications have restricted
quantities
These copays apply to the maximum
out-of-pocket
Convenient mail-order is available;
contact CommunityCare for details
Home delivery and extended supply
are available; contact GlobalHealth
for details
Prescription copays apply to the
out-of-pocket maximum
90-day for two copays
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. Refer to Contact Information on page 29.
Plan changes are indicated in bold text.
23
2
0
1
5
P
H
A
R
M
A
C
Y
COMPARISON OF BENEFITS FOR DENTAL PLANS
2
0
1
5
D
E
N
T
A
L
P
L
A
N
C
O
M
P
A
R
I
S
O
N
HealthChoice
Dental
Annual
Deductible
Diagnostic and
Preventive Care
(cleanings,
routine oral exams)
Allowed Charges
Apply
Basic Care
(extractions, oral
surgery)
Allowed Charges
Apply
Major Care
(dentures,
bridge work)
Allowed Charges
Apply
Orthodontic Care
Allowed Charges
Apply
Plan Year
Maximum
Filing Claims
Assurant
Employee Benefits
Freedom Preferred
Assurant
Employee Benefits
Heritage Plus
and Heritage Secure
Network: $25 Basic and
Major services combined
Non-Network: $25
Preventive, Basic and Major
services combined plus
amounts above Allowed
Charges
Network: $0
Non-Network: $0 of Allowed
Charges after deductible
$25 per person, per policy year,
waived for in-Network preventive
services
No deductibles
Network: $0
Plan pays 100% of negotiated fee
No deductible
Non-Network: $0
Plan pays 100% of usual and
customary
Deductible applies
No charge for routine cleaning
(once every 6 months)
No charge for topical fluoride
application (up to age 18)
No charge for periodic oral
evaluations
Network: 15%
Non-Network: 30% plus
amounts above Allowed
Charges
Deductible applies
Network: 15%
Plan pays 85% of usual and
customary
Non-Network: 30%
Plan pays 70% of usual and
customary
Deductible applies
Fillings
Minor oral surgery
Refer to the copay schedule
for each plan
Network: 40%
Non-Network: 50% plus
amounts above Allowed
Charges
Deductible applies
Network: 40%
Plan pays 60% of usual and
customary
Deductible applies
Non-Network: 50%
Plan pays 50% of usual and
customary
Deductible applies
Root canal
Periodontal
Crowns
Refer to the copay schedule
for each plan
Network: 50%
Non-Network: 50% plus
amounts above Allowed
Charges
12-month waiting period
applies
No lifetime maximum
Covered for members under
age 19 and members age 19
and older with TMD
Network: 40%
Plan pays 60% of negotiated fee
Non-Network: 50%
Plan pays 50% of usual and
customary – deductible applies
Network and Non-Network:
$2,000 lifetime maximum
Coverage only for dependent
children under age 19
12-month waiting period may
apply
25% discount
Adults and children
Network and non-Network:
$2,500 per person, per year
$2,000 per person, per policy year
No annual maximum for
general dentist
Network: No claims to file
Member/provider must file claims
Non-Network: You file claims
No claims to file
Plan changes are indicated by bold text.
This is only a sample of the services covered by each plan. For services that are not listed in this comparison chart,
contact each plan. Refer to Contact Information on page 29.
