Plan guide for Medicare eligible members : health, dental, vision.

              E 3610.5 P699m 2011 c.1
OSEEGIB Oklahoma State and Education
~ Employees Group Insurance Board
Plan Guide for
Medicare Eligible Members
Health
Monthly Premiums for Medicare Eligible Members
Plan Year January 1, 2011 - December 31,2011
MEDICARE SUPPLEMENT PLANS
HealthChoice Employer PDP High Option With Part D $308.34 per enrolled person
HealthChoice Employer PDP Low Option With Part D $251.66 per enrolled person
HealthChoice High Option Without Part D $363.06 per enrolled person
HealthChoice Low Option Without Part D $306.38 per enrolled person
UnitedHealthcare Senior Supplement High Option $381.88 per enrolled person
UnitedHealthcare Senior Supplement Low Option $342.70 per enrolled person
MEDICARE ADVANTAGE PRESCRIPTION DRUG (MA-PD) PLANS
CommunityCare Senior $220.00 per enrolled person
CommunityCare Senior Alternate $180.00 per enrolled person
Generations Healthcare by GlobalHealth $186.07 per enrolled person
Secure Horizons Medicare Complete Retiree Plan $219.50 per enrolled person
DENTAL PLANS MEMBER SPOUSE CHILD CHILDREN
HealthChoice Dental $29.84 $29.84 $24.88 $64.56
Assurant Freedom Preferred $28.83 $28.67 $21.50 $57.80
Assurant Heritage Plus with SBA (Prepaid) $11.74 $ 8.86 $ 7.60 $15.20
Assurant Heritage Secure (Prepaid) $ 7.20 $ 5.98 $ 5.20 $10.38
CIGNA Dental Care Plan (Prepaid) $ 9.26 $ 6.06 $ 7.08 $15.32
Delta Dental PPO $31.14 $31.14 $27.10 $68.56
Delta Dental Premier $35.52 $35.52 $30.90 $78.20
Delta Dental PPO - Choice $13.94 $31.64 $31.90 $77.42
VISION PLANS MEMBER SPOUSE CHILD CIDLDREN
Humana/CompBenefits Vision Care Plan $6.76 $5.06 $3.57 $ 4.46
Primary Vision Care Services (PVCS) $9.25 $8.00 $8.50 $10.75
Superior Vision Plan $6.98 $6.90 $6.60 $ 6.60
UnitedHealthcare Vision $8.18 $5.79 $4.59 $ 6.98
Vision Service Plan (VSP) $8.76 $5.87 $5.62 $12.64
These rates do not reflect any contribution from your retirement system.
TABLE OF CONTENTS
Section I
Plan Identification and General Infonnation...................................................... 1
Section II
HealthChoice Medicare Supplement Plans.......... 7
Section III
UnitedHealthcare Senior Supplement Plans 21
Section IV
Medicare Advantage Prescription Drug Plans (MA-PD Plans) 29
Section V
Dental and Vision Plan Options 42
How to Access the Online Provider Networks 49
Help Lines........................................................................................................ 51
This publication was printed by the Oklahoma State and Education Employees Group Insurance Board as
authorized by 74 O.S. Section 1301, et seq; 475 copies have been printed at a cost of$0.168 each. Copies have
been deposited with the Publications Clearinghouse of the Oklahoma Department of Libraries.
2011 Plan Year
Section I
Plan Identification
and
General Information
The information contained in this Guide is only a brief summary of the listed options.
All benefits and limitations of these plans are governed in all cases by the relevant plan
documents, insurance contracts, handbooks, Rules of the Oklahoma State and Education
Employees Group Insurance Board, and the regulations governing the Medicare
Prescription Drug Benefit, Improvement, and Modernization Act. The Federal Regulation
at 42 C.F.R. § 423 et seq. and 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.
2011 Plan Year 1
Health Plan Identification Information
Plan Administrator
Oklahoma State and Education Employees Group Insurance Board (OSEEGIB)
3545 NW 58th Street, Suite 110, Oklahoma City, OK 73112
1-405-717-8701 or toll-free 1-800-752-9475
HealthChoice Medicare Supplement & Part D Prescription Drug Plan
Member Services / Monday through Friday /7:30 a.m. to 4:30 p.m. Central time
1-405-717-8780 or toll-free 1-800-752-9475; Fax: 1-405-717-8942
TDD 1-405-949-2281 or toll-free 1-866-447-0436
Website: www.sib.ok.gov or www.healthchoiceok.com
UnitedHealthcare Senior Supplement Plans
Member Services I Monday through Friday 19:00 a.m. to 9:00 p.m. Central time
PO Box 6072, Cypress, CA 90630
Toll-free 1-800-851-3802 or toll-freeTYY 1-800-851-3802, ext. 711
Website: www.UHCRetiree.com
CommunityCare Senior Health Plans
Member Services I Monday through Sunday 18:00 a.m. to 8:00 p.m. Central time
PO Box 3327, Tulsa, OK 74101
1-918-594-5323 or toll-free 1-800-642-8065
Relay Service for the Hearing Impaired toll-free 1-800-722-0353
Website: www.ccok.com
Generations Healthcare by GlobalHealth
Member Services I Monday through Friday 18:00 a.m. to 5:0Qp.m. Central time
55 N Robinson, Oklahoma City, OK 73102
Toll-free 1-866-496-7817 or toll-free TTY/TDDNoice 1-800-958-2692
Website: www.generationshealthcare.cc
Secure Horizons Medicare Complete Retiree Plan (HMO)
Member Services I Monday through Friday 18:00 a.m. to 5:00 p.m. Central time
7666 E 61st Street, Tulsa, OK 74133
Toll-free 1-888-867-5548 or toll-free TYY 1-888-867-5548, ext. 711
Website: www.UHCRetiree.com
Medicare
Customer Service I 24 hours a day I 7 days a week
Toll-free 1-800-MEDICARE (1-800-633-4227) or toll-free TTY 1-877-486-2048
Website: www.medicare.gov
Website Questions and Answers: http://questions.medicare.gov
Social Security Administration
Customer Service I Monday through Friday I 7:00 a.m. to 7:00 p.m. Central time
Toll-free 1-800-772-1213 or toll-free TTY 1-800-325-0778
Website: www.socialsecurity.gov
2 2011 Plan Year
General Information
The benefit information provided in this Guide is only a brief description of each plan's
benefits. If you need additional information to help you make a coverage decision, contact each
individual plan. See Help Lines on pages 51 and 52 of this Guide.
