The Oklahoma State and Education Employees Group
Insurance Board
For
Plan Year January 1, 2010 through December 31, 2010
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.
http://www.sib.ok.gov
and http://www.healthchoiceok.com
FORMS ARE BEING MAILED SEPARATELY
You should
have already received a schedule of retiree Option Period meetings. If you are
making changes to your coverage, your Option Period Enrollment/Change Form must
be postmarked by December 4, 2009.
If you are not making
changes to your coverage, you do not need to return your Option Period
Enrollment/Change Form. Keep your Option Period Enrollment/Change Form as
verification of your coverage.
Monthly Premiums for Former Employees and
Surviving Dependents
Monthly Premiums for COBRA Employees and
Dependents
2010 Plan Changes
Introduction
Health, Dental, and Vision Plan Highlights
Comparison of Benefits for
Health Plans – All Plans
HealthChoice High Option
Plan Benefits
HealthChoice Basic Plan
Benefits
HealthChoice S-Account Plan
Benefits
Aetna Alternative HMO Plan Benefits
CommunityCare Alternative
HMO Plan Benefits
GlobalHealth Alternative
HMO Plan Benefits
PacifiCare Alternative HMO
Plan Benefits
Comparison of Benefits for
Dental Plans – All Plans
HealthChoice Dental Plan
Benefits
Assurant Freedom Preferred Plan
Benefits
Assurant Prepaid Plans,
Heritage Plus with SBA, and Heritage Secure Plan Benefits
Cigna Dental Care Plan Benefits
Delta Dental PPO ‘Point of Service’ - PPO Network,
Premier Network, and Non-Network Plan Benefits
Delta’s Choice PPO – PPO Network
Comparison of Benefits for Vision Plans –
All Plans
Humana/CompBenefits
VisionCare Plan
If
you have any questions concerning anything in this guide, please refer to Help
Lines for
contact information for each plan.
The
participating carriers reviewed and approved the information in this Guide.
There is no guarantee that a provider will remain with a plan’s network or have
open patient slots throughout the year. Please verify your provider’s
participation in your plan’s network.
A
searchable text version of this Option Period Guide is available on the OSEEGIB
website at http://www.sib.ok.gov or http://www.healthchoiceok.com. This Guide is also available in CD format at the
Oklahoma Library for the Blind and Physically Handicapped (OLBPH). Contact the
OLBPH at 1-405-521-3514, toll-free 1-800-523-0288, and TDD 1-405-521-4672.
For
Plan Year January 1, 2010 through December 31, 2010
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, refer to the Frequently Asked
Questions section of the HealthChoice website and search for blended rates.
Member $442.80
Spouse $625.88
Child $228.32
Children $342.44
Member $384.22
Spouse $546.84
Child $200.36
Children $300.88
Member $365.80
Spouse $513.68
Child $190.32
Children $283.98
Member $678.57
Spouse $678.57
Child $226.33
Children $339.31
Member $715.40
Spouse $951.38
Child $488.78
Children $782.04
Member $502.32
Spouse $668.02
Child $343.20
Children $549.12
Member $775.08
Spouse $1,108.34
Child $387.54
Children $620.06
Member $534.54
Spouse $764.38
Child $267.28
Children $427.64
Member $344.18
Spouse $510.70
Child $184.56
Children $294.30
Member $312.90
Spouse $464.30
Child $167.82
Children $267.54
Member $605.20
Spouse $870.16
Child $302.38
Children $483.92
Member $417.38
Spouse $600.10
Child $208.52
Children $333.72
Member $30.28
Spouse $30.28
Child $25.24
Children $65.50
Member $26.33
Spouse $26.18
Child $19.63
Children $52.79
Member $11.74
Spouse $8.86
Child $7.60
Children $15.20
Member $7.20
Spouse $5.98
Child $5.20
Children $10.38
Member $9.26
Spouse $6.06
Child $7.08
Children $15.32
Member $30.48
Spouse $30.50
Child $26.80
Children $68.22
Member $13.40
Spouse $30.44
Child $30.68
Children $74.46
Member $6.76
Spouse $5.06
Child $3.57
Children $4.46
Member $9.25
Spouse $8.00
Child $8.50
Children $10.75
Member $6.98
Spouse $6.90
Child $6.60
Children $6.60
Member $8.18
Spouse $5.79
Child $4.59
Children $6.98
Member $8.96
Spouse $6.00
Child $5.74
Children $12.92
From $5,000 to $40,000 -
$1.94 per thousand
Age-Rated Supplemental
Life Cost Per $1,000 for $41,000 and Up
Under 30 $0.05
30 – 34 $0.05
35 – 39 $0.08
40 – 44 $0.12
45 – 49 $0.19
50 – 54 $0.32
55 – 59 $0.52
60 – 64 $0.60
65 - 69 $0.99
70 – 74 $1.67
75 and older $2.60
$0.97 per $500 Unit, per dependent
Low Option $2.60
Spouse coverage of $6,000
Children over 6 months coverage of $3,000
Birth to 6 months $1,000
Standard Option $4.32
Spouse coverage of $10,000
Children over 6 months coverage of $5,000
Birth to 6 months $1,000
Premier Option $8.64
Spouse coverage of $20,000
Children over 6 months coverage of
$10,000
Birth to 6 months $1,000
$0.97 per $500 Unit, per dependent
For
Plan Year January 1, 2010 through December 31, 2010
It is the policy of the Oklahoma State and Education Employees
Group Insurance Board that for any benefit continued under COBRA, one person must always pay the
primary member premium. In cases where a spouse, child, or children are insured under a particular
benefit and the member did not retain coverage, one person will always be billed at the primary
member rate.
Member $451.66
Spouse $638.40
Child $232.89
Children $349.29
Member $391.90
Spouse $557.78
Child $204.37
Children $306.90
Member $373.12
Spouse $523.95
Child $194.13
Children $289.66
Member $692.14
Spouse $692.14
Child $230.86
Children $346.10
Member $729.71
Spouse $970.41
Child $498.56
Children $797.68
Member $512.37
Spouse $681.38
Child $350.06
Children $560.10
Member $790.58
Spouse $1,130.51
Child $395.29
Children $632.46
Member $545.23
Spouse $779.67
Child $272.63
Children $436.19
Member $351.06
Spouse $520.91
Child $188.25
Children $300.19
Member $319.16
Spouse $473.59
Child $171.18
Children $272.89
Member $617.30
Spouse $887.56
Child $308.43
Children $493.60
Member $425.73
Spouse $612.10
Child $212.69
Children $340.39
Member $30.89
Spouse $30.89
Child $25.74
Children $66.81
Member $26.86
Spouse $26.70
Child $20.02
Children $53.85
Member $11.97
Spouse $9.04
Child $7.75
Children $15.50
Member $7.34
Spouse $6.10
Child $5.30
Children $10.59
Member $9.45
Spouse $6.18
Child $7.22
Children $15.63
Member $31.09
Spouse $31.11
Child $27.34
Children $69.58
Member $13.67
Spouse $31.05
Child $31.29
Children $75.95
Member $6.90
Spouse $5.16
Child $3.64
Children $4.55
Member $9.44
Spouse $8.16
Child $8.67
Children $10.97
Member $7.12
Spouse $7.04
Child $6.73
Children $6.73
Member $8.34
Spouse $5.91
Child $4.68
Children $7.12
Member $9.14
Spouse $6.12
Child $5.85
Children $13.18
Copays are being increased from $25 to $50.
Preferred Medication – Pharmacy copays are
being increased. For a medication costing $100 or less, you pay up to $30 or
actual cost if less. For a medication costing more than $100, you pay 25% up to
a $60 maximum.
Non-Preferred Medication – Pharmacy copays
are being increased. For a medication costing $100 or less, you pay up to $60
or actual cost if less. For a medication costing more than $120, you pay 50% up
to a $120 maximum.
Brand-name triptans, which are used to treat
migraine headaches, are non-Preferred medications. Sumatriptan, the generic
form for Imitrex, is the Preferred medication in this category.
Several of the out-of-pocket maximums, copays, and pharmacy copays are
changing.
Some HMO service areas are changing.
GlobalHealth has new phone numbers. The new local number is 1-405-280-5600
and the new toll-free number is 1-877-280-5600.
Topical fluoride treatments will be covered
only for children through age 12.
CIGNA Dental Care Plan has a new phone
number. The new toll-free number is 1-800-244-6224. Also, their customer
service hours have been extended to 24 hours a day, seven days a week..
Humana/CompBenefits will apply a $25 copay
for frames purchased out-of-network.
The Oklahoma State and Education Employees Group
Insurance Board (OSEEGIB) produced this Option Period 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, and COBRA participants.
Review
Section B of your pre-printed Option Period Enrollment/Change Form. This is the
coverage you will have effective January 1, 2010, if you do not make changes
during Option Period.
If you do
not want to make any changes to your coverage, no further action is necessary
and you do NOT need to return your Option Period Enrollment/Change Form.
If you
do not make any changes to your coverage, you will not receive a Confirmation
Statement from OSEEGIB. Keep your Option Period Enrollment/Change Form as
verification of your insurance coverage.
Review
premium rates and plan changes for 2010. Premium rates are listed at the
beginning of this Guide and plan changes are listed after that.
Use the
following resources to help you decide on coverage for yourself and your
dependents – this guide, plan websites, customer services telephone numbers,
provider directories, and OSEEGIB Member Services.
Decide on
the coverage for yourself (and your dependents) for 2010.
Check the
appropriate boxes in Section C of your Option Period Enrollment/Change Form for
the coverage changes you wish to make effective January 1.
Complete
your Option Period Enrollment/Change Form and return it to OSEEGIB by December
4, 2009.
Review your
Confirmation Statement when you receive it in the mail to verify your coverage
is correct.
Contact
OSEEGIB Member Services if your Confirmation Statement is incorrect.
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 NW 58th St., Ste. 110, Oklahoma
City, OK, 73112.
There are 12
health plans available – HealthChoice High Option Plan, HealthChoice Basic
Plan, HealthChoice S-Account Plan, HealthChoice USA Plan*, Aetna Standard and Alternative
HMO, CommunityCare Standard and Alternative HMO, GlobalHealth Standard and Alternative
HMO, and PacifiCare Standard and Alternative HMO.
All health plans
coordinate benefits with other group insurance plans you have in force. For
more information, check with each health plan.
There are
no preexisting condition exclusions or limitations applied to any of the health
plans.
All plans have
toll-free numbers for customer service; refer to Help
Lines at the end of this document.
To enroll
in the HealthChoice S-Account Plan, you must provide OSEEGIB with proof you
have set up a Health Savings Account at a bank or other financial institution.
This proof must be submitted by December 15, 2009. Without proof, your health
plan will default to the HealthChoice Basic Plan.
You must
live within the HMO’s ZIP Code service area to be eligible for an HMO. Post Office
Box addresses cannot be used to determine your eligibility for an HMO. Refer to
the HMO Zip Code List.
Check with
each health plan if you have benefit questions.
Pre-Medicare retirees who live outside of Oklahoma and Arkansas may be
eligible to enroll in HealthChoice USA which includes a national provider
network. Call HealthChoice for details. Refer to Help
Lines at the end of this document.
There are
seven dental plans available – HealthChoice Dental, Assurant Freedom Preferred,
Assurant Heritage Plus with SBA Prepaid, Assurant Heritage Secure Prepaid,
CIGNA Dental Care Plan Prepaid, Delta Dental PPO – POS, and Delta’s Choice –
PPO
All dental plans
have toll-free numbers for customer service; refer to Help Lines at the end of this
document.
Check with
each dental plan if you have benefit questions.
There are five vision plans available – Humana/CompBenefits
VisionCare Plan, Primary Vision Care Services, Superior Vision Plan,
UnitedHealthcare Vision, and Vision Service Plan (VSP).
All vision
plans have limited coverage for services received from out-of-network
providers.
All plans
have toll-free numbers for customer service; refer to Help Lines at the end of this
document.
Verify your
vision provider is a member of the vision plan’s network by calling the
toll-free numbers provided, or check each plan’s website for the most
up-to-date list of providers.
Check with
each vision plan if you have benefit questions.
If your provider leaves your health, dental, or
vision plan, you cannot change plans until the next annual Option Period. You
may change providers within your plan as needed.