24
COMPARISON OF BENEFITS FOR DENTAL PLANS
CIGNA Dental Care
Plan (Prepaid)
Delta Dental PPO
In-Network and
Out-of-Network
Delta Dental
PPO Plus Premier
In-Network and
Out-of-Network
Delta Dental
PPO – Choice
PPO Network
No deductible or plan
maximum
$5 office copay applies
$25 per person, per
year, applies to Basic
and Major Care only
$50 per person,
per year, applies
to Diagnostic,
Preventive, Basic and
Major Care
$100 per person, per year,
applies to Major Care
only (Level 4)
Sealant: $17 per tooth
No charge for routine
cleaning once every 6
months
No charge for topical
fluoride application
(through age 18)
No charge for periodic
oral evaluations
$0 of allowable
amounts
No deductible applies
$0 of allowable
amounts after
deductible
Schedule of covered
services and copays
Copay examples:
Routine cleaning $5
Periodic oral evaluation
$5
Topical fluoride
application (up to age 19)
$5
Amalgam: One surface, 15% of allowable
Basic Care
permanent teeth $23
amounts after
(extractions, oral
deductible
surgery)
Allowed Charges
Apply
30% of allowable
amounts after
deductible
Root canal, anterior:
40% of allowable
$375
amounts after
Periodontal/scaling/root deductible
planing 1-3 teeth (per
quadrant): $75
50% of allowable
amounts after
deductible
Schedule of covered
services and copays
Copay example:
Amalgam - one surface,
primary or permanent
tooth $12
Schedule of covered
services and copays
Copay examples:
Crown - porcelain/
ceramic substrate $241
Complete denture maxillary $320
Annual
Deductible
Diagnostic and
Preventive Care
(cleanings,
routine oral
exams)
Allowed Charges
Apply
Major Care
(dentures,
bridge work)
Allowed Charges
Apply
Orthodontic
Care
$2,472 out-of-pocket
for children through
age 18
$3,384 out-of-pocket
for adults
Allowed Charges 24-month treatment
excludes orthodontic
Apply
treatment plan and
banding
Plan Year
Maximum
Filing Claims
40% of allowable
amounts, up to
lifetime maximum of
$2,000
No deductible
No waiting period
Orthodontic benefits
are available to the
employee, their lawful
spouse and eligible
dependent children
40% of allowable
amounts, up to
lifetime maximum of
$2,000
No deductible
No waiting period
Orthodontic benefits
are available to the
employee, their lawful
spouse and eligible
dependent children
You pay amounts in
excess of $50 per month
Lifetime maximum up to
$1,800
No deductible
No waiting period
Orthodontic benefits
are available to the
employee, their lawful
spouse and eligible
dependent children
No maximum
$2,500 per person, per $3,000 per person, per $2,000 per person, per
year
year
year
No claims to file
Claims are filed by
participating dentists
Claims are filed by
participating dentists
Claims are filed by
participating dentists
Plan changes are indicated by bold text.
This is only a sample of the services covered by each plan. For services that are not listed in this comparison
chart, contact each plan. Refer to Contact Information on page 29.
25
2
0
1
5
D
E
N
T
A
L
P
L
A
N
C
O
M
P
A
R
I
S
O
N
2
0
1
5
V
I
S
I
O
N
P
L
A
N
C
O
M
P
A
R
I
S
O
N
COMPARISON OF BENEFITS FOR VISION PLANS
Humana/CompBenefits
VisionCare Plan
In-Network
Eye Exams
$10 copay
One exam for
eyeglasses
or contacts
every calendar
year
Plan pays up to $0 copay
$35; one exam No limit to
every calendar frequency
year
Plan pays up to $15 copay
$40
One exam for
Limit one exam eyeglasses
or contacts
every calendar
year
Plan pays up to
$40
One exam
every calendar
year
$25 copay for
single/multifocal lenses
Plan pays up to:
$25 single
$40 bifocals
$60 trifocals
$100 lenticular
You pay
wholesale cost
with no limit
on number of
pairs
You pay normal
doctor’s fee,
reimbursed up
to $60, for one
set of lenses
and frames
annually
$15 copay
Single,
bifocals,
trifocals
lenticular
lenses paid in
full
Progressive
lenses paid up
to $115
Plan pays up to:
$30 single
$45 bifocals
$55 trifocals
$75 lenticular
$60 progressive
$25 copay, up
to plan limits
One set of
frames every
calendar year
Plan pays up to You pay
$45
wholesale cost
No limit to
number of
frames
$0 copay
$160 frame
allowance
Plan pays up to
$35
$130
allowance for
conventional
or disposable
lenses and
fitting fee in
lieu of all other
benefits every
calendar year
Medically
necessary
contacts, plan
pays 100%
$130 allowance
for contacts and
fitting fee in
lieu of all other
benefits
You pay normal