Eligibility Requirements
To participate in the Medicare supplement plans described in this Guide, you must be:
• Entitled to benefits under Medicare Part A (Hospital) or enrolled in Medicare Part B
(Medical). *
• Enrolled in only one Part D plan. If you have Part D coverage through another plan and
wish to continue that coverage, you must select the HealthChoice High or Low Option
Medicare Supplement Plan Without Part D. Enrolling in another Medicare supplement
plan with Part D will end your current Part D coverage.
The Medicare supplement plans provide coverage throughout the United States. If you move
out of the United States, you must notify your plan so that you can be disenrolled and find a
new plan in your area.
To participate in the Medicare Advantage Prescription Drug (MA-PD) Plans described in
this Guide:
• You must be a permanent resident of the MA-PD plan's service area. This service area is
a federally qualified area in which the MA-PD provides services. Check the MA-PD Plan
Service Areas on page 41 to make sure your county is in the MA-PD's service area. Not
all ZIP Codes in every county fall within the MA-PD Plan's Service Area. If you are
unsure, check with each MA-PD plan to verify your address is in its service area.
• You must be enrolled in both Medicare Part A (Hospital) and Part B (Medical) and
continue to pay your monthly Medicare Part B premium. If you are already enrolled in
a Medicare Managed Care Plan and have only Medicare Part B, you can stay with your
current plan.
You are not eligible to enroll in an MA-PD plan if you have been diagnosed with End-Stage
Renal Disease (ESRD). If you are currently enrolled in an MA-PD plan and develop ESRD or
undergo a transplant, you can remain with your plan. Please contact each MA-PD plan directly
for further information. See Help Lines on pages 51 and 52.
*OSEEGIB Rules state that all covered individuals who are eligible for Medicare, except
current employees, must be enrolled in a Medicare supplement or MA-PD plan offered through
OSEEGIB, regardless of age. To maximize your benefits, you need to be enrolled in 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.
2011 Plan Year 3
Creditable Coverage Notice
Prescription drug coverage is called "creditable" if the value of the Part D coverage equals or
exceeds the value of Medicare's standard prescription drug plan. The Medicare supplement
plans and MA-PD plans offered through OSEEGIB provide prescription drug coverage that is
equal to, or better than, the standard benefits of Medicare's prescription drug plan. The high
option plans exceed the standards and the low option plans meet the standards set by the Centers
for Medicare and Medicaid Services.
Limiting Charge/Financial Responsibiltiy
Under Medicare guidelines, the highest amount you can be charged for a covered service by
doctors and other health care suppliers who don't accept assignment is known as the limiting
charge (15% over Medicare's approved amount). The limiting charge applies only to certain
services and not to supplies or equipment.
Extra Help Paying for Part D - Medicare Low Income Subsidy Information
Extra Help - If You Are Already Qualified
You may be able to get extra help to pay for your prescription drug premiums and costs.
This extra help, known as a low income subsidy, is offered through the Social Security
Administration. If you are eligible, Medicare helps pay your drug costs including monthly
prescription drug premiums, annual pharmacy deductibles, and prescription copays. Qualified
participants are not subject to the Coverage Gap or Medicare's late enrollment penalty. For
more information, contact the Social Security Administration or Medicare. See page 2 for
contact information.
If you are already qualified for the low income subsidy for Medicare Part D Prescription Drug
costs, the amount of your monthly premiums and pharmacy costs is less. Your plan may request
a copy of your letter from Social Security confirming you are qualified for extra help. Once you
are enrolled in a plan with Medicare Part D, Medicare or your plan tells us how much assistance
you receive. We then send you the amount you will pay.
Finding a Provider
To find a health, dental, or vision provider or to check the network status of a provider, visit
each plan's website or call its customer service number for assistance. See How to Access the
Online Provider Networks on pages 49 and 50 for directions on accessing each plan's online
provider directory. See Help Lines on pages 51 and 52 of this Guide for customer service
numbers.