Please take time this Option Period to consider your
Life insurance needs. Former employees and surviving dependents have the
following life insurance options.
Retain your
current amount of life insurance
Reduce your
amount of life insurance
Reduce your
amount of dependent life insurance, if enrolled
Change
beneficiaries (not limited to Option Period)
Your Option Period Enrollment/Change Form will
indicate the amounts and types of life insurance you currently carry. Please take
time to evaluate your coverage for the 2010 plan year. Keep in mind that as a
former employee or surviving dependent, you cannot reinstate any life insurance
that you terminate or decrease.
Benefits are paid to your beneficiaries in a lump
sum. Your beneficiary designation may be changed at any time. For a Beneficiary
Designation Form or more information, contact HealthChoice Member Services.
Refer to Help Lines
at the end of this document for contact information. Beneficiary Designation
Forms are also available on the HealthChoice website at www.sib.ok.gov or
www.healthchoiceok.com. Be aware that life insurance benefits for covered
dependents are always paid to the member.
Following are the options that former employees
(retired, vested, and non-vested), COBRA participants, and surviving dependents
have during Option Period.
Former employees and surviving dependents can:
Change
health and/or dental plans that are currently in place
Drop
benefits and/or dependents
Decrease
life insurance coverage
Enroll in
or change vision plans
COBRA participants can:
Add
dependents
Add or
change coverage (health, dental, or vision) as long as the former employer
participates in that benefit
Drop
benefits and/or dependents
If you are not making any changes to your coverage,
you do not need to return your Option Period Enrollment/Change Form. Your
current coverage will continue for the 2010 plan year.
The benefits you select will be in effect from
January 1, 2010 through December 31, 2010. Please contact the insurance plans
at the phone numbers or websites listed in the Help
Lines at the end of this document for more information.
After enrollment, the plans you have selected will
provide a member handbook or additional material with more information about
your benefits. Once enrolled in any of the plans, it is your responsibility to
review your benefits carefully so you know what is covered, as well as the
plan’s policies and procedures, before you use your benefits.
If one eligible
dependent is covered, all eligible dependents must be covered. Eligible
dependents include:
Your legal
spouse (including common-law).
Your
unmarried children up to age 25, including your natural child or stepchild,
provided you are primarily responsible for their support, and your natural
child or stepchild, regardless of residence, if ordered by the court; court
documentation is required.
A
dependent, regardless of age, who is incapable of self-support because of a
disability that was diagnosed prior to age 25, subject to medical review and
approval.
Other
dependent children with an approved Declaration of Dependency form. This form
is required when the member has not been granted custody, adoption, or
guardianship by a court, and the member’s most recent income tax return does
not list the child as a dependent for income tax purposes.
If your
spouse is enrolled separately in one of the OSEEGIB plans, your dependents may
be covered under one parent’s health, dental, or vision plan (but not both);
however, dependents may be covered by both parents for dependent life
insurance.
Dependents may only be enrolled in the same types of coverage and in the
same plans you have as the primary member.
To enroll
your newborn, a letter must be sent to OSEEGIB within 30 days of the birth. If
you are a former employee or surviving spouse and do not enroll your newborn
during this 30-day period, you will not be able to do so at a later date. If
you are a COBRA participant and do not enroll your newborn during this 30-day
period, you will not be able to do so until the next annual Option Period.
Direct notification to an HMO will not enroll your newborn, or any other
dependents. The newborn’s Social Security Number is not required at the time of
initial enrollment, but must be provided once it is received from the Social
Security Administration. Insurance premiums for the month the child was born
must be paid, and deductible and coinsurance may apply.
Without enrollment, newborns will be covered
only for the first 48 hours following a vaginal birth or the first 96 hours
following a cesarean section birth. Deductible and coinsurance apply.
Dependents
who lose eligibility may apply for continuation of health, dental, or vision coverage
under COBRA for a maximum of 36 months. Dropping dependents during Option
Period is not a COBRA qualifying event. Contact OSEEGIB Member Services at the
number listed in the Help Lines
at the end of this document for more information.
COBRA coverage may be available for dependents who
become ineligible. Examples of COBRA qualifying events for dependents include:
Reaching
age 25
Divorce of
a spouse
Marriage of
a child
Death of
the covered employee
If
you are under age 65 and eligible for Medicare, you must notify OSEEGIB to
begin the enrollment process into a Medicare supplement/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 coverage. Your
Medicare coverage will become effective as of the date you become eligible for
Medicare or the first of the month after you complete the enrollment process,
whichever is later.
You
will receive a letter approximately two months prior to your 65th
birthday detailing your options for Medicare coverage. If you are enrolled in
HealthChoice, you will automatically be enrolled in the HealthChoice Employer
PDP High Option Medicare Supplement With Part D Plan. If you are enrolled in an
HMO, you may enroll in either their Medicare supplement (if available) or MA-PD
Plan (if available).
To
maximize your benefits, you are encouraged 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.
If you do not live in the
ZIP Code area for a plan, that plan is not available to you. Post office box
addresses cannot be used to determine HMO enrollment eligibility. There is no
guarantee that all providers remain with the plans or that they have open
patient slots all year long. Please verify availability and physician status
prior to scheduling an appointment.
Use
your screen readers find command to search for a specific ZIP Code. Press the
letter H to move to the heading that begins the next section.
73001
GlobalHealth
73002
GlobalHealth, PacifiCare
73003
Aetna, CommunityCare, GlobalHealth, PacifiCare
73004
Aetna, GlobalHealth, PacifiCare
73005
GlobalHealth
73006
GlobalHealth
73007
Aetna, CommunityCare, GlobalHealth, PacifiCare
73008
Aetna, CommunityCare, GlobalHealth, PacifiCare
73009
GlobalHealth
73010
Aetna, GlobalHealth, PacifiCare
73011
GlobalHealth, PacifiCare
73012
Aetna, CommunityCare, GlobalHealth, PacifiCare
73013
Aetna, CommunityCare, GlobalHealth, PacifiCare
73014
CommunityCare, GlobalHealth, PacifiCare
73015
GlobalHealth
73016
GlobalHealth, PacifiCare
73017
GlobalHealth
73018
GlobalHealth, PacifiCare
73019
Aetna, CommunityCare, GlobalHealth, PacifiCare
73020
Aetna, CommunityCare, GlobalHealth, PacifiCare
73022
Aetna, CommunityCare, GlobalHealth, PacifiCare
73023
GlobalHealth
73025
Aetna, CommunityCare, GlobalHealth, PacifiCare
73026
Aetna, CommunityCare, GlobalHealth, PacifiCare
73027
Aetna, CommunityCare, GlobalHealth, PacifiCare
73028
Aetna, CommunityCare, GlobalHealth, PacifiCare
73029
GlobalHealth
73030
GlobalHealth
73031
Aetna, GlobalHealth, PacifiCare
73032
GlobalHealth
73033
GlobalHealth
73034
Aetna, CommunityCare, GlobalHealth, PacifiCare
73036
Aetna, CommunityCare, GlobalHealth, PacifiCare
73037
CommunityCare, PacifiCare
73038
GlobalHealth
73039
GlobalHealth
73040
GlobalHealth
73041
GlobalHealth
73042
GlobalHealth
73043
GlobalHealth
73044
Aetna, CommunityCare, GlobalHealth, PacifiCare
73045
Aetna, CommunityCare, GlobalHealth, PacifiCare
73047
GlobalHealth
73048
GlobalHealth
73049
Aetna, CommunityCare, GlobalHealth, PacifiCare
73050
Aetna, CommunityCare, GlobalHealth, PacifiCare
73051
Aetna, CommunityCare, GlobalHealth, PacifiCare
73052
GlobalHealth
73053
GlobalHealth
73054
Aetna, CommunityCare, GlobalHealth, PacifiCare
73055
GlobalHealth
73056
Aetna, CommunityCare, GlobalHealth, PacifiCare
73057
GlobalHealth, PacifiCare
73058
Aetna, CommunityCare, GlobalHealth, PacifiCare
73059
Aetna, GlobalHealth, PacifiCare
73061
CommunityCare, GlobalHealth
73062
GlobalHealth
73063
Aetna, CommunityCare, GlobalHealth, PacifiCare
73064
Aetna, CommunityCare, GlobalHealth, PacifiCare
73065
Aetna, GlobalHealth, PacifiCare
73066
Aetna, CommunityCare, GlobalHealth, PacifiCare
73067
GlobalHealth, PacifiCare
73068
Aetna, CommunityCare, GlobalHealth, PacifiCare
73069
Aetna, CommunityCare, GlobalHealth, PacifiCare
73070
Aetna, CommunityCare, GlobalHealth, PacifiCare
73071
Aetna, CommunityCare, GlobalHealth, PacifiCare
73072
Aetna, CommunityCare, GlobalHealth, PacifiCare
73073
Aetna, CommunityCare, GlobalHealth, PacifiCare
73074
GlobalHealth
73075
GlobalHealth
73077
CommunityCare, GlobalHealth
73078
Aetna, CommunityCare, GlobalHealth, PacifiCare
73079
GlobalHealth, PacifiCare
73080
Aetna, GlobalHealth, PacifiCare
73082
GlobalHealth
73083
Aetna, CommunityCare, GlobalHealth, PacifiCare
73084
Aetna, CommunityCare, GlobalHealth, PacifiCare
73085
Aetna, CommunityCare, GlobalHealth, PacifiCare
73086
GlobalHealth
73089
Aetna, GlobalHealth, PacifiCare
73090
Aetna, CommunityCare, GlobalHealth, PacifiCare
73091
GlobalHealth
73092
GlobalHealth, PacifiCare