doctor’s fees,
reimbursed up
to $60, for one
set of lenses
and frames per
year
Limit of one set
annually in lieu
of eyeglasses
You pay normal
doctor’s fees
reimbursed up
to $60
$160
allowance for
conventional
or disposable
lenses
$80
allowance for
conventional
or disposable
lenses
$250 allowance
for medically
necessary
contacts
$80 allowance
for medically
necessary
contacts
Members
can access
information
on providers
through the
website or
by calling
customer
service
No benefit
15% discount
No benefit
Frames
Contact
Lenses
Laser
Vision
Correction
In-Network
You pay
wholesale cost
for annual
supply of
contacts
Medically
necessary
contacts, plan
pays up to $210
Out-ofNetwork
Vision Care Direct
Covered
Services
Lenses
Per Pair
Out-ofNetwork
Primary Vision
Care Services
Discount
No benefit
offered through
nJoy Vision
in OKC and
Tulsa; previous
TLC locations
$1,000 savings
between June
1 – Sept. 30,
2015
Call PVCS for
details
26
In-Network
Out-ofNetwork
COMPARISON OF BENEFITS FOR VISION PLANS
Superior Vision
Covered
Services
In-Network
$10 copay
Out-ofNetwork
UnitedHealthcare Vision
In-Network
Out-ofNetwork
Plan pays:
$10 copay
$34 Ophthalmologist
$26 Optometrist
Reimbursed
up to $40
Lenses
Per Pair
$25 copay
Standard
Progressive:
$25 copay
Refer to notes on
the next page
Plan pays:
Single up to $26
Bifocals up to $39
Trifocals up to
$49
Lenticular up to
$78
Standard
Progressive:
Up to $49
$25 copay
Standard single
vision, lined
bifocal & trifocal
lenses covered in
full
Scratch resistant,
UV coating, tints
and polycarbonate
lenses are also
covered in full
Single up to
$40
Bifocals up to
$60
Trifocals up
to $80
Lenticular up
to $80
Plan pays up to
$68
Frames
$25 copay then
plan pays up to
$125 retail
$25 copay
Reimbursed
$130 retail frame up to $45
allowance
$0 copay
Plan pays up to
$120 all contacts
Medically
necessary contacts
covered in full
(Contact lens fit
copay: Standard
$25, after copay,
covered in full;
specialty $25,
after copay, plan
pays up to $50)
$0 copay
Plan pays up to
$100 all contacts;
$210 medically
necessary contacts
(Contact lens fit
copay: Standard
not covered;
specialty not
covered)
$25 copay on
covered-in-full
qualifying lenses
$150 contact lens
benefit applies
to the fitting/
evaluation fees
and purchase of
contact lenses
20-50% Discount
No benefit
15% discount
No benefit
off the usual
and customary
price, 5% off
promotional
price at any
Laser Vision
Network of
America provider
Eye Exams
Contact
Lenses
Laser
Vision
Correction
27
Reimbursed up
to $150
elective
contact lenses;
$210
medically
necessary
contact lenses
Vision Service Plan
(VSP)
In-Network
$10 copay
$25 copay
applies to
lenses or
frames
Single
vision, lined
bifocal and
trifocal lenses
covered in
full
Out-ofNetwork
$10 copay
Plan pays up
to $35
$25 copay
then plan pays:
Single up to
$25
Bifocals up to
$40
Trifocals up to
$55
Lenticular up
to $80
$25 copay
$25 copay
then plan pays then plan pays
up to $120
up to $45
$0 copay
Plan pays up
to $120
conventional
or disposable;
$25 copay
on medically
necessary
contact lenses
$0 copay
Plan pays
up to $105
conventional
or disposable;
$210
medically
necessary
contacts after
$25 copay
15% average
off usual and
customary
price or 5%
off the laser
center’s
promotional
price
No benefit
2
0
1
5
V
I
S
I
O
N
P
L
A
N
C
O
M
P
A
R
I
S
O
N
Vision Plan Notes
Humana/CompBenefits VisionCare Plan: The contact lens benefit provides a $130 yearly allowance for the annual
vision exam to evaluate eye health, contact lens exam for fitting and evaluation, and the purchase of either conventional
or disposable contacts. If a member prefers contact lenses, the plan provides the contact lens allowance in lieu of all
other benefits. Instead, if a member opts for lenses and frames during the plan year, a $25 copay applies for these two
material items. More than 23,000 frames are covered in full by the $25 copay with in-network providers. Exams, lenses
and frame benefits are provided once every 12 months. Oklahoma City LASIK Plus Traditional Intralase (bladeless)
with a one-year plan with insurance discount is $695 per eye equals $1,390. Traditional Intralase (bladeless) with a
lifetime plan with insurance discount is $1395 per eye equals $2,790. CustomVue Intralase (bladeless) with lifetime
plan with insurance discount is $1,784.15 per eye; equals $3,568.30.
