HealthChoice High Alternative : summary of benefits and coverage, 2013

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HealthChoice High Alternative: OMES: Employees Group Ins. Div. Coverage Period 1/01/2013 – 12/31/2013
Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Member, Spouse, Child, Children | Plan Type: Indemnity
Questions: Call 1-800-752-9475 or visit us at www.ok.gov/sib.
If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary
at www.dol.gov/ebsa/healthreform or call 1-800-752-9475 to request a copy.
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.ok.gov/sib or by calling 1-800-752-9475.
Important Questions
Answers
Why this Matters:
What is the overall deductible?
$750 Individual, $2,250 family.
Does not apply to preventive care and pharmacy.
You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible.
Are there other
deductibles for specific services?
No.
You don’t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers.
Is there an out–of–pocket limit on my expenses?
Yes.
For network providers $3,050 person/$9,150 family; For non-Network providers $3,550 person/$10,650 family.
$2,500/person Network pharmacy
The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses.
What is not included in
the out–of–pocket limit?
Premiums, balance-billed charges, health care this plan doesn’t cover, copayments, amounts above maximum benefit limitations.
Even though you pay these expenses, they don’t count toward the out–of–pocket limit.
Is there an overall annual limit on what the plan pays?
No.
The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits.
Does this plan use a network of providers?
Yes. For a list of Network Providers, see www.ok.gov/sib, or call 1-800-752-9475.
If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers.
Do I need a referral to see a specialist?
No.
You can see the specialist you choose without permission from this plan.
Are there services this plan doesn’t cover?
Yes.
Some of the services this plan doesn’t cover are listed on page 5. See your policy or plan document for additional information about excluded services.
OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146
Corrected on May 11, 2012
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