73093
Aetna, GlobalHealth, PacifiCare
73094
GlobalHealth
73095
GlobalHealth, PacifiCare
73096
GlobalHealth
73097
Aetna, CommunityCare, GlobalHealth, PacifiCare
73098
GlobalHealth
73099
Aetna, CommunityCare, GlobalHealth, PacifiCare
73100
CommunityCare
73101
Aetna, CommunityCare, GlobalHealth, PacifiCare
73102
Aetna, CommunityCare, GlobalHealth, PacifiCare
73103
Aetna, CommunityCare, GlobalHealth, PacifiCare
73104
Aetna, CommunityCare, GlobalHealth, PacifiCare
73105
Aetna, CommunityCare, GlobalHealth, PacifiCare
73106
Aetna, CommunityCare, GlobalHealth, PacifiCare
73107
Aetna, CommunityCare, GlobalHealth, PacifiCare
73108
Aetna, CommunityCare, GlobalHealth, PacifiCare
73109
Aetna, CommunityCare, GlobalHealth, PacifiCare
73110
Aetna, CommunityCare, GlobalHealth, PacifiCare
73111
Aetna, CommunityCare, GlobalHealth, PacifiCare
73112
Aetna, CommunityCare, GlobalHealth, PacifiCare
73113
Aetna, CommunityCare, GlobalHealth, PacifiCare
73114
Aetna, CommunityCare, GlobalHealth, PacifiCare
73115
Aetna, CommunityCare, GlobalHealth, PacifiCare
73116
Aetna, CommunityCare, GlobalHealth, PacifiCare
73117
Aetna, CommunityCare, GlobalHealth, PacifiCare
73118
Aetna, CommunityCare, GlobalHealth, PacifiCare
73119
Aetna, CommunityCare, GlobalHealth, PacifiCare
73120
Aetna, CommunityCare, GlobalHealth, PacifiCare
73121
Aetna, CommunityCare, GlobalHealth, PacifiCare
73122
Aetna, CommunityCare, GlobalHealth, PacifiCare
73123
Aetna, CommunityCare, GlobalHealth, PacifiCare
73124
Aetna, CommunityCare, GlobalHealth, PacifiCare
73125
Aetna, CommunityCare, GlobalHealth, PacifiCare
73126
Aetna, CommunityCare, GlobalHealth, PacifiCare
73127
Aetna, CommunityCare, GlobalHealth, PacifiCare
73128
Aetna, CommunityCare, GlobalHealth, PacifiCare
73129
Aetna, CommunityCare, GlobalHealth, PacifiCare
73130
Aetna, CommunityCare, GlobalHealth, PacifiCare
73131
Aetna, CommunityCare, GlobalHealth, PacifiCare
73132
Aetna, CommunityCare, GlobalHealth, PacifiCare
73134
Aetna, CommunityCare, GlobalHealth, PacifiCare
73135
Aetna, CommunityCare, GlobalHealth, PacifiCare
73136
Aetna, CommunityCare, GlobalHealth, PacifiCare
73137
Aetna, CommunityCare, GlobalHealth, PacifiCare
73139
Aetna, CommunityCare, GlobalHealth, PacifiCare
73140
Aetna, CommunityCare, GlobalHealth, PacifiCare
73141
Aetna, CommunityCare, GlobalHealth, PacifiCare
73142
Aetna, CommunityCare, GlobalHealth, PacifiCare
73143
Aetna, CommunityCare, GlobalHealth, PacifiCare
73144
Aetna, CommunityCare, GlobalHealth, PacifiCare
73145
Aetna, CommunityCare, GlobalHealth, PacifiCare
73146
Aetna, CommunityCare, GlobalHealth, PacifiCare
73147
Aetna, CommunityCare, GlobalHealth, PacifiCare
73148
Aetna, CommunityCare, GlobalHealth, PacifiCare
73149
Aetna, CommunityCare, GlobalHealth, PacifiCare
73150
Aetna, CommunityCare, GlobalHealth, PacifiCare
73151
Aetna, CommunityCare, GlobalHealth, PacifiCare
73152
Aetna, CommunityCare, GlobalHealth, PacifiCare
73153
Aetna, CommunityCare, GlobalHealth, PacifiCare
73154
Aetna, CommunityCare, GlobalHealth, PacifiCare
73155
Aetna, CommunityCare, GlobalHealth, PacifiCare
73156
Aetna, CommunityCare, GlobalHealth, PacifiCare
73157
Aetna, CommunityCare, GlobalHealth, PacifiCare
73159
Aetna, CommunityCare, GlobalHealth, PacifiCare
73160
Aetna, CommunityCare, GlobalHealth, PacifiCare
73162
Aetna, CommunityCare, GlobalHealth, PacifiCare
73163
Aetna, CommunityCare, GlobalHealth, PacifiCare
73164
CommunityCare, GlobalHealth, PacifiCare
73165
Aetna, CommunityCare, GlobalHealth, PacifiCare
73167
Aetna, CommunityCare, GlobalHealth, PacifiCare
73169
Aetna, CommunityCare, GlobalHealth, PacifiCare
73170
Aetna, CommunityCare, GlobalHealth, PacifiCare
73172
Aetna, CommunityCare, GlobalHealth, PacifiCare
73173
Aetna, CommunityCare, GlobalHealth, PacifiCare
73177
CommunityCare, PacifiCare
73178
Aetna, CommunityCare, GlobalHealth, PacifiCare
73179
Aetna, CommunityCare, GlobalHealth, PacifiCare
73180
CommunityCare, PacifiCare
73184
Aetna, CommunityCare, GlobalHealth, PacifiCare
73185
Aetna, CommunityCare, GlobalHealth, PacifiCare
73189
Aetna, CommunityCare, GlobalHealth, PacifiCare
73190
Aetna, CommunityCare, GlobalHealth, PacifiCare
73193
CommunityCare, PacifiCare
73194
Aetna, CommunityCare, GlobalHealth, PacifiCare
73195
Aetna, CommunityCare, GlobalHealth, PacifiCare
73196
Aetna, CommunityCare, GlobalHealth, PacifiCare
73197
Aetna, CommunityCare, PacifiCare
73198
Aetna, CommunityCare, GlobalHealth, PacifiCare
73199
Aetna, CommunityCare, PacifiCare
73401
GlobalHealth
73402
GlobalHealth
73403
GlobalHealth
73425
GlobalHealth
73430
GlobalHealth
73432
GlobalHealth
73433
GlobalHealth
73434
GlobalHealth
73435
GlobalHealth
73436
GlobalHealth
73437
GlobalHealth
73438
GlobalHealth
73441
GlobalHealth
73442
GlobalHealth
73443
GlobalHealth
73444
GlobalHealth
73446
GlobalHealth
73447
GlobalHealth
73448
GlobalHealth
73450
GlobalHealth
73453
GlobalHealth
73455
GlobalHealth
73458
GlobalHealth
73459
GlobalHealth
73460
GlobalHealth
73461
GlobalHealth
73463
GlobalHealth
73481
GlobalHealth
73487
GlobalHealth
73488
GlobalHealth
73491
GlobalHealth
73521
GlobalHealth
73522
GlobalHealth
73523
GlobalHealth
73526
GlobalHealth
73529
GlobalHealth
73532
GlobalHealth
73533
GlobalHealth
73534
GlobalHealth
73536
GlobalHealth
73537
GlobalHealth
73539
GlobalHealth
73544
GlobalHealth
73549
GlobalHealth
73550
GlobalHealth
73554
GlobalHealth
73556
GlobalHealth
73559
GlobalHealth
73560
GlobalHealth
73564
GlobalHealth
73566
GlobalHealth
73571
GlobalHealth
73601
GlobalHealth
73620
GlobalHealth
73625
GlobalHealth
73639
GlobalHealth
73646
GlobalHealth
73651
GlobalHealth
73655
GlobalHealth
73658
GlobalHealth
73669
GlobalHealth
73701
GlobalHealth
73702
GlobalHealth
73703
GlobalHealth
73705
GlobalHealth
73706
GlobalHealth
73716
GlobalHealth
73718
GlobalHealth
73720
GlobalHealth
73724
GlobalHealth
73727
GlobalHealth
73729
GlobalHealth
73730
GlobalHealth
73733
GlobalHealth
73734
GlobalHealth
73735
GlobalHealth
73736
GlobalHealth
73737
GlobalHealth
73738
GlobalHealth
73742
GlobalHealth
73743
GlobalHealth
73744
GlobalHealth
73747
GlobalHealth
73750
GlobalHealth
73753
GlobalHealth
73754
GlobalHealth
73755
GlobalHealth
73756
GlobalHealth
73757
CommunityCare, GlobalHealth
73760
GlobalHealth
73762
GlobalHealth, PacifiCare
73763
GlobalHealth
73764
GlobalHealth
73768
GlobalHealth
73770
GlobalHealth
73772
GlobalHealth
73773
GlobalHealth
73838
GlobalHealth
73860
GlobalHealth
74001
CommunityCare, GlobalHealth
74002
CommunityCare, GlobalHealth, PacifiCare
74003
CommunityCare, GlobalHealth
74004
CommunityCare
74005
CommunityCare
74006
CommunityCare
74008
Aetna, CommunityCare, GlobalHealth, PacifiCare
74009
CommunityCare
74010
CommunityCare, GlobalHealth, PacifiCare
74011
Aetna, CommunityCare, GlobalHealth, PacifiCare
74012
Aetna, CommunityCare, GlobalHealth, PacifiCare
74013
Aetna, CommunityCare, GlobalHealth, PacifiCare
74014
Aetna, CommunityCare, GlobalHealth, PacifiCare
74015
Aetna, CommunityCare, GlobalHealth, PacifiCare
74016
Aetna, CommunityCare, GlobalHealth, PacifiCare
74017
Aetna, CommunityCare, GlobalHealth, PacifiCare
74018
Aetna, CommunityCare, GlobalHealth, PacifiCare
74019
Aetna, CommunityCare, GlobalHealth, PacifiCare
74020
CommunityCare, GlobalHealth, PacifiCare
74021
Aetna, CommunityCare, GlobalHealth, PacifiCare
74022
CommunityCare, GlobalHealth
74023
CommunityCare, GlobalHealth, PacifiCare
74026
GlobalHealth, PacifiCare
74027
CommunityCare, GlobalHealth
74028
CommunityCare, GlobalHealth, PacifiCare
74029
CommunityCare
74030
CommunityCare, GlobalHealth, PacifiCare
74031
Aetna, CommunityCare, GlobalHealth, PacifiCare
74032
CommunityCare, GlobalHealth, PacifiCare
74033
Aetna, CommunityCare, GlobalHealth, PacifiCare
74034
CommunityCare, GlobalHealth
74035
CommunityCare, GlobalHealth, PacifiCare
74036
Aetna, CommunityCare, GlobalHealth, PacifiCare
74037
Aetna, CommunityCare, GlobalHealth, PacifiCare
74038
CommunityCare, GlobalHealth, PacifiCare
74039
Aetna, CommunityCare, GlobalHealth, PacifiCare
74041
CommunityCare, GlobalHealth, PacifiCare
74042
CommunityCare, GlobalHealth
74043
Aetna, CommunityCare, GlobalHealth, PacifiCare
74044
CommunityCare, GlobalHealth, PacifiCare
74045
CommunityCare, GlobalHealth
74046
CommunityCare, GlobalHealth, PacifiCare
74047
Aetna, CommunityCare, GlobalHealth, PacifiCare
74048
CommunityCare, GlobalHealth
74050
Aetna, CommunityCare, GlobalHealth, PacifiCare
74051
CommunityCare, GlobalHealth
74052
CommunityCare, GlobalHealth, PacifiCare
74053
Aetna, CommunityCare, GlobalHealth, PacifiCare
74054
Aetna, CommunityCare, GlobalHealth, PacifiCare
74055
Aetna, CommunityCare, GlobalHealth, PacifiCare
74056
CommunityCare, GlobalHealth
74058
CommunityCare, GlobalHealth
74059
CommunityCare, GlobalHealth, PacifiCare
74060
Aetna, CommunityCare, GlobalHealth, PacifiCare
74061
CommunityCare, GlobalHealth, PacifiCare
74062
CommunityCare, GlobalHealth, PacifiCare
74063
Aetna, CommunityCare, GlobalHealth, PacifiCare
74066
Aetna, CommunityCare, GlobalHealth, PacifiCare
74067
Aetna, CommunityCare, GlobalHealth, PacifiCare
74068
CommunityCare, GlobalHealth, PacifiCare
74070
Aetna, CommunityCare, GlobalHealth, PacifiCare
74071
CommunityCare, GlobalHealth, PacifiCare
74072
CommunityCare, GlobalHealth
74073
Aetna, CommunityCare, GlobalHealth, PacifiCare
74074
CommunityCare, GlobalHealth, PacifiCare
74075
CommunityCare, GlobalHealth, PacifiCare
74076
CommunityCare, GlobalHealth, PacifiCare
74077
CommunityCare, GlobalHealth
74078
CommunityCare, GlobalHealth
74079
GlobalHealth, PacifiCare
74080
Aetna, CommunityCare, GlobalHealth, PacifiCare
74081
CommunityCare, GlobalHealth, PacifiCare
74082
CommunityCare, PacifiCare
74083
CommunityCare, GlobalHealth
74084
CommunityCare, GlobalHealth
74085
CommunityCare, GlobalHealth, PacifiCare
74100
CommunityCare
74101
Aetna, CommunityCare, GlobalHealth, PacifiCare
74102
Aetna, CommunityCare, GlobalHealth, PacifiCare
74103
Aetna, CommunityCare, GlobalHealth, PacifiCare
74104
Aetna, CommunityCare, GlobalHealth, PacifiCare
74105
Aetna, CommunityCare, GlobalHealth, PacifiCare
74106
Aetna, CommunityCare, GlobalHealth, PacifiCare
74107
Aetna, CommunityCare, GlobalHealth, PacifiCare
74108
Aetna, CommunityCare, GlobalHealth, PacifiCare
74110
Aetna, CommunityCare, GlobalHealth, PacifiCare
74112
Aetna, CommunityCare, GlobalHealth, PacifiCare
74114
Aetna, CommunityCare, GlobalHealth, PacifiCare
74115
Aetna, CommunityCare, GlobalHealth, PacifiCare
74116
Aetna, CommunityCare, GlobalHealth, PacifiCare
74117
Aetna, CommunityCare, GlobalHealth, PacifiCare
74119
Aetna, CommunityCare, GlobalHealth, PacifiCare
74120
Aetna, CommunityCare, GlobalHealth, PacifiCare
74121
Aetna, CommunityCare, GlobalHealth, PacifiCare
74126
Aetna, CommunityCare, GlobalHealth, PacifiCare
74127
Aetna, CommunityCare, GlobalHealth, PacifiCare
74128
Aetna, CommunityCare, GlobalHealth, PacifiCare
74129
Aetna, CommunityCare, GlobalHealth, PacifiCare
74130
Aetna, CommunityCare, GlobalHealth, PacifiCare
74131
Aetna, CommunityCare, GlobalHealth, PacifiCare
74132
Aetna, CommunityCare, GlobalHealth, PacifiCare
74133
Aetna, CommunityCare, GlobalHealth, PacifiCare
74134
Aetna, CommunityCare, GlobalHealth, PacifiCare
74135
Aetna, CommunityCare, GlobalHealth, PacifiCare
74136
Aetna, CommunityCare, GlobalHealth, PacifiCare
74137
Aetna, CommunityCare, GlobalHealth, PacifiCare
74141
Aetna, CommunityCare, GlobalHealth, PacifiCare
74145
Aetna, CommunityCare, GlobalHealth, PacifiCare
74146
Aetna, CommunityCare, GlobalHealth, PacifiCare
74147
Aetna, CommunityCare, GlobalHealth, PacifiCare
74148
Aetna, CommunityCare, GlobalHealth, PacifiCare
74149
Aetna, CommunityCare, GlobalHealth, PacifiCare
74150
Aetna, CommunityCare, GlobalHealth, PacifiCare
74152
Aetna, CommunityCare, GlobalHealth, PacifiCare
74153
Aetna, CommunityCare, GlobalHealth, PacifiCare
74155
Aetna, CommunityCare, GlobalHealth, PacifiCare
74156
Aetna, CommunityCare, GlobalHealth, PacifiCare
74157
Aetna, CommunityCare, GlobalHealth, PacifiCare
74158
Aetna, CommunityCare, GlobalHealth, PacifiCare
74159
Aetna, CommunityCare, GlobalHealth, PacifiCare
74169
Aetna, CommunityCare, GlobalHealth, PacifiCare
74170
Aetna, CommunityCare, GlobalHealth, PacifiCare
74171
Aetna, CommunityCare, GlobalHealth, PacifiCare
74172
Aetna, CommunityCare, GlobalHealth, PacifiCare
74182
Aetna, CommunityCare, GlobalHealth, PacifiCare
74183
Aetna, CommunityCare, PacifiCare
74184
Aetna, CommunityCare
74186
Aetna, CommunityCare, GlobalHealth, PacifiCare
74187
Aetna, CommunityCare, GlobalHealth, PacifiCare
74189
Aetna, CommunityCare, PacifiCare
74192
Aetna, CommunityCare, GlobalHealth, PacifiCare
74193
Aetna, CommunityCare, GlobalHealth, PacifiCare
74194
Aetna, CommunityCare, PacifiCare
74301
CommunityCare, PacifiCare
74330
Aetna, CommunityCare, GlobalHealth, PacifiCare
74331
CommunityCare
74332
CommunityCare, GlobalHealth
74333
CommunityCare
74335
CommunityCare
74337
Aetna, CommunityCare, GlobalHealth, PacifiCare
74338
CommunityCare
74339
CommunityCare
74340
Aetna, CommunityCare, GlobalHealth, PacifiCare
74342
CommunityCare
74343
CommunityCare
74344
CommunityCare
74345
CommunityCare
74346
CommunityCare
74347
CommunityCare
74349
Aetna, CommunityCare, GlobalHealth, PacifiCare
74350
Aetna, CommunityCare, GlobalHealth, PacifiCare
74352
Aetna, CommunityCare, GlobalHealth, PacifiCare
74353
CommunityCare, PacifiCare
74354
CommunityCare
74355
CommunityCare
74358
CommunityCare
74359
CommunityCare
74360
CommunityCare
74361
Aetna, CommunityCare, GlobalHealth, PacifiCare
74362
Aetna, CommunityCare, GlobalHealth, PacifiCare
74363
CommunityCare
74364
Aetna, CommunityCare, GlobalHealth, PacifiCare
74365
Aetna, CommunityCare, GlobalHealth, PacifiCare
74366
Aetna, CommunityCare, GlobalHealth, PacifiCare
74367
Aetna, CommunityCare, GlobalHealth, PacifiCare
74368
CommunityCare
74369
CommunityCare
74370
CommunityCare
74401
CommunityCare, GlobalHealth
74402
CommunityCare, GlobalHealth
74403
CommunityCare, GlobalHealth
74421
CommunityCare, GlobalHealth, PacifiCare
74422
CommunityCare, GlobalHealth, PacifiCare
74423
CommunityCare, GlobalHealth
74425
CommunityCare
74426
CommunityCare, GlobalHealth
74427
CommunityCare, GlobalHealth
74428
CommunityCare, GlobalHealth
74429
Aetna, CommunityCare, GlobalHealth, PacifiCare
74430
CommunityCare
74431
CommunityCare, GlobalHealth, PacifiCare
74432
CommunityCare, GlobalHealth
74434
CommunityCare, GlobalHealth
74435
CommunityCare, GlobalHealth
74436
CommunityCare, GlobalHealth, PacifiCare
74437
CommunityCare, GlobalHealth, PacifiCare
74438
CommunityCare, GlobalHealth
74439
CommunityCare, GlobalHealth
74440
CommunityCare
74441
CommunityCare, GlobalHealth
74442
CommunityCare
74444
CommunityCare, GlobalHealth
74445
CommunityCare, GlobalHealth, PacifiCare
74446
CommunityCare, GlobalHealth, PacifiCare
74447
CommunityCare, GlobalHealth, PacifiCare
74450
CommunityCare, GlobalHealth
74451
CommunityCare, GlobalHealth
74452
CommunityCare, GlobalHealth
74454
CommunityCare, GlobalHealth, PacifiCare
74455
CommunityCare, GlobalHealth
74456
CommunityCare, GlobalHealth, PacifiCare
74457
CommunityCare
74458
CommunityCare, GlobalHealth, PacifiCare
74459
CommunityCare, GlobalHealth
74460
CommunityCare, GlobalHealth, PacifiCare
74461
CommunityCare, GlobalHealth
74462
CommunityCare
74463
CommunityCare, GlobalHealth
74464
CommunityCare, GlobalHealth
74465
CommunityCare, GlobalHealth
74466
CommunityCare, PacifiCare
74467
CommunityCare, GlobalHealth, PacifiCare
74468
CommunityCare, GlobalHealth
74469
CommunityCare, GlobalHealth
74470
CommunityCare, GlobalHealth
74471
CommunityCare, GlobalHealth
74472
CommunityCare
74477
CommunityCare, GlobalHealth, PacifiCare
74501
CommunityCare
74502
CommunityCare
74521
CommunityCare
74522
CommunityCare
74523
CommunityCare
74526
CommunityCare
74528
CommunityCare
74529
CommunityCare
74530
GlobalHealth
74531
GlobalHealth
74536
CommunityCare
74543
CommunityCare
74545
CommunityCare
74546
CommunityCare
74547
CommunityCare
74548
CommunityCare
74549
CommunityCare
74552
CommunityCare
74553
CommunityCare
74554
CommunityCare
74557
CommunityCare
74558
CommunityCare
74559
CommunityCare
74560
CommunityCare
74561
CommunityCare
74562
CommunityCare
74563
CommunityCare
74565
CommunityCare
74567
CommunityCare
74570
GlobalHealth
74571
CommunityCare
74574
CommunityCare
74577
CommunityCare
74578
CommunityCare
74604
CommunityCare, GlobalHealth
74630
CommunityCare, GlobalHealth
74633
CommunityCare, GlobalHealth
74637
CommunityCare, GlobalHealth
74640
GlobalHealth
74644
CommunityCare, GlobalHealth
74650
CommunityCare, GlobalHealth
74651
CommunityCare, GlobalHealth
74652
CommunityCare, GlobalHealth
74727
CommunityCare
74735
CommunityCare
74738
CommunityCare
74743
CommunityCare
73748
GlobalHealth
74756
CommunityCare
74759
CommunityCare
74760
CommunityCare
74761
CommunityCare
74801
Aetna, CommunityCare, GlobalHealth, PacifiCare
74802
Aetna, CommunityCare, GlobalHealth, PacifiCare
74804
Aetna, CommunityCare, GlobalHealth, PacifiCare
74818
CommunityCare, GlobalHealth, PacifiCare
74820
GlobalHealth
74821
GlobalHealth
74824
GlobalHealth, PacifiCare
74825
GlobalHealth
74826
Aetna, CommunityCare, GlobalHealth, PacifiCare
74827
GlobalHealth
74829
GlobalHealth, PacifiCare
74830
CommunityCare, GlobalHealth, PacifiCare
74831
Aetna, GlobalHealth, PacifiCare
74832
GlobalHealth, PacifiCare
74833
GlobalHealth, PacifiCare
74834
GlobalHealth, PacifiCare
74835
PacifiCare
74836
GlobalHealth
74837
CommunityCare, GlobalHealth, PacifiCare
74838
PacifiCare
74839
GlobalHealth
74840
Aetna, CommunityCare, GlobalHealth, PacifiCare
74842
GlobalHealth
74843
GlobalHealth
74844
GlobalHealth
74845
CommunityCare, GlobalHealth
74848
GlobalHealth
74849
CommunityCare, GlobalHealth, PacifiCare
74850
GlobalHealth
74851
Aetna, CommunityCare, GlobalHealth, PacifiCare
74852
Aetna, CommunityCare, GlobalHealth, PacifiCare
74854
Aetna, CommunityCare, GlobalHealth, PacifiCare
74855
Aetna, GlobalHealth, PacifiCare
74856
GlobalHealth
74857
Aetna, CommunityCare, GlobalHealth, PacifiCare
74859
GlobalHealth, PacifiCare
74860
GlobalHealth, PacifiCare
74862
PacifiCare
74864
GlobalHealth, PacifiCare
74865
GlobalHealth
74866
Aetna, CommunityCare, GlobalHealth, PacifiCare
74867
CommunityCare, GlobalHealth, PacifiCare
74868
CommunityCare, GlobalHealth, PacifiCare
74869
Aetna, GlobalHealth, PacifiCare
74871
GlobalHealth
74872
GlobalHealth
74873
Aetna, CommunityCare, GlobalHealth, PacifiCare
74875
GlobalHealth, PacifiCare
74878
Aetna, CommunityCare, GlobalHealth, PacifiCare
74880
GlobalHealth, PacifiCare
74881
Aetna, GlobalHealth, PacifiCare
74882
PacifiCare
74883
GlobalHealth
74884
CommunityCare, GlobalHealth, PacifiCare
74901
CommunityCare
74902
CommunityCare
74930
CommunityCare
74931
CommunityCare
74932
CommunityCare
74935
CommunityCare
74936
CommunityCare, GlobalHealth
74937
CommunityCare
74939
CommunityCare
74940
CommunityCare
74941
CommunityCare
74942
CommunityCare
74943
CommunityCare
74944
CommunityCare
74945
CommunityCare, GlobalHealth
74946
CommunityCare, GlobalHealth
74947
CommunityCare
74948
CommunityCare, GlobalHealth
74949
CommunityCare
74951
CommunityCare
74953
CommunityCare
74954
CommunityCare, GlobalHealth
74955
CommunityCare, GlobalHealth
74956
CommunityCare
74959
CommunityCare
74960
CommunityCare
74962
CommunityCare, GlobalHealth
74964
CommunityCare
74965
CommunityCare
74966
CommunityCare
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 the Help
Lines at
the end of this document for contact information.
This
chart reflects your cost for the listed Network services.