PVCS: The only Oklahoma owned and operated vision care plan with unlimited in-network services. Member selects
either in-network or out-of-network for entire year. Out-of-network services are limited (one eye exam, one set of
eyeglasses or contacts) to once annually. A $50 service fee applies to soft contact lens fittings; a $75 service fee applies
to rigid or gas permeable contact lens fittings; and a $150 service fee applies to hybrid contact lens fittings. Simple
replacements are not assessed with these fees. Limitations/Exclusions include the following: 1) Medical eye care, 2)
Vision therapy, 3) Non routine vision services and tests, 4) Luxury frames (wholesale cost of frame exceeds $100), 5)
Premium prescription lenses, and 6) Non prescriptive eye wear. For more information, call 1-888-357-6912.
Superior Vision: Materials copay applies to lenses and/or frames. Discounts for lens add-ons will be given by
contracted providers with “Accepts Discounts” in their listing. Online, in-network contact lens materials available
at www.svcontacts.com. Exams, lenses and frames are provided once per calendar year. Progressive lenses (no-line
bifocals) – you pay the difference between the retail price of the selected progressive lens and the retail price of the
provider’s lined trifocal. The difference may also be subject to a discount. Standard contact lens fitting applies to an
existing contact lens user who wears disposable, daily wear or extended wear lenses only. Specialty contact lens fitting
applies to new contact lens wearers and/or members who wear toric, gas permeable or multifocal lenses.
UHC Vision: For either glasses or contact lenses, there is a one-time $25 materials copay. In lieu of lenses and frames,
you may select contact lenses. Covered contact lens benefit includes the fitting/evaluation fee, contact lenses and up to
two follow-up visits. If covered disposable contact lenses are chosen, up to six boxes (depending on prescription) are
included when obtained from a network provider. It is important to note that UHC covered contact lenses may vary by
provider. Should you choose contact lenses outside the covered selection, a $150 allowance will be applied toward the
fitting/evaluation fees and purchase of contact lenses (material copay does not apply). Toric and gas permeable contact
lenses are examples of contact lenses that are outside of our covered contacts. Necessary contacts are covered-in-full
after applicable copay. Exams, lenses and frame benefits provided once every calendar year.
Vision Care Direct: Our plan offers low copays for your exam and lenses. There are NO COPAYS for contacts
or frames. We have a $160 frame or contact allowance and have removed all the restrictions such as minimum
prescriptions. We are an Oklahoma based company and are NOT an insurance company. We are an association of
optometrists committed to providing a better patient care. We have a new option available in 2015. If you want hidef polycarbonate lenses and both anti-reflected coating and scratch protection but don’t want to pay extra for it, then
you can choose from our VCD line of frames (60 to choose from); you pay nothing out of pocket, only your copay. If
you work on a computer all day, ask about iBlue Coat, it will reduce the strain on your eyes and can be added to your
lenses; ask your doctor for pricing. We also have special pricing if you purchase a pair of glasses or order a year’s
supply of contacts, you are eligible for discounts for a backup pair of glasses. Be sure to ask your doctor about special
pricing on a second pair of glasses. For more information, call 1-855-918-2020 or email us at vco@visioncaredirect.
com. Locate one of our local independent optometrists at www.visioncaredirect.com.