4 2011 Plan Year
Your Medicare Part D plan through OSEEGIB provides both health and pharmacy coverage. If
you enroll in a Medicare Part D plan outside of OSEEGIB, Medicare must disenroll you from
your current Medicare Part D plan (Medicare allows only one Part D plan at a time). Since your
Medicare Part D (pharmacy) benefits are packaged with your health benefits, disenrollment
from your pharmacy benefits would ordinarily result in the loss of both pharmacy and health
coverage. To guard against unintentional disenrollment in your health benefits and loss of
any retirement contribution, OSEEGIB changes your coverage to the HealthChoice Medicare
Supplement Plan Without Part D. Your coverage is similar and includes prescription drug
coverage, but not Medicare Part D benefits. The premium for this plan is higher since Medicare
is not contributing a subsidy on your behalf. Once this occurs, you have three choices:
1. If you do nothing, you will remain enrolled in both the prescription drug plan outside of
OSEEGIB and the HealthChoice Medicare Supplement Plan Without Part D, which includes
both Medicare supplement health benefits and non-Part D prescription drug benefits. If you
choose to continue your health benefits under the Without Part D plan, you must continue on the
plan Without Part D benefits until the next annual Option Period and pay the higher premium
associated with that plan.
2. Or, since you have other Part D (prescription) coverage, you can drop your health and
prescription coverage through OSEEGIB and keep only your non-OSEEGIB Part D coverage.
Please remember, if you drop your coverage through OSEEGIB, you cannot regain coverage
through OSEEGIB in the future, and you lose any premium contribution made by your
retirement system.
3. Or, you can choose to drop your non-OSEEGIB Part D coverage and enroll in one of the
plans offered by OSEEGIB that include Part D coverage. This option is available only if your
decision is made prior to the effective date of your non-OSEEGIB Part D coverage.
Address Information
Medicare requires that you report changes in your home address to your plan.
If You Are Already Enrolled in a Plan With Part D Prescription Drug Coverage
If You Currently Have Health Coverage Through Your Employer or Union
If you or your spouse have health coverage through an employer or union, joining one of the
plans offered by OSEEGIB may change your current coverage. Please read the information sent
to you by your employer or union. If you have questions, see your benefits administrator.
If you leave your plan and do not get other Medicare Part D coverage or other coverage that is
as good as Medicare's (Creditable Coverage), in the future, you may have to pay Medicare's
late enrollment penalty in addition to your premium for Part D prescription drug coverage.
2011 Plan Year 5
Release of Information
HealthChoice uses and discloses your protected health information for your treatment, payment
for services, and business operations. HealthChoice also releases your information, including
your prescription drug event date, to Medicare, who may release it for research and other
purposes which follow federal statutes and regulations.
More Information
• If you have eligibility questions, call OSEEGIB Member Services at 1-405-717-8780 or
toll-free 1-800-752-9475. TDD users call 1-405-949-2281 or toll-free 1-866-447-0436.
• Plan specific benefit questions must be directed to each plan. See Help Lines on pages 51
and 52 of this Guide.
• You can also call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7
days a week. TTY/TDD users call toll-free 1-877-486-2048.
6 2011 Plan Year
2011 Plan Year 7
Section II
HealthChoice Medicare
Supplement Plans
HealthChoice Medicare Supplement Plans
Contracting Statement for Medicare Part D
The Oklahoma State and Education Employees Group Insurance Board (OSEEGIB)
contracts with the Centers for Medicare and Medicaid Services (CMS), a division of the
federal government, to provide Part D coverage. The HealthChoice Employer PDP Medicare
Supplement Plans With Part D are Medicare approved Part D plans. OSEEGIB's contract with
CMS is renewed annually and is not guaranteed beyond the 2011 contract year. OSEEGIB has
the right to refuse to renew its contract with CMS or CMS may refuse to renew its contract with
OSEEGIB. Termination or non-renewal of the contract will result in the termination of your
enrollment in a HealthChoice Employer PDP Medicare Supplement Plan With Part D.
The Plans With Part D
The Plans with Part D benefits include Medicare Part D prescription drug coverage.
The Plans Without Part D
The Plans without Part D include pharmacy benefits, but they are not Medicare Part D plans. These
plans are specifically designed for members who:
• Already have Medicare Part D coverage through another plan or employer.
• Receive a subsidy for prescription drug benefits from their or their spouse's employer.
• Receive Veterans Administration health benefits for prescription drugs.
Note: Premiums for the Plans without Part D are higher because HealthChoice does not receive
a subsidy from Medicare for members enrolled in these plans.
Extra Help Paying for Part D - Medicare Low Income Subsidy Information
If you qualify for extra help through Social Security, you pay $0 or a reduced monthly premium
for the prescription drug portion of your coverage. This extra help assists you in paying for your
prescription drugs. For more information, contact Social Security at the number listed on page 2
of this Guide.
Enrollment Periods
There are three time periods when you can enroll in or disenroll from the HealthChoice Medicare
Supplement Plans.
• Initial Enrollment Period - Initial Enrollment Period refers to the time period when
8 2011 Plan Year
you first become eligible for enrollment in a Part D plan. This seven-month period
begins three months prior to your month of eligibility and extends three months beyond
your month of eligibility. Your coverage is effective the first of the month you become
Medicare eligible, or the first of the month after HealthChoice receives your completed
enrollment form, whichever is later.
• The Annual Enrollment Period - The HealthChoice annual Option Period (Annual
Enrollment Period) occurs during the fall of each year; however, your plan selection
may be changed up until December 7, the end of the Annual Enrollment Period. After
December 7, plan changes cannot be made until the next annual Option Period.
• Special Enrollment Periods - Special Enrollment Periods are allowed under certain
situations. Coverage is effective following the processing of your paperwork. Examples
include:
• You move outside the United States.
• CMS or HealthChoice terminates the Plans' participation in the Part D Program.
• You lose Creditable Coverage for reasons other than failure to pay premiums.
• You meet other exception rules as set out by CMS.
• For more information on Special Enrollment Periods, contact HealthChoice Member
Services. See Help Lines on pages 51 and 52 of this Guide.
Grievance and Appeals Procedures
Under Medicare guidelines, HealthChoice uses a process to handle grievances and appeals regarding
complaints about care or services related to your Part D prescription drug benefits. HealthChoice
has similar processes in place for all other types of claims not related to Part D. Details are available
on the HealthChoice website and in the member handbook.
Disenrollment - Voluntary
• You can voluntarily disenroll from a HealthChoice Medicare Supplement Plan only
during a specified enrollment period.
• All disenrollments must be submitted in writing to OSEEGIB, and CMS determines the
effective date of the disenrollment.
• HealthChoice can deny a voluntary request for disenrollment if the request is made
outside of an enrollment period.
NOTE: If you drop your coverage through OSEEGIB, you cannot regain coverage through
OSEEGIB in the future.
2011 Plan Year 9
I •
Disenrollment - Involuntary
HealthChoice must disenroll you from the Plan if you:
• Move outside the United States.
• Lose entitlement to Medicare.
• Fail to pay premiums on time.
• Die.
HealthChoicePharmacy Network
The HealthChoice Pharmacy Network offers a host of participating pharmacies across
Oklahoma and throughout the nation. To locate a Network Pharmacy near you, contact Medco,
the HealthChoice pharmacy benefit manager, toll-free at 1-800-590-6828 orTTD 1-800-716-
3231, or log on to the HealthChoice website at www.sib.ok.gov or www.healthchoiceok.com.
ID Cards
HealthChoice members have two ID cards, one for health and/or dental benefits, and another for
pharmacy benefits. If you are currently a HealthChoice member and choose a plan with Part D,
you will receive a new prescription drug card with the Medicare RX logo on it. If you choose a
plan without Part D, continue using your current ID cards. If you are new to HealthChoice, you
are issued new ID cards.
10 2011 Plan Year
• Tier 1 - Generics
• Tier 2 - Preferred brand
• Tier 3 - Non-Preferred brand
• Tier 4 - Very high cost or specialty drugs
• Tier 5 - Tobacco cessation medications
The drugs in Tiers 1, 2, and 4 offer the lowest
or Preferred copay, Tier 3 drugs have the
highest copay, and Tier 5 drugs (tobacco
cessation products) have a $5 copay. Drugs
not listed in the formulary are not covered.
HealthChoice Pharmacy
Benefit Information
HealthChoice Medicare Formulary (List of Covered Drugs)
The HealthChoice Medicare Formulary applies to all HealthChoice Medicare Supplement
Plans. The HealthChoice Plans cover both brand-name and generic drugs.
Both brand-name and generic drugs are covered, and drugs are sorted into five tiers:
During 2011, if HealthChoice makes any formulary changes that alter your drug's tier level or
increase your cost, we will notify you 60 days before the change.
Pharmacy Prior Authorization
Prior authorization medications are medications that may be covered under the Plan if the
prescribed use meets approved guidelines. Prior authorization requests must be submitted by
your physician. Please note, HealthChoice may add or remove medications from the list of
drugs that require prior authorization.
Quantities of Medications
Pharmacy benefits generally cover up to a 34-day supply or 100 units, whichever is greater,
not to exceed the FDA approved 'usual' dosage for a 100-day supply. Specific therapeutic
categories, medications, and/or dosage forms may have more restrictive quantity and/or
duration of therapy limitations. Some medications have a maximum quantity limitation and/or
the medication is not dispensed in a tablet or capsule form. Be aware that quantity limitations
may be added to or removed from some medications for 2011. Also, be aware that under certain
circumstances, HealthChoice makes exceptions to quantity limitations.
2011 Plan Year 11
Transition Supply of Medication (Applies Only to Plans With Part D)
During transition to a HealthChoice Part D plan or transition to a formulary medication, you
can be authorized to purchase a one-time supply of a non-covered medication. This transition
supply, not to exceed a 34-day supply, is available to help you make a successful transition to
a HealthChoice Medicare Formulary medication. This temporary supply is provided, when
necessary, prior to initiating or completing the coverage review process for a medication
requiring prior authorization. Please note that under certain circumstances, this 34-day supply
can be extended. For information on how to obtain a covered transition supply of medication,
have your pharmacy contact Medco. See Help Lines on pages 51 and 52 of this Guide.
Network Pharmacy Access
You always receive a greater benefit when you use a HealthChoice Network Pharmacy. The
HealthChoice Pharmacy Network includes both local and national retail pharmacies. To check
the Network status of your pharmacy, you can contact Medco customer service. Members with
Part D call toll-free 1-800-590-6828 or toll-free TDD 1-800-716-3231. Members without Part
D call toll-free 1-800-903-8113 or toll-free TDD 1-800-825-1230. You can also access the
HealthChoice Pharmacy Directory online at www.sib.ok.gov or www.healthchoiceok.com.
Non-Network Pharmacy Access
Although HealthChoice covers your prescriptions if they are obtained from a non-Network
pharmacy, a reduced benefit applies. An exception may be made for use of a non-Network
pharmacy in the event of an emergency.
12 2011 Plan Year
Summary of HealthChoice High and Low Option
Medicare Supplement Plans
Medicare Part A (Hospitalization) Services
All benefits are based on Medicare Approved Amounts
Services
Description
Medicare HealthChoice You
or Items Part A Pays Pays Pay
Hospitalization: First 60 days All except $1,132, the Part 0%
Semiprivate room, $1,132 the Part A deductible
meals, drugs as part A deductible
of your inpatient 61 st through 90th day All except $283 per day 0%
treatment, and other $283 per day
hospital services and
supplies 91st day and after All except $566 per day 0%
using 60 Medicare $566 per day
lifetime reserve days
Once Medicare's 0% 100% 0%
lifetime reserve of Medicare
days are used, eligible
HealthChoice expenses
provides additional
lifetime reserve days Certification by
Limited to 365 days HealthChoice is
required
Beyond the 365 0% 0% 100%
HealthChoice lifetime
reserve days
Skilled Nurse Facility First 20 days All approved 0% 0%
Care: amounts
Must meet Medicare 21 st through 100th All except $141.50 per day 0%
requirements, including day $141.50 per
inpatient hospitalization day
for at least 3 days and 101st day and after 0% 0% 100%
entering a Medicare
approved facility within
30 days of leaving the
hospital. Limited to
100 days per calendar
year.
2011 Plan Year 13
Medicare Part A (Hospitalization) Services - Continued
Services Description Medicare HealthChoice You
or Items Part A Pays Pays Pay
Hospice Care Available as long as All but very limited 0% Balance
your doctor certifies coinsurance for
you are terminally outpatient drugs
ill and you elect to and inpatient
receive these services respite care
Blood Limited to the first 3 0% 100% 0%
pints unless you or
someone else donates
blood to replace what
you use
Medicare Part B (Medical) Services
All Benefits are Based on Medicare Approved Amounts
Services Description Medicare Part HealthChoice You
or Items BPays Pays Pay
Medical $162, the Part B 0% 0% $162, the
Expenses: deductible PartB
Inpatient and deductible
outpatient hospital
treatment, such Remainder of 80% 20% 0%
as physician Medicare approved
services, medical amounts
and surgical Part B charges in 0% 100% 0%
services and excess of Medicare
supplies, physical approved amounts
and speech
therapy, and
diagnostic tests
(Medicare limits
apply)
Clinical Blood tests and 100% 0% 0%
Laboratory urinalysis for
Services diagnostic services
14 2011 Plan Year
2011 Plan Year 15
Medicare Part B (Medical) Services - Continued
Services
Description
Medicare HealthChoice You
or Items Part B Pays Pays Pay
Home Health Care: Medically necessary 100% 0% 0%
Medicare approved skilled care and
services medical supplies
Durable Medical $162, the Part B 0% 0% $162, the
Equipment deductible PartB
deductible
Remainder of 80% 20% 0%
Medicare approved
amounts
Blood Amounts in addition 80% after 20% after 0%
to the coverage the Part B the Part B
under Part A unless deductible deductible
you or someone else
donates blood to
replace what you use
Hospice Covered for 80% 20% 0%
Prescription Medicare
beneficiaries with a
terminal illness
One-time Initial All Medicare 80% 20% 0%
Wellness Physical beneficiaries No Part B No Part B
Exam: deductible deductible
To be completed
within 12months of
the day you first enroll
in Medicare Part B
Medicare Part B (Preventive) Services
All Benefits are Based on Medicare Approved Amounts
Preventive Who is Medicare HealthChoice
You Pay
Services Covered Pays Pays
Screening All female Medicare 80% 20% 0%
Mammogram: beneficiaries age 40 No PartB No Part B
Once every and older deductible deductible
12months
Medicare Part B (Preventive) Services - Continued
PSreevrevnicteivse CWovheoreisd MePdaiycasre HealPthaCyshoice You Pay
Screening Blood All Medicare 100% 0% 0%
Tests for Early beneficiaries
Detection of
Cardiovascular
(Heart) Disease
Pap Test and Pelvic All female Medicare Pap Test, 100% 0% 0%
Exam: beneficiaries No Part B
Once every 24 deductible
months; includes a
clinical breast exam
For all other For all other 0%
Once every 12 exams, 80% exams, 20%
months if high risk! No Part B No Part B
abnormal Pap test deductible deductible
in preceding 36
months
Diabetes Screening All Medicare 100% 0% 0%
Test beneficiaries at risk
for diabetes
Diabetes All Medicare 80% after the Part 20% after the 0%
Self-Management beneficiaries with B deductible Part B deductible
Training diabetes (insulin and
non-insulin users)
Diabetes All Medicare 80% after the Part 20% after the 0%
Monitoring: beneficiaries with B deductible Part B deductible
Includes coverage diabetes - must be
for glucose requested by your
monitors, test strips, doctor
and lancets without
regard to the use of
insulin
Bone Mass All Medicare 80% after the Part 20% after the 0%
Measurements: beneficiaries at risk B deductible Part B deductible
Once every 24 for losing bone mass
months for qualified
individuals
16 2011 Plan Year
Medicare Part B (Preventive) Services - Continued
Preventive Who is Medicare HealthChoice.
You Pay
Services Covered Part B Pays Pays
Glaucoma Medicare 80% after the Part B 20% after 0%
Screening: Once beneficiaries deductible the Part B
every 12 months; at high risk or deductible
must be performed having a family
or supervised by an history of
eye doctor who is glaucoma
authorized to do this
within the scope of
his/her practice
Colorectal Cancer All Medicare For the fecal occult 0% for the fecal 0%
Screening beneficiaries age blood test, 100% occult blood test
Fecal Occult Blood 50 and older No Part B deductible
Test: Limited to once
every 12 months
Flexible For all other tests, For all other 0%
Sigmoidoscopy: 80% after the Part B tests, 20%
Limited to once every deductible after the Part B
48 months for age 50 deductible
and older; for those
not at high risk, 10
years after a previous
screenmg
Colonoscopy: There is no
Limited to once every .. mmnnum age
24 months if you are for having a
at high risk for colon colonoscopy
cancer; if not, once
every 10 years, but not
within 48 months of
a screening flexible
sigmoidoscopy
Barium Enema: Note: For a flexible sigmoidoscopy or screening colonoscopy in an
Doctor can substitute outpatient hospital setting or an ambulatory surgical center, you pay
for sigmoidoscopy or 25% of the Medicare Approved Amount
colonoscopy
Providers who do not accept Medicare assignment cannot charge a Medicare beneficiary more
than 115% of the Medicare Approved Amount. If your doctor does not accept Medicare, you are
responsible for all charges above the Medicare approved amounts.
2011 Plan Year 17
Medicare Part B (Preventive) Services - Continued
Preventive Who is Medicare HealthChoice You
Services Covered Part B Pays Pays Pay
Prostate Cancer All male For the digital For the digital 0%
Screening Medicare rectal exam, 80% rectal exam, 20%
beneficiaries after the Part B after the Part B
Digital Rectal Exam: age 50 and older deductible deductible
Once every 12 months
For the PSA test, 0% for the PSA 0%
Prostate Specific 100% test
Antigen Test (PSA): No Part B
Once every 12 months deductible
Preventive Services - Vaccinations
Flu Vaccination: For all Medicare beneficiaries with Part B, the vaccination and
One per flu season administration are covered at 100% if the provider accepts Medicare
assignment.
Pneumococcal For all Medicare beneficiaries with Part B, the vaccination and
Vaccination: administration are covered at 100% if the provider accepts Medicare
One-time vaccination assignment.
Hepatitis B For members with Part D, the vaccine and administration are covered
Vaccination: under the HealthChoice pharmacy benefit.
Medicare beneficiaries
at medium to high risk For members without Part D, the vaccine and administration are
for Hepatitis B covered under the Medicare Part B benefit.
For Services Not Covered by Medicare
Services Benefits Medicare HealthChoice You
Part B Pays Pays Pay
Foreign Travel: Contact 0% 80% of billed First $250 each
Medically necessary Medicare for charges after the calendar year,
emergency care foreign travel first $250 of each then 20%
services beginning exceptions that calendar year All amounts
during the first 60 days are covered by over the
of each trip outside the Medicare $50,000 lifetime $50,000 lifetime
U.S.A. maximum maximum
No Medicare
deductible
18 2011 Plan Year
2011 Pharmacy Benefits for HealthChoice
High Option Medicare Supplement Plans
With and Without Part D
HOW THE HIGH OPTION PLANS WORK
There is no annual deductible and no Coverage Gap. An annual out-of-pocket maximum
applies. Discounts apply after $2,840 in total drug spend. Benefits are as follows:
Prescription Medicare HealthChoice You
Medications Pays Pays Pay
Generic JTier 1) or Preferred (Tier 2
Allowed Charges
and Tier 4) medications costing $100 Copay up to $30
$0 in excess of your
or less purchased at a HealthChoice maximum per fill
Network Pharmacy
copay
Generic (Tier 1) or Preferred (Tier 2
Allowed Charges Copay of 25% up to
and Tier 4) medications costing more
$0 in excess of your $60 maximum per
than $100 purchased at a HealthChoice
copay fill
Network Pharmacy
Non-Preferred (Tier 3) medications Allowed Charges
Copay up to $60 per
costing $100 or less purchased at a $0 in excess of your
fill
HealthChoice Network Pharmacy copay
Non-Preferred (Tier 3) medications Allowed Charges Copay of 50% up to
costing more than $100 purchased at a $0 in excess of your $120 maximum per
HealthChoice Network Pharmacy copay fill
(Tier 5) medications for tobacco Allowed Charges
cessation prescription drugs purchased $0 in excess of your Copay of $5 per fill
at a HealthChoice Network Pharmacy copay
THE PHARMACY OUT-OF-POCKET MAXIMUM
Out-of-Pocket Maximum After Out-of-Pocket is Met
The annual out-of-pocket maximum is $4,550.
Only copays for covered prescription drugs
purchased at Network Pharmacies apply to the
out-of-pocket maximum. See the chart above
for copay amounts.
After your pharmacy out-of-pocket costs
reach $4,550, HealthChoice pays 100% of
Allowed Charges for covered prescription
drugs purchased at Network Pharmacies for
the remainder of the calendar year.
PHARMACY DISCOUNTS AFTER $2,840 IN DRUG SPEND
Once total drug spend reaches $2,840, a 50% discount will apply to the copay for covered
brand-name drugs.
2011 Plan Year 19
2011 Pharmacy Benefits for HealthChoice
Low Option Medicare Supplement Plans
With and Without Part D
THE BENEFIT STAGES OF THE LOW OPTION PLANS
Annual
Deductible
$310
Initial
Coverage Limit
$2,530
Annual Out-of-Pocket
Maximum
$4,550
Coverage
Gap
$3,607.50
After you spend $4,550 out-of-
pocket, HealthChoice
pays 100% of Allowed
Charges for covered
prescription drugs for the
remainder of the calendar
year.
After the deductible, you
and HealthChoice share the
costs of the next $2,530 of
prescription drug costs.
You pay
100% of
the next
$3,607.50 of
prescription
You pay 25% ($632.50) and drug costs.
HealthChoice pays 75%
($1,897.50).
REACHING THE ANNUAL OUT-OF-POCKET MAXIMUM OF $4,550
$ 310.00
$ 632.50
$3,607.50
$4,550.00
Deductible
25% of the Initial Coverage Limit of$2,530
Coverage Gap - you pay 100% of prescription drug costs
Total annual out-of-pocket maximum
YOUR COSTS FOR COVERED MEDICATIONS
You Pay HealthChoice Pays
Annual deductible of $310 $0
$632.50 (25%) of the next $2,530 of prescription $1,897.50 (75%) of the next $2,530.
drug costs.
During the Coverage Gap, you are responsible HealthChoice provides a 7% discount
for the next $3,607.50 of prescription drug costs; on the cost of generic drugs during the
however, you receive a 50% discount on the cost Coverage Gap
of brand-name drugs and a 7% discount on the
cost of generic drugs.
$0 after you have spent $4,550 out-of-pocket for 100% of Allowed Charges for covered
drugs for the remainder of the calendar
prescription drugs. year.
20 2011 Plan Year
Section III
UnitedHealthcare
Senior Supplement Plans
2011Plan Year 21
UnitedHealthcare Senior Supplement High and Low Option Plans
Medicare Part A (Hospitalization) Services
All Benefits are based on Medicare Approved Amounts
Services
or Items
UnitedHealthcare
Pays
You
Pay
Medicare
Part A Pays Description
First 60 days 100% of the
Part A deductible
Hospitalization:
Semiprivate room,
meals, drugs as part
of your inpatient
treatment, and other
hospital services and
supplies
All except
the Part A
deductible
0%
61st through 90th
day
All except the
COInsurance
per day
The coinsurance per
day
0%
91st day and after
Using 60 Medicare
lifetime reserve
days
The coinsurance per
day
All except the 0%
COInsurance
per day
Once Medicare's
lifetime reserve
days are used,
UnitedHealthcare
provides additional
lifetime reserve
days
Limited to 365 days
100%
of Medicare eligible
expenses
0% 0%
Certification is
required
Beyond the 365
UnitedHealthcare
lifetime reserve
days
0% 0% 100%
Skilled Nurse
Facility Care:
Must meet Medicare
requirements,
including inpatient
hospitalization for
at least 3 days and
entering a Medicare
approved facility
within 30 days of
leaving the hospital.
Limited to 100 days
per calendar year.
First 20 days All approved
amounts
0% 0%
21st through 100th
day
All except the
COInsurance
per day
The coinsurance per
day
0%
101st day and after 0% 0% 100%
22 2011 Plan Year
Medicare Part B (Medical) Services
All Benefits are Based on Medicare Approved Amounts
Medicare Part A (Hospitalization) Services - Continued
Services
Description
Medicare UnitedHealthcare You
or Items Part A Pays Pays Pay
Hospice Care Available as long as All but very 0% Balance
your doctor certifies limited
you are terminally coinsurance
ill and you elect for outpatient
to receive these drugs and
services inpatient
respite care
Blood Limited to the first 0% 100% 0%
3 pints unless you
or someone else
donates blood to
replace what you use
Services
Description
Medicare UnitedHealthcare You
or Items Part B Pays Pays Pay
Medical Expenses: The PartB 0% 0% The
Inpatient and deductible PartB
outpatient hospital deductible
treatment, such as
physician services,
medical and surgical Remainder of 80% 20% 0% services and Medicare approved
supplies, physical amounts
and speech therapy,
and diagnostic tests Part B charges in 0% 100% 0%
(Medicare limits excess of Medicare
apply) approved amounts
Clinical Laboratory Blood tests and 100% 0% 0%
Services urinalysis for
diagnostic services
2011 Plan Year 23
Medicare Part B (Medical) Services - Continued
Services
Description
Medicare UnitedHealthcare You
or Items Part B Pays Pays Pay
Home Health Care: Medically necessary 100% 0% 0%
Medicare Approved skilled care and
Services medical supplies
Durable Medical The Part B 0% 0% 100%
Equipment deductible
Remainder of 80% 20% 0%
Medicare approved
amounts
Blood Amounts in addition 80% after 20% after the Part B 0%
to coverage under the Part B deductible
Part A unless you deductible
or someone else
donates blood to
replace what you use
Hospice Covered for 80% 20% 0%
Prescription Medicare
beneficiaries with a
terminal illness
One-time Initial All Medicare 80% 20% 0%
Wellness Physical beneficiaries No Part B No Part B deductible
Exam: deductible
To be completed
within 12 months
of the day you first
enroll in Medicare
PartB
Medicare Part B (Preventive) Services
All Benefits are Based on Medicare Approved Amounts
Preventive Who is Medicare UnitedHealthcare
Services Covered Pays Pays You Pay
Screening Female Medicare 80% 20% 0%
Mammogram: beneficiaries age No Part B No Part B deductible
Once every 12 40 and older deductible
months
24 2011 Plan Year
Medicare Part B (Preventive) Services - Continued
Preventive Who is Medicare UnitedHealthcare You
Services Covered Pays Pays Pay
Screening Blood All Medicare 100% 0% 0%
Tests for Early beneficiaries
Detection of
Cardiovascular
(Heart) Disease
Pap Test and Female Medicare Pap Test, 100% 0% 0%
Pelvic Exam: beneficiaries No Part B
Once every 24 deductible
months; includes a
clinical breast exam
For all other For all other 0%
Once every 12 exams, 80% exams, 20%
months if high risk! No Part B No Part B deductible
abnormal Pap test deductible
in preceding 36
months
Diabetes Screening All Medicare 100% 0% - 0%
Test beneficiaries at risk
for diabetes
Diabetes All Medicare 80% after the 20% after the Part B 0%
Self-Management beneficiaries with Part B deductible deductible
Training diabetes (insulin
users and non-insulin
users)
Diabetes All Medicare 80% after the 20% after the Part B 0%
Monitoring: beneficiaries with Part B deductible deductible
Includes coverage diabetes - must be
for glucose requested by your
monitors, test strips, doctor
and lancets without
regard to the use of
insulin
Bone Mass Medicare 80% after the 20% after the Part B 0%
Measurements: beneficiaries at risk Part B deductible deductible
Once every 24 for losing bone
months for qualified mass
individuals
2011 Plan Year 25
Medicare Part B (Preventive) Services - Continued
Preventive Who is Medicare UnitedHealthcare You
Services Covered Part B Pays Pays Pay
Glaucoma Medicare 80% after the Part 20% after the Part B 0%
Screening: Once beneficiaries B deductible deductible
every 12 months; at high risk or
must be performed family history
or supervised by an of glaucoma
eye doctor who is
authorized to do this
within the scope of
his/her practice
Colorectal Cancer All Medicare For the fecal 0% for the fecal 0%
Screening beneficiaries occult blood test, occult blood test
Fecal Occult Blood age 50 and 100%
Test: Limited to once older No Part B
every 12 months deductible
Flexible
Sigmoidoscopy:
Limited to once every For all other tests, For all other tests, 0%
48 months for age 50 80% after the Part 20% after the Part B
and older; for those B deductible deductible
not at high risk, 10
years after a previous
screemng
Colonoscopy: There is no
Limited to once every rm.m. mum age
24 months if you are for having a
at high risk for colon colonoscopy
cancer; if not, once
every 10 years, but not
within 48 months of
a screening flexible
sigmoidoscopy
Barium Enema: Note: For a flexible sigmoidoscopy or screening colonoscopy in an
Doctor can substitute outpatient hospital setting or an ambulatory surgical center, you pay
for sigmoidoscopy or 25% of the Medicare Approved Amount
colonoscopy
Providers who do not accept Medicare assignment cannot charge a Medicare
beneficiary more than 115% of the Medicare Approved Amount.
26 2011 Plan Year
Medicare Part B (Preventive) Services - Continued
Preventive Who is Medicare UnitedHealthcare You
Services Covered Part B Pays Pays Pay
Prostate Cancer All male For the digital For the digital rectal 0%
Screening Medicare rectal exam, 80% exam, 20% after the
beneficiaries after the Part B Part B deductible
Digital Rectal age 50 and deductible
Exam: Once every 12 older
months
For the PSA test, 0% for the PSA test 0%
Prostate Specific 100% No Part B
Antigen (PSA) deductible
Test: Once every 12
months
Preventive Services - Vaccinations
Flu Vaccination: For all Medicare beneficiaries with Part B, the
One per :flu season vaccination and administration are covered at 100% if the
provider accepts Medicare assignment.
Pneumococcal Vaccination: .- For all Medicare beneficiaries with Part B, the
One-time vaccination vaccination and administration are covered at 100% if the
provider accepts Medicare assignment.
Hepatitis B Vaccination: The vaccine and administration are covered under the
Medicare beneficiaries at medium pharmacy benefit.
to high risk for Hepatitis B
Services Not Covered by Medicare
Services Benefits
Medicare UnitedHealthcare
Part B Pays Pays You Pay
Foreign Travel: Contact 0% 80% of billed charges First $250
Medically necessary Medicare for after the first $250 of each calendar
emergency care foreign travel each calendar year year, then 20%
services beginning exceptions that All amounts
during the first 60 are covered by $50,000 lifetime over the
days of each trip Medicare maximum $50,000
outside the U.S.A. lifetime
maximum
2011 Plan Year 27
UnitedHealthcare Senior Supplement
High and Low Option Plans
Prescription Drug Coverage
Prescription You
Medications Pay
Tier 1 - Preferred Generics $10
Tier 2 - Preferred Brand $30
Tier 3 -Non-Preferred $60
Tier 4 - Specialty 33%
UnitedHealthcare Senior Supplement High and Low Option Plans - You pay the applicable
copays of $10 for Tier 1 prescriptions, $30 for Tier 2 prescriptions