$500 individual and
$1,500 family
$500 individual and
$1,000 family; deductible applies after Plan pays first $500 of Allowed Charges
$1,500 individual and
$3,000 family; the combined medical and pharmacy deductible must be met before
benefits are paid
No deductible
No deductible
No deductible
No deductible
No deductible
$2,800 Network,
individual and $3,300 non-Network individual, plus amounts over Allowed Charges
$5,500 individual and
$11,000 family
$4,000 individual and
$8,000 family; non-Network charges do not apply
$2,500 individual and
$5,000 family
$3,000 individual and
$6,000 family
$3,000 individual and
$6,000 family
$3,000 individual and
$5,000 family
$2,500 individual and
$5,000 family
$50 copay
Copays do not apply;
refer to the HealthChoice Basic Plan Benefits section for more specific plan
information
Member pays 100% of
Allowed Charges until deductible is met; $50 copay applies after deductible
$30 copay/PCP and $40
copay/specialist
$55 copay/PCP and $65
copay/specialist
$35 copay/PCP and $50
copay/specialist
$25 copay/PCP and $50
copay/specialist
$35 copay/PCP and $50
copay/specialist
20% of Allowed Charges
after deductible
Refer to the
HealthChoice Basic Plan Benefits section for more specific plan information
20% of Allowed Charges
after deductible
No copay/laboratory
services or outpatient radiology; $150 copay per MRI, CAT, MRA, or PET scan
$65 copay per visit; per
scan for MRI, CT, MRA, and PET scan
No additional
copay/laboratory services or outpatient radiology; $200 copay per MRI, CAT,
MRA, or PET scan
$0 copay; $250 copay per
MRI, MRA, PET, or CAT
$0 copay/standard lab
and radiology; $200 copay per MRI, MRA, PET, or CAT
20% of Allowed Charges
after deductible; $300 deductible per non-Network admission
Refer to the
HealthChoice Basic Plan Benefits section for more specific plan information
20% of Allowed Charges
after deductible; $300 deductible per non-Network admission
$350 copay;
preauthorization required
$1,000 copay;
preauthorization required
$500 copay
$250 copay per day; $750
maximum per admission
$1,000 copay/admission
20% of Allowed Charges
after deductible
Refer to the
HealthChoice Basic Plan Benefits section for more specific plan information
20% of Allowed Charges
after deductible
$250 copay;
preauthorization required
$500 per visit copay;
must be preauthorized
$300 copay
$250 copay
$500 copay
$50 copay; no deductible
applies
Refer to the
HealthChoice Basic Plan Benefits section for more specific plan information
$50 copay; no deductible
applies
$0 copay
$0 copay up to age 2
$0 copay up to age 2
$0 copay/PCP; $25 copay
PCP over age 2
$0 copay
No charge for well baby
and adult immunizations; $50 office visit copay and/or administration fee may
apply
Refer to the
HealthChoice Basic Plan Benefits section for more specific plan information
No charge for well baby
and adult immunizations; $50 office visit copay and/or administration fee may
apply
$0 copay/birth through
age 18; $10 copay/ages 19 and over
$0 copay/ages birth
through age 18; $10 copay/ages 19 and over
$0 copay/ages birth
through 18 years; $25 copay/ages 19 and over
$0 copay/ages birth to
age 18; $25 copay/PCP office visit for adults; standard copays may apply in
conjunction with office visit
$0 copay/birth through
age 18 (if no other service is rendered); $10 copay ages 19 and over
$50 copay per exam, one
mammogram per year at no charge for women age 40 and over
One mammogram at no
charge for women age 40 and over; refer to the HealthChoice Basic Plan Benefits
section for more specific plan information
$50 copay per exam, one
mammogram at no charge for women age 40 and over
$10 copay per visit for
routine physicals
$10 copay for ages 19
and over
$25 copay
$25 copay/PCP; Limit:
one per year
$35 copay/PCP; $50
copay/specialist
20% of Allowed Charges
after deductible; Limit: 60 tests every 24 months
Refer to the
HealthChoice Basic Plan Benefits section for more specific plan information
20% of Allowed Charges
after deductible; Limit: 60 tests every 24 months
$30 copay/PCP; $40
copay/specialist; $30 for 6 week supply of antigen (including shots)
$20 copay per visit; $20
copay for 6 week supply of antigen (includes shots)
$35 copay/PCP visit; $50
copay/specialist visit; $30 copay for 6 week supply of antigen (including
shots)
$25 copay/PCP visit; $50
copay/specialist; $30 copay for 6 week supply of antigen (including shots)
$35 copay/PCP; $50
copay/specialist; $35 serum and shots including a 6 week supply of antigen
20% of Allowed Charges
after deductible; Additional $100 ER deductible, waived if admitted
Refer to the
HealthChoice Basic Plan Benefits section for more specific plan information
20% of Allowed Charges
after deductible; Additional $100 ER deductible, waived if admitted
$150 copay; waived if
admitted
$200 per visit copay;
waived if admitted
$200 copay; waived if
admitted
$150 copay; waived if
admitted
$200 copay; waived if
admitted
20% of Allowed Charges
after deductible
Refer to the
HealthChoice Basic Plan Benefits section for more specific plan information
20% of Allowed Charges
after deductible
$40 copay
$75 per visit copay
$50 copay per visit
$25 copay/PCP; $50
copay/all others
$50 copay per visit
*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.
20% of Allowed Charges
after deductible; Limit: 30 days per year*
Refer to the
HealthChoice Basic Plan Benefits section for more specific plan information
20% of Allowed Charges
after deductible; Limit: 30 days per year*
$350 copay
$1,000 copay; Must be
preauthorized
$500 copay; Must be
preauthorized and approved through CCOK Behavioral Health Services
$250 copay; $750 maximum
per admission
$1,000 copay
*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.
20% of Allowed Charges
after deductible; Limit: 26 visits per year*
Refer to the
HealthChoice Basic Plan Benefits section for more specific plan information
20% of Allowed Charges
after deductible; Limit: 26 visits per year*
$30 copay/PCP; $40
copay/specialist
$55 copay/PCP; $65
copay/specialist; Single or group therapy except for the biologically-based
diagnoses treated as other illnesses
$35 copay/PCP; $50
copay/specialist; Must be preauthorized and approved through CCOK Behavioral
Health Services
$50 copay; Must be
preauthorized
$35 copay/PCP; $50
copay/specialist
20% of Allowed Charges
after deductible for purchase, rental, repair, or replacement
Refer to the
HealthChoice Basic Plan Benefits section for more specific plan information
20% of Allowed Charges
after deductible for purchase, rental, repair, or replacement
20% coinsurance initial
device; 20% coinsurance repair and replacement
20% of contracted rate
20% coinsurance initial
device; 20% coinsurance repair and replacement
20% coinsurance; $5,000
annual maximum
20% coinsurance; $10,000
annual maximum
20% of Allowed Charges
after deductible; For each service – Limit: 20 visits per year without prior
authorization; Maximum of 60 visits per year
Refer to the
HealthChoice Basic Plan Benefits section for more specific plan information
20% of Allowed Charges
after deductible; For each service – Limit: 20 visits per year without prior
authorization; Maximum of 60 visits per year
No copay inpatient; $30
copay/PCP; $40 copay/specialist; Limit: 60 treatment days per illness
No copay inpatient; $65
copay/outpatient therapy; Limit: 60 consecutive days per illness
No copay inpatient; $50
copay outpatient therapy; Limit: 60 days per illness
No copay inpatient; $50
copay per outpatient visit; Limit: 60 consecutive days per illness
$1,000 copay inpatient;
Outpatient - $35 copay/PCP; $50 copay/specialist; Limit: 60 days per illness
20% of Allowed Charges
after deductible; Limit: 20 visits per year without prior authorization;
Maximum of 60 visits
Refer to the
HealthChoice Basic Plan Benefits section for more specific plan information
20% of Allowed Charges
after deductible; Limit: 20 visits per year without prior authorization;
Maximum of 60 visits
No copay inpatient; $30
copay/PCP; $40 copay/specialist; Limit: 60 treatment days per illness
$65 copay outpatient
therapy; Limit: 60 consecutive days per illness
No copay inpatient; $50
copay outpatient therapy; Limit: 60 days per illness
No copay inpatient; $50
copay per outpatient visit; Limit: 60 consecutive days per illness
$1,000 copay inpatient;
Outpatient - $35 copay/PCP; $50 copay/specialist; Limit: 60 days per illness
Chiropractic services -
20% of Allowed Charges after deductible; Limit: 20 visits per year without
prior authorization; Maximum of 60 visits per year
Manipulative therapy -
Refer to Physical Therapy/Physical Medicine
Refer to the
HealthChoice Basic Plan Benefits section for more specific plan information
Chiropractic services -
20% of Allowed Charges after deductible; Limit: 20 visits per year without
prior authorization; Maximum of 60 visits per year
Manipulative therapy -
Refer to Physical Therapy/Physical Medicine
$40 copay; Limit: 15
visits per year; PCP referral required
$65 copay; Limit: 15
visits per calendar year
$50 copay; Limit: 15
visits per year
$50 copay; Limit: 15
visits per year – referral required
$50 copay; Limit: 15
visits per year – referral required; Limited to treatment of neurological and
orthopedic conditions
20% of Allowed Charges
after deductible; Includes one postpartum home visit – criteria must be met
Refer to the
HealthChoice Basic Plan Benefits section for more specific plan information
20% of Allowed Charges
after deductible; Includes one postpartum home visit – criteria must be met
$30 copay for initial
visit; $350 copay per hospital admission
$65 copay for initial
visit; thereafter covered at 100%; $1,000 copay per hospital admission
$35 copay for initial
visit; $500 copay per hospital admission
$25 copay initial visit
only; $250 copay per hospital admission per day; $750 maximum per admission
$35 copay/PCP; $50
copay/specialist for initial visit once diagnosis of pregnancy is confirmed;
$1,000 copay hospital admission
$50 copay/basic hearing
screening; Limit: one per year; Hearing aids are covered as durable medical
equipment for children up to age 18
Refer to the
HealthChoice Basic Plan Benefits section for more specific plan information
$50 copay/basic hearing
screening; Limit: one per year; Hearing aids are covered as durable medical
equipment for children up to age 18
$30 copay; Limit: one
per year; Hearing aids – 20% coinsurance for children up to age 18
$10 copay; Limit: one
per ear every 48 months; Hearing aids covered for children up to age 18
$35 copay; Limit: one
per year; Hearing aids – 20% coinsurance for children up to age 18
$25 copay per visit;
Limit: one visit per year; Hearing aids – 20% coinsurance; Covered for children
up to age 18; Limit: $5,000 combined DME, orthotics, and prosthetics
$35 copay/PCP; Hearing aids –
covered for children up to age 18
NETWORK:
Generic Mandate
PREFERRED MEDICATION:
The cost of medication is $100 or less – you
pay up to $30 or actual cost if less
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:
The cost of medication is $100 or less – you
pay up to $60 or actual cost if less
The cost of medication is more than $100 –
you pay 50% up to a $120 maximum
Out-of-pocket maximums do 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
HealthChoice Health
Plans offer each covered individual a lifetime pharmacy benefit of $2 million
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 $75
maximum plus a dispensing fee
NON-PREFERRED
MEDICATION:
You pay the cost of medication up to $125
maximum plus a dispensing fee
After the combined medical
and pharmacy $1,500 individual or $3,000 family deductible has been met, the
pharmacy benefits are:
NETWORK:
Generic Mandate
PREFERRED MEDICATION:
The cost of medication is $100 or less – you
pay up to $30 or actual cost if less
The cost of medication is more than $100 –
you pay 25% up to a $60 maximum
NON-PREFERRED
MEDICATION:
The cost of medication is $100 or less – you
pay up to $60 or actual cost if less
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 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
HealthChoice Health
Plans offer each covered individual a lifetime pharmacy benefit of $2 million
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 $75
maximum plus a dispensing fee
NON-PREFERRED
MEDICATION:
You pay the cost of medication up to $125
maximum plus a dispensing fee
Up to $5 generic
formulary
Up to $30 brand
formulary (when no generic is available)
Up to $60 brand
formulary (when generic is available)
The lesser of 30-day
supply or 100 units
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 own formulary design
Tier 1: $20
Tier 2: $40
Tier 3: $70
MAIL ORDER 90-DAY SUPPLY
$40 copay for formulary
generic drugs
$80 copay for formulary
drugs
$140 copay for
non-formulary brand-name and non-formulary generic drugs
Greater of 30-day supply
or 100 units
Certain medications have
restricted quantities
Tier 1: $10
Tier 2: $40
Tier 3: $65
Up to $65 non-formulary
The lesser of 30-day
supply or 100 units
Selected medications may
have restricted quantities
Tier 1: $10
Tier 2: $50
Tier 3: $75
The lesser of 30-day
supply or 100 units
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 for
non-formulary generic and non-formulary brand drugs
30-day supply or 100
units
Certain medications have
restricted quantities
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 the Help
Lines at
the end of this document for contact information.
This
chart reflects your cost for the listed Network services.
$500 individual and
$1,500 family
$2,800 Network,
individual and $3,300 non-Network individual, plus amounts over Allowed Charges
$50 copay
20% of Allowed Charges
after deductible
20% of Allowed Charges
after deductible; $300 deductible per non-Network admission
20% of Allowed Charges
after deductible
$50 copay; no deductible
applies
No charge for well baby
and adult immunizations; $50 office visit copay and/or administration fee may
apply
$50 copay per exam, one
mammogram per year at no charge for women age 40 and over
20% of Allowed Charges
after deductible; Limit: 60 tests every 24 months
20% of Allowed Charges
after deductible; Additional $100 ER deductible, waived if admitted
20% of Allowed Charges
after deductible
*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.
20% of Allowed Charges
after deductible; Limit: 30 days per year*
*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.
20% of Allowed Charges
after deductible; Limit: 26 visits per year*
20% of Allowed Charges
after deductible for purchase, rental, repair, or replacement
20% of Allowed Charges
after deductible; For each service – Limit: 20 visits per year without prior
authorization; Maximum of 60 visits per year
20% of Allowed Charges
after deductible; Limit: 20 visits per year without prior authorization;
Maximum of 60 visits
Chiropractic services -
20% of Allowed Charges after deductible; Limit: 20 visits per year without
prior authorization; Maximum of 60 visits per year
Manipulative therapy -
Refer to Physical Therapy/Physical Medicine
20% of Allowed Charges
after deductible; Includes one postpartum home visit – criteria must be met
$50 copay/basic hearing
screening; Limit: one per year; Hearing aids are covered as durable medical
equipment for children up to age 18
NETWORK:
Generic Mandate
PREFERRED MEDICATION:
The cost of medication is $100 or less – you
pay up to $30 or actual cost if less
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:
The cost of medication is $100 or less – you
pay up to $60 or actual cost if less
The cost of medication is more than $100 –
you pay 50% up to a $120 maximum
Out-of-pocket maximums do 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
HealthChoice Health
Plans offer each covered individual a lifetime pharmacy benefit of $2 million
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 $75
maximum plus a dispensing fee
NON-PREFERRED
MEDICATION:
You pay the cost of medication up to $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. Refer to the Help
Lines at
the end of this document for contact information.
This
chart reflects your cost for the listed Network services.
$500 individual and
$1,000 family; deductible applied after Plan pays first $500 of Allowed Charges
$5,500 individual and
$11,000 family
*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.
Copays do not apply
All services, benefits, exceptions,
limitations, and conditions are identical between the HealthChoice High Option
Plan and the HealthChoice Basic Plan
For Network Services, you pay:
$0 of Allowed Charges
through the first $500
100% through the next
$500 of deductible (only Allowed Charges apply to the deductible)
50% of the next $10,000
of Allowed Charges
$0 of Allowed Charges
over $11,000
You may use non-Network
providers, but it will be more costly
NETWORK:
Generic Mandate
PREFERRED MEDICATION:
The cost of medication is $100 or less – you
pay up to $30 or actual cost if less
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:
The cost of medication is $100 or less – you
pay up to $60 or actual cost if less
The cost of medication is more than $100 –
you pay 50% up to a $120 maximum
Out-of-pocket maximums do 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
HealthChoice Health
Plans offer each covered individual a lifetime pharmacy benefit of $2 million
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 $75
maximum plus a dispensing fee
NON-PREFERRED MEDICATION:
You pay the cost of medication up to $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. Refer to the Help
Lines at
the end of this document for contact information.
This
chart reflects your cost for the listed Network services.
$1,500 individual and
$3,000 family; the combined medical and pharmacy deductible must be met before
benefits are paid
$4,000 individual and
$8,000 family; non-Network charges do not apply
Member pays 100% of
Allowed Charges until deductible is met; $50 copay applies after deductible
20% of Allowed Charges
after deductible
20% of Allowed Charges
after deductible; $300 deductible per non-Network admission
20% of Allowed Charges
after deductible
$50 copay; no deductible
applies
No charge for well baby
and adult immunizations; $50 office visit copay and/or administration fee may
apply
$50 copay per exam, one
mammogram at no charge for women age 40 and over
20% of Allowed Charges
after deductible; Limit: 60 tests every 24 months
20% of Allowed Charges
after deductible; Additional $100 ER deductible, waived if admitted
20% of Allowed Charges
after deductible
*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.
20% of Allowed Charges
after deductible; Limit: 30 days per year*
*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.
20% of Allowed Charges
after deductible; Limit: 26 visits per year*
20% of Allowed Charges
after deductible for purchase, rental, repair, or replacement
20% of Allowed Charges
after deductible; For each service – Limit: 20 visits per year without prior
authorization; Maximum of 60 visits per year
20% of Allowed Charges
after deductible; Limit: 20 visits per year without prior authorization;
Maximum of 60 visits
Chiropractic services -
20% of Allowed Charges after deductible; Limit: 20 visits per year without
prior authorization; Maximum of 60 visits per year
Manipulative therapy -
Refer to Physical Therapy/Physical Medicine
20% of Allowed Charges
after deductible; Includes one postpartum home visit – criteria must be met
$50 copay/basic hearing
screening; Limit: one per year; Hearing aids are covered as durable medical
equipment for children up to age 18
After the combined
medical and pharmacy $1,500 individual or $3,000 family deductible has been
met, the pharmacy benefits are:
NETWORK:
Generic Mandate
PREFERRED MEDICATION:
The cost of medication is $100 or less – you
pay up to $30 or actual cost if less
The cost of medication is more than $100 –
you pay 25% up to a $60 maximum
NON-PREFERRED
MEDICATION:
The cost of medication is $100 or less – you
pay up to $60 or actual cost if less
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 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
HealthChoice Health
Plans offer each covered individual a lifetime pharmacy benefit of $2 million
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 $75
maximum plus a dispensing fee
NON-PREFERRED
MEDICATION:
You pay the cost of medication up to $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. Refer to the Help
Lines at
the end of this document for contact information.
This
chart reflects your cost for the listed Network services.
No deductible
$2,500 individual and
$5,000 family
$30 copay/PCP and $40
copay/specialist
No copay/laboratory
services or outpatient radiology; $150 copay per MRI, CAT, MRA, or PET scan
$350 copay;
preauthorization required
$250 copay;
preauthorization required
$0 copay
$0 copay/birth through
age 18; $10 copay/ages 19 and over
$10 copay per visit for
routine physicals
$30 copay/PCP; $40
copay/specialist; $30 for 6 week supply of antigen (including shots)
$150 copay; waived if
admitted
$40 copay
$350 copay
$30 copay/PCP; $40
copay/specialist
20% coinsurance initial
device; 20% coinsurance repair and replacement
No copay inpatient; $30
copay/PCP; $40 copay/specialist; Limit: 60 treatment days per illness
No copay inpatient; $30
copay/PCP; $40 copay/specialist; Limit: 60 treatment days per illness
$40 copay; Limit: 15
visits per year; PCP referral required
$30 copay for initial
visit; $350 copay per hospital admission
$30 copay; Limit: one
per year; Hearing aids – 20% coinsurance for children up to age 18
Up to $5 generic
formulary
Up to $30 brand
formulary (when no generic is available)
Up to $60 brand
formulary (when generic is available)
The lesser of 30-day
supply or 100 units
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 own formulary design
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 the Help
Lines at
the end of this document for contact information.
This
chart reflects your cost for the listed Network services.
No deductible
$3,000 individual and
$6,000 family
$55 copay/PCP and $65
copay/specialist
$65 copay per visit; per
scan for MRI, CT, MRA, and PET scan
$1,000 copay;
preauthorization required
$500 per visit copay;
must be preauthorized
$0 copay up to age 2
$0 copay/ages birth
through age 18; $10 copay/ages 19 and over
$10 copay for ages 19
and over
$20 copay per visit; $20
copay for 6 week supply of antigen (includes shots)
$200 per visit copay;
waived if admitted
$75 per visit copay
$1,000 copay; Must be
preauthorized
$55 copay/PCP; $65
copay/specialist; Single or group therapy except for the biologically-based
diagnoses treated as other illnesses
20% of contracted rate
No copay inpatient; $65
copay/outpatient therapy; Limit: 60 consecutive days per illness
$65 copay outpatient
therapy; Limit: 60 consecutive days per illness
$65 copay; Limit: 15
visits per calendar year
$65 copay for initial
visit; thereafter covered at 100%; $1,000 copay per hospital admission
$10 copay; Limit: one
per ear every 48 months; Hearing aids covered for children up to age 18
Tier 1: $20
Tier 2: $40
Tier 3: $70
MAIL ORDER 90-DAY SUPPLY
$40 copay for formulary
generic drugs
$80 copay for formulary
drugs
$140 copay for
non-formulary brand-name and non-formulary generic drugs
Greater of 30-day supply
or 100 units
Certain medications have
restricted quantities
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 the Help
Lines at
the end of this document for contact information.
This
chart reflects your cost for the listed Network services.
No deductible
$3,000 individual and
$6,000 family
$35 copay/PCP and $50
copay/specialist
No additional
copay/laboratory services or outpatient radiology; $200 copay per MRI, CAT,
MRA, or PET scan
$500 copay
$300 copay
$0 copay up to age 2
$0 copay/ages birth
through 18 years; $25 copay/ages 19 and over
$25 copay
$35 copay/PCP visit; $50
copay/specialist visit; $30 copay for 6 week supply of antigen (including
shots)
$200 copay; waived if
admitted
$50 copay per visit
$500 copay; Must be
preauthorized and approved through CCOK Behavioral Health Services
$35 copay/PCP; $50
copay/specialist; Must be preauthorized and approved through CCOK Behavioral
Health Services
20% coinsurance initial
device; 20% coinsurance repair and replacement
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
$35 copay for initial
visit; $500 copay per hospital admission
$35 copay; Limit: one
per year; Hearing aids – 20% coinsurance for children up to age 18
Tier 1: $10
Tier 2: $40
Tier 3: $65
Up to $65 non-formulary
The lesser of 30-day
supply or 100 units
Selected medications may
have restricted quantities
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 the Help
Lines at
the end of this document for contact information.
This
chart reflects your cost for the listed Network services.
No deductible
$3,000 individual and
$5,000 family
$25 copay/PCP and $50
copay/specialist
$0 copay; $250 copay per
MRI, MRA, PET, or CAT
$250 copay per day; $750
maximum per admission
$250 copay
$0 copay/PCP; $25 copay
PCP over age 2
$0 copay/ages birth to
age 18; $25 copay/PCP office visit for adults; standard copays may apply in
conjunction with office visit
$25 copay/PCP; Limit:
one per year
$25 copay/PCP visit; $50
copay/specialist; $30 copay for 6 week supply of antigen (including shots)
$150 copay; waived if
admitted
$25 copay/PCP; $50
copay/all others
$250 copay; $750 maximum
per admission
$50 copay; Must be
preauthorized
20% coinsurance; $5,000
annual maximum
No copay inpatient; $50
copay per outpatient visit; Limit: 60 consecutive days per illness
No copay inpatient; $50
copay per outpatient visit; Limit: 60 consecutive days per illness
$50 copay; Limit: 15
visits per year – referral required
$25 copay initial visit
only; $250 copay per hospital admission per day; $750 maximum per admission
$25 copay per visit;
Limit: one visit per year; Hearing aids – 20% coinsurance; Covered for children
up to age 18; Limit: $5,000 combined DME, orthotics, and prosthetics
Tier 1: $10
Tier 2: $50
Tier 3: $75
The lesser of 30-day
supply or 100 units
Certain medications may
have restricted quantities
These copays do not
apply to the maximum out-of-pocket
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 the Help
Lines at
the end of this document for contact information.
This
chart reflects your cost for the listed Network services.
No deductible
$2,500 individual and
$5,000 family
$35 copay/PCP and $50
copay/specialist
$0 copay/standard lab
and radiology; $200 copay per MRI, MRA, PET, or CAT
$1,000 copay/admission
$500 copay
$0 copay
$0 copay/birth through
age 18 (if no other service is rendered); $10 copay ages 19 and over
$35 copay/PCP; $50
copay/specialist
$35 copay/PCP; $50
copay/specialist; $35 serum and shots including a 6 week supply of antigen
$200 copay; waived if
admitted
$50 copay per visit
$1,000 copay
$35 copay/PCP; $50
copay/specialist
20% coinsurance; $10,000
annual maximum
$1,000 copay inpatient;
Outpatient - $35 copay/PCP; $50 copay/specialist; Limit: 60 days per illness
$1,000 copay inpatient;
Outpatient - $35 copay/PCP; $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
$35 copay/PCP; $50
copay/specialist for initial visit once diagnosis of pregnancy is confirmed;
$1,000 copay hospital admission
$35 copay/PCP; Hearing aids –
covered for children up to age 18
$5 copay for formulary
generic drugs
$30 copay for formulary
brand-name drugs
$60 copay for
non-formulary generic and non-formulary brand drugs
30-day supply or 100
units
Certain medications have
restricted quantities
For
services that are not listed in this comparison chart, contact each plan. Refer
to the Help Lines at the end of this document for contact information.
This
chart reflects your cost for the listed services.
Network: $25 Basic and Major;
Non-Network: $25 Preventive, Basic, and Major
$25 per person, per
calendar year; Waived for preventive services in-network
No deductible
No deductible or plan
maximum; $5 office copay applies
PPO Network: $25 per
person, per year applies to Basic and Major Care only
Premier Network and
Non-Network: $100 per person, per year
PPO Network: $100 per
person, per year applies to Major Care only (Level 4)
Allowed Charges apply
Network: $0; Non-Network: $0
of Allowed Charges after deductible
$0 with no deductible
when in-network
No charge for routine
cleaning (once every six months); No charge for topical fluoride application
(up to age 18); No charge for periodic oral evaluations
Sealant: $15 per tooth;
No charge for routine cleaning once every six months; No charge for topical
fluoride application (through age 18); No charge for periodic oral evaluations
PPO Network: $0 of
allowable amounts; No deductible applies
Premier Network and
Non-Network: $0 of allowable amounts after deductible
PPO Network: Schedule of
covered services and copays. Copay examples: Routine cleaning $5; Periodic oral
evaluations $5; Topical fluoride application (up to age 19) $5
Allowed Charges apply
Network: 15%; Non-Network:
30%; Deductible applies
Network: 15%;
Non-Network 30%; Plan pays 85% of usual and customary when in-network:
Deductible applies
Fillings; Minor oral
surgery; Refer to the copay schedule for each plan
Amalgam: One surface,
permanent teeth $20
PPO Network: 15% of
allowable amounts after deductible
Premier Network and
Non-Network: 30% of allowable amounts after deductible
PPO Network: Schedule of
covered services and copays. Copay example: Amalgam, one surface, primary or
permanent tooth $12
Allowed Charges apply
Network: 40%; Non-Network:
50%; Deductible applies
Network: 40%;
Non-Network: 50%; Plan pays 60% of usual and customary when in-network;
Deductible applies
Root canal; Periodontal;
Crowns; Refer to the copay schedule for each plan
Root canal, anterior:
$325; Periodontal/scaling/root planing one to three teeth (per quadrant): $65
PPO Network: 40% of allowable
amounts after deductible
Premier Network and
Non-Network: 50% of allowable amounts after deductible
PPO Network: Schedule of
covered services and copays. Copay examples: Crown, porcelain/ceramic substrate
$241; Complete denture, maxillary $320
Allowed Charges apply
Network: 50%; Non-Network:
50%; 12 month waiting period may apply; No lifetime orthodontic maximum for
Network or non-Network; Covered for members under age 19 and members over age
19 with TMD
Network: 40%;
Non-Network: 50%; Up to $1,800 lifetime maximum for members under age 19; 24
month waiting period may apply
25% discount; Adults and
children
$2,100 out-of-pocket for
children through age 18; $2,900 out-of-pocket for adults; 24 month treatment
excludes orthodontic treatment plan and banding
PPO Network: 40% of
allowable amounts, up to lifetime maximum of $1,800; No deductible applies; No
waiting period
Premier Network and
Non-Network: 40% of allowable amounts, up to lifetime maximum of $1,800; No
deductible applies; No waiting period
PPO Network: You pay
amounts in excess of $50 per month; Lifetime maximum up to $1,800; No
deductible applies; No waiting period
Network and non-Network:
$2,000 per person, per year
$2,000
No annual maximum for
general dentist
No maximum
PPO Network: $2,000 per
person, per year
Premier Network and
Non-Network: $2,000 per person, per year
PPO Network: $2,000 per
person, per year
Network: No claims to file;
Non-Network: You file claims
Member/provider must
file claims
No claims to file
No claims to file
PPO Network: Claims are
filed by participating dentists
Premier Network and
Non-Network: Claims are filed by participating dentists
PPO Network: Claims are
filed by participating dentists
For
services that are not listed in this comparison chart, contact each plan. Refer
to the Help Lines at the end of this document for contact information.
This
chart reflects your cost for the listed services.
Network: $25 Basic and Major;
Non-Network: $25 Preventive, Basic, and Major
Allowed Charges apply
Network: $0; Non-Network: $0
of Allowed Charges after deductible
Allowed Charges apply
Network: 15%; Non-Network:
30%; Deductible applies
Allowed Charges apply
Network: 40%; Non-Network:
50%; Deductible applies
Allowed Charges apply
Network: 50%; Non-Network:
50%; 12 month waiting period may apply; No lifetime orthodontic maximum for
Network or non-Network; Covered for members under age 19 and members over age
19 with TMD
Network and non-Network:
$2,000 per person, per year
Network: No claims to file;
Non-Network: You file claims
For
services that are not listed in this comparison chart, contact each plan. Refer
to the Help Lines at the end of this document for contact information.
This
chart reflects your cost for the listed services.
$25 per person, per
calendar year; Waived for preventive services in-network
Allowed Charges apply
$0 with no deductible
when in-network
Allowed Charges apply
Network: 15%;
Non-Network 30%; Plan pays 85% of usual and customary when in-network:
Deductible applies
Allowed Charges apply
Network: 40%;
Non-Network: 50%; Plan pays 60% of usual and customary when in-network;
Deductible applies
Allowed Charges apply
Network: 40%;
Non-Network: 50%; Up to $1,800 lifetime maximum for members under age 19; 24
month waiting period may apply
$2,000
Member/provider must
file claims
For
services that are not listed in this comparison chart, contact each plan. Refer
to the Help Lines at the end of this document for contact information.
This
chart reflects your cost for the listed services.
No deductible
Allowed Charges apply
No charge for routine
cleaning (once every six months); No charge for topical fluoride application
(up to age 18); No charge for periodic oral evaluations
Allowed Charges apply
Fillings; Minor oral
surgery; Refer to the copay schedule for each plan
Allowed Charges apply
Root canal; Periodontal;
Crowns; Refer to the copay schedule for each plan
Allowed Charges apply
25% discount; Adults and
children
No annual maximum for
general dentist
No claims to file
For
services that are not listed in this comparison chart, contact each plan. Refer
to the Help Lines at the end of this document for contact information.
This
chart reflects your cost for the listed services.
No deductible
Allowed Charges apply
No charge for routine
cleaning (once every six months); No charge for topical fluoride application
(up to age 18); No charge for periodic oral evaluations
Allowed Charges apply
Fillings; Minor oral
surgery; Refer to the copay schedule for each plan
Allowed Charges apply
Root canal; Periodontal;
Crowns; Refer to the copay schedule for each plan
Allowed Charges apply
25% discount; Adults and
children
No annual maximum for
general dentist
No claims to file
For
services that are not listed in this comparison chart, contact each plan. Refer
to the Help Lines at the end of this document for contact information.
This
chart reflects your cost for the listed services.
No deductible or plan
maximum; $5 office copay applies
Allowed Charges apply
Sealant: $15 per tooth;
No charge for routine cleaning once every six months; No charge for topical
fluoride application (through age 18); No charge for periodic oral evaluations
Allowed Charges apply
Amalgam: One surface,
permanent teeth $20
Allowed Charges apply
Root canal, anterior:
$325; Periodontal/scaling/root planing one to three teeth (per quadrant): $65
Allowed Charges apply
$2,100 out-of-pocket for
children through age 18; $2,900 out-of-pocket for adults; 24 month treatment
excludes orthodontic treatment plan and banding
No maximum
No claims to file
For
services that are not listed in this comparison chart, contact each plan. Refer
to the Help Lines at the end of this document for contact information.
This
chart reflects your cost for the listed services.
PPO Network: $25 per
person, per year applies to Basic and Major Care only
Premier Network and
Non-Network: $100 per person, per year
Allowed Charges apply
PPO Network: $0 of
allowable amounts; No deductible applies
Premier Network and Non-Network:
$0 of allowable amounts after deductible
Allowed Charges apply
PPO Network: 15% of
allowable amounts after deductible
Premier Network and
Non-Network: 30% of allowable amounts after deductible
Allowed Charges apply
PPO Network: 40% of
allowable amounts after deductible
Premier Network and
Non-Network: 50% of allowable amounts after deductible
Allowed Charges apply
PPO Network: 40% of
allowable amounts, up to lifetime maximum of $1,800; No deductible applies; No
waiting period
Premier Network and
Non-Network: 40% of allowable amounts, up to lifetime maximum of $1,800; No
deductible applies; No waiting period
PPO Network: $2,000 per
person, per year
Premier Network and
Non-Network: $2,000 per person, per year
PPO Network: Claims are
filed by participating dentists
Premier Network and
Non-Network: Claims are filed by participating dentists
For
services that are not listed in this comparison chart, contact each plan. Refer
to the Help Lines at the end of this document for contact information.
This
chart reflects your cost for the listed services.
PPO Network: $100 per
person, per year applies to Major Care only (Level 4)
Allowed Charges apply
PPO Network: Schedule of
covered services and copays. Copay examples: Routine cleaning $5; Periodic oral
evaluations $5; Topical fluoride application (up to age 19) $5
Allowed Charges apply
PPO Network: Schedule of
covered services and copays. Copay example: Amalgam, one surface, primary or
permanent tooth $12
Allowed Charges apply
PPO Network: Schedule of
covered services and copays. Copay examples: Crown, porcelain/ceramic substrate
$241; Complete denture, maxillary $320
Allowed Charges apply
PPO Network: You pay
amounts in excess of $50 per month; Lifetime maximum up to $1,800; No
deductible applies; No waiting period
PPO Network: $2,000 per
person, per year
PPO Network: Claims are
filed by participating dentists
Vision
benefits apply from January 1 through December 31, 2010.
For
services that are not listed in this comparison chart, contact your plan. Refer
to the Help Lines at the end of this document for contact information.
In-Network: $10 copay; One
exam for eyeglasses or contacts per year
Out-of-Network: Copays do not
apply; Plan pays up to $35; One exam per year
In-Network: $0 copay; No
limit on exams per year
Out-of-Network*: Exam
fee reimbursed up to $40; One exam per year
*Out-of-Network limited
to one eye exam and one set of eyeglasses or contact lenses annually. Cannot be
used with In-Network services
In-Network: $10 copay; One
exam per year
Out-of-Network: OD - $26 max;
MD - $34 max
In-Network: $10 copay; One
exam per year
Out-of-Network: Plan pays up
to $40
In-Network: $10 copay; One
exam per year
Out-of-Network: $10 copay;
Plan pays up to $35
In-Network: $25 material
copay applies to lenses and/or frames (single, lined bifocal, trifocal,
lenticular are covered at 100%); A discount applies to progressive lenses; One
pair of lenses per year
Out-of-Network: Plan pays up
to $25 single, $40 bifocals, $60 trifocals, $100 lenticular; One pair of lenses
per year
In-Network: You pay
wholesale cost with no limit on number of pairs
Out-of-Network*: Fees
reimbursed up to $40-$60 for one set of lenses and frames
*Out-of-Network limited
to one eye exam and one set of eyeglasses or contact lenses annually. Cannot be
used with In-Network services
In-Network: $25 copay; One
pair of lenses per year
Out-of-Network: Plan pays up
to $26 single, $39 bifocals, $49 trifocals, $78 lenticular
In-Network: $25 copay; One
pair of lenses per year
Out-of-Network: Plan pays up to
$40 single, $60 bifocals, $80 trifocals, $80 lenticular
In-Network: $25 copay*; One
set of lenses per year; Polycarbonate lenses covered in full for dependent
children; Average 35-40% savings on all non-covered lens options
Out-of-Network: $25 copay*;
Plan pays up to $25 single, $40 bifocals, $55 trifocals, $80 lenticular
*Benefit includes an annual
$25 materials copay for lenses or frames, but not both. Contact VSP for
additional information regarding in-network added value discounts.
In-Network: $25 material
copay applies to lenses and/or frames; $45 wholesale frame allowance; One set
of frames per year
Out-of-Network: $25 copay;
Plan pays up to $45; One set of frames per year
In-Network: You pay
wholesale cost with no limit on number of pairs
Out-of-Network*: Fees
reimbursed up to $40-$60 for one set of lenses and frames
*Out-of-Network limited
to one eye exam and one set of eyeglasses or contact lenses annually. Cannot be
used with In-Network services
In-Network: $25 copay; Plan
pays up to $125; One set of frames per year
Out-of-Network: Plan pays up
to $68
In-Network: $25 copay; One
set of frames per year
Out-of-Network: Plan pays up
to $45
In-Network: $25 copay*; One
frame per year $120 allowance; 20% off any out-of-pocket costs above the
allowance
Out-of-Network: $25 copay*;
Plan pays up to $45
*Benefit includes an annual
$25 materials copay for lenses or frames, but not both. Contact VSP for
additional information regarding in-network added value discounts.
In-Network: $130 allowance
for conventional or disposable lenses and fitting fee in lieu of all other
benefits; Medically necessary, plan pays 100%; One set of contacts per year
Out-of-Network: $130
allowance for exam, contacts, and fitting fee in lieu of all other benefits;
Medically necessary, plan pays $210; One set of contacts per year
In-Network: You pay
wholesale cost for an annual supply of contacts; For first time fittings, $50
copay on soft lenses and $75 copay on all rigid gas permeable lenses
Out-of-Network*: Fees
reimbursed up to $60; One set annually (in lieu of glasses)
*Out-of-Network limited
to one eye exam and one set of eyeglasses or contact lenses annually. Cannot be
used with In-Network services
In-Network: $0 copay; Plan
pays up to $120; Medically necessary contacts are covered in full (in lieu of
glasses)
Out-of-Network: $0 copay;
Plan pays up to $100; Medically necessary contacts, plan pays up to $210 (in
lieu of glasses)
In-Network: $25 copay covers
fitting/evaluation fees, contacts (including disposables), and up to two
follow-up visits (in lieu of glasses)
Out-of-Network: Plan pays up
to $150; For medically necessary contacts, plan pays up to $210 (in lieu of
glasses)
In-Network: $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)
Out-of-Network: $0 copay;
Plan pays up to $105 for disposable or conventional contact lenses (in lieu of
glasses)
In-Network: $895 copay
conventional; $1,295 copay custom; $1,895 copay custom plus bladeless when
services are rendered by a TLC Network Provider
Out-of-Network: No benefit
In-Network: Discounted
laser refractive surgery at multiple state locations
Out-of-Network*: No
benefit
*Out-of-Network limited
to one eye exam and one set of eyeglasses or contact lenses annually. Cannot be
used with In-Network services
In-Network: 20% off retail
price
Out-of-Network: No benefit
In-Network: Members have
access to discounted refractive eye surgery from numerous provider locations
throughout the U.S.
Out-of-Network: No benefit
In-Network: Laser vision
correction services (PRK, LASIK, and Custom LASIK) are provided at a reduced
cost through VSP’s contracted laser surgery centers
Out-of-Network: No benefit
Vision
benefits apply from January 1 through December 31, 2010.
For
services that are not listed in this comparison chart, contact your plan. Refer
to the Help Lines at the end of this document for contact information.
In-Network: $10 copay; One
exam for eyeglasses or contacts per year
Out-of-Network: Copays do not
apply; Plan pays up to $35; One exam per year
In-Network: $25 material
copay applies to lenses and/or frames (single, lined bifocal, trifocal,
lenticular are covered at 100%); A discount applies to progressive lenses; One
pair of lenses per year
Out-of-Network: Plan pays up
to $25 single, $40 bifocals, $60 trifocals, $100 lenticular; One pair of lenses
per year
In-Network: $25 material
copay applies to lenses and/or frames; $45 wholesale frame allowance; One set
of frames per year
Out-of-Network: $25 copay;
Plan pays up to $45; One set of frames per year
In-Network: $130 allowance
for conventional or disposable lenses and fitting fee in lieu of all other
benefits; Medically necessary, plan pays 100%; One set of contacts per year
Out-of-Network: $130
allowance for exam, contacts, and fitting fee in lieu of all other benefits;
Medically necessary, plan pays $210; One set of contacts per year
In-Network: $895 copay
conventional; $1,295 copay custom; $1,895 copay custom plus bladeless when
services are rendered by a TLC Network Provider
Out-of-Network: No benefit
Vision
benefits apply from January 1 through December 31, 2010.
For
services that are not listed in this comparison chart, contact your plan. Refer
to the Help Lines at the end of this document for contact information.
In-Network: $0 copay; No
limit on exams per year
Out-of-Network*: Exam
fee reimbursed up to $40; One exam per year
*Out-of-Network limited
to one eye exam and one set of eyeglasses or contact lenses annually. Cannot be
used with In-Network services
In-Network: You pay
wholesale cost with no limit on number of pairs
Out-of-Network*: Fees
reimbursed up to $40-$60 for one set of lenses and frames
*Out-of-Network limited
to one eye exam and one set of eyeglasses or contact lenses annually. Cannot be
used with In-Network services
In-Network: You pay
wholesale cost with no limit on number of pairs
Out-of-Network*: Fees
reimbursed up to $40-$60 for one set of lenses and frames
*Out-of-Network limited
to one eye exam and one set of eyeglasses or contact lenses annually. Cannot be
used with In-Network services
In-Network: You pay
wholesale cost for an annual supply of contacts; For first time fittings, $50
copay on soft lenses and $75 copay on all rigid gas permeable lenses
Out-of-Network*: Fees
reimbursed up to $60; One set annually (in lieu of glasses)
*Out-of-Network limited
to one eye exam and one set of eyeglasses or contact lenses annually. Cannot be
used with In-Network services
In-Network: Discounted
laser refractive surgery at multiple state locations
Out-of-Network*: No
benefit
*Out-of-Network limited
to one eye exam and one set of eyeglasses or contact lenses annually. Cannot be
used with In-Network services
Vision
benefits apply from January 1 through December 31, 2010.
For
services that are not listed in this comparison chart, contact your plan. Refer
to the Help Lines at the end of this document for contact information.
In-Network: $10 copay; One
exam per year
Out-of-Network: OD - $26 max;
MD - $34 max
In-Network: $25 copay; One
pair of lenses per year
Out-of-Network: Plan pays up
to $26 single, $39 bifocals, $49 trifocals, $78 lenticular
In-Network: $25 copay; Plan
pays up to $125; One set of frames per year
Out-of-Network: Plan pays up
to $68
In-Network: $0 copay; Plan
pays up to $120; Medically necessary contacts are covered in full (in lieu of
glasses)
Out-of-Network: $0 copay;
Plan pays up to $100; Medically necessary contacts, plan pays up to $210 (in
lieu of glasses)
In-Network: 20% off retail
price
Out-of-Network: No benefit
Vision
benefits apply from January 1 through December 31, 2010.
For
services that are not listed in this comparison chart, contact your plan. Refer
to the Help Lines at the end of this document for contact information.
In-Network: $10 copay; One
exam per year
Out-of-Network: Plan pays up
to $40
In-Network: $25 copay; One
pair of lenses per year
Out-of-Network: Plan pays up
to $40 single, $60 bifocals, $80 trifocals, $80 lenticular
In-Network: $25 copay; One
set of frames per year
Out-of-Network: Plan pays up
to $45
In-Network: $25 copay covers
fitting/evaluation fees, contacts (including disposables), and up to two
follow-up visits (in lieu of glasses)
Out-of-Network: Plan pays up
to $150; For medically necessary contacts, plan pays up to $210 (in lieu of
glasses)
In-Network: Members have
access to discounted refractive eye surgery from numerous provider locations
throughout the U.S.
Out-of-Network: No benefit
Vision
benefits apply from January 1 through December 31, 2010.
For
services that are not listed in this comparison chart, contact your plan. Refer
to the Help Lines at the end of this document for contact information.
In-Network: $10 copay; One
exam per year
Out-of-Network: $10 copay;
Plan pays up to $35
In-Network: $25 copay*; One
set of lenses per year; Polycarbonate lenses covered in full for dependent
children; Average 35-40% savings on all non-covered lens options
Out-of-Network: $25 copay*;
Plan pays up to $25 single, $40 bifocals, $55 trifocals, $80 lenticular
*Benefit includes an annual
$25 materials copay for lenses or frames, but not both. Contact VSP for
additional information regarding in-network added value discounts.
In-Network: $25 copay*; One
frame per year $120 allowance; 20% off any out-of-pocket costs above the
allowance
Out-of-Network: $25 copay*;
Plan pays up to $45
*Benefit includes an annual
$25 materials copay for lenses or frames, but not both. Contact VSP for
additional information regarding in-network added value discounts.
In-Network: $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)
Out-of-Network: $0 copay;
Plan pays up to $105 for disposable or conventional contact lenses (in lieu of
glasses)
In-Network: Laser vision
correction services (PRK, LASIK, and Custom LASIK) are provided at a reduced
cost through VSP’s contracted laser surgery centers
Out-of-Network: No benefit
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 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 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, contact HealthChoice Member
Services at the numbers listed in Help Lines at the end of this
document.
About
two months before you or one of your eligible dependents turn 65, OSEEGIB will
send you a letter that explains the Medicare plan options available to you.
The
letter will include instructions on how to enroll with a Medicare Supplement or
Medicare Advantage Prescription Drug plan. If you or one of your dependents are
soon becoming Medicare eligible, check your mail for important information
about enrollment.
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
Website http://www.sib.ok.gov
or http://www.healthchoiceok.com
All Areas 1-800-903-8113
TDD All Areas 1-800-825-1230
All Areas 1-800-848-8121
TDD All Areas 1-877-267-6367
Oklahoma City Area 1-405-717-8780
All Other Areas 1-800-752-9475
TDD Oklahoma City Area 1-405-949-2281
TDD All Other Areas 1-866-447-0436
Oklahoma City Area 1-405-841-9686
All Areas 1-800-722-2567
TDD All Areas 1-800-863-5488
Customer Service and Claims 1-800-782-5218
Provider Information 1-877-877-0715 ext. 4059
TDD All Areas 1-800-941-2160
Website http://www.choicecarenetwork.com
All Areas 1-800-949-3104
TDD All Areas
1-800-628-3323
Website
http://www.aetnaokstateemployees.com
All Areas 1-800-777-4890
TDD All Areas 1-800-722-0353
Website http://www.ccok.com
Oklahoma
City Area 1-405-280-5600
All Other Areas 1-877-280-5600
TDD All Areas 1-800-522-8506
Website http://www.globalhealth.cc
All Areas 1-800-825-9355
TDD All Areas
1-800-557-7595
Website
http://www.pacificare.com
Prepaid
Plan 1-800-443-2995
Indemnity Plan 1-800-442-7742
Website http://www.assurantemployeebenefits.com
All Areas 1-800-244-6224
Hearing
Impaired Relay Service 1-405-948-3303
Website http://www.cigna.com
Oklahoma
City Area 1-405-607-2100
All Other Areas 1-800-522-0188
Website http://www.deltadentalok.org/state_employees/
All Areas 1-800-865-3676
TDD
All Areas 1-877-553-4327
Website http://www.compbenefits.com/custom/stateofoklahoma
All Areas 1-888-357-6912
TDD
All Areas 1-800-722-0353
Website http://www.pvcs-usa.com
All Areas 1-800-507-3800
TDD
All Areas 1-916-852-2382
Website http://www.superiorvision.com
All Areas 1-800-638-3120
TDD
All Areas 1-800-524-3157
Website http://www.myuhcvision.com
All Areas 1-800-877-7195
TDD All Areas 1-800-428-4833
Website http://www.vsp.com