VSP: Exam, lenses and frame benefit provided annually. The $25 materials copay applies to lenses or frames, but
not to both. Copays/prices listed are for standard lens options. Premium lens options will vary. If you choose a frame
valued at more than your allowance, you’ll save 20% on your out-of-pocket costs when you use a VSP doctor. Contact
lenses are in lieu of spectacle lenses and frame. The $120 in-network allowance applies to the contact lenses. With a
VSP provider, the contact lens exam (fitting and evaluation) is covered in full after a copay up to $60. The $105 outof-network allowance applies to the contacts and contact lens exam. Your contact lens exam is performed in addition
to your routine eye exam to check for eye health risks associated with improper wearing or fitting of contacts. Both the
exam and materials copay apply with medically necessary contacts. Prescription glasses - 30% off additional complete
pairs of glasses and sunglasses, including lens options, from the same VSP doctor on the same day as your WellVision
Exam, or get 20% off from any VSP doctor within 12 months from your last WellVision Exam. Contact VSP or visit
www.vsp.com to learn about retail chain affiliate providers.
28
Contact Information
Dental Plans
HealthChoice
Assurant Inc. Dental
PPO Freedom Preferred
1-800-442-7742
Prepaid Heritage Plans
1-800-443-2995
www.assurantemployeebenefits.com
CIGNA Prepaid Dental
All Areas
1-800-244-6224
Toll-free Hearing Impaired Relay
1-800-654-5988
www.cigna.com
Delta Dental
Oklahoma City Area
1-405-607-2100
All Other Areas
1-800-522-0188
www.DeltaDentalOK.org
Health, Dental and Life Claims, Benefits,
Eligibility and ID Cards
Oklahoma City Area
1-405-416-1800
All Other Areas
1-800-782-5218
TDD Oklahoma City Area
1-405-416-1525
TDD All Other Areas
1-800-941-2160
www.healthchoiceok.com or www.sib.ok.gov
Pharmacy Claims, Formulary and ID Cards
All Areas
TDD All Areas
1-800-903-8113
1-800-825-1230
Member Services/Provider Directory
Vision Plans
Oklahoma City Area
1-405-717-8780
All Other Areas
1-800-752-9475
TDD
1-405-949-2281 or All Areas 1-866-447-0436
Humana/CompBenefits
VisionCare Plan
All Areas
1-800-865-3676
TDD All Areas
1-877-553-4327
www.compbenefits.com/custom/stateofoklahoma
Primary Vision Care Services (PVCS)
All Areas
1-888-357-6912
TDD All Areas
1-800-722-0353
www.pvcs-usa.com
Superior Vision
All Areas
1-800-507-3800
TDD
1-916-852-2382
www.superiorvision.com
UnitedHealthcare Vision
All Areas
1-800-638-3120
TDD All Areas
1-800-524-3157
www.myuhcvision.com
Vision Care Direct
All Areas
1-877-488-8900
TDD All Areas
1-877-488-8900
visioncaredirect.com
Vision Service Plan (VSP)
All Areas
1-800-877-7195
TDD All Areas
1-800-428-4833
www.vsp.com
HealthChoice USA
Customer Service & Claims
1-800-782-5218
Provider Information
1-877-877-0715
TDD All Areas
1-800-941-2160
www.choicecarenetwork.com
American Fidelity Health
Services Administration
Health Savings Account (HSA)
Oklahoma City Area
All Areas
www.afhsa.com
1-405-523-5699
1-866-326-3600
HMO Plans
All Areas
TDD All Areas
CommunityCare
1-800-777-4890
1-800-722-0353
state.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
www.globalhealth.com
29
EGID
3545 N.W. 58th St., Ste. 110
Oklahoma City, OK 73112
E
D
I
U
G
D
O
5
I
1
R
0
E
2
P
R
N
A
E
O
I
Y
T
P
N
O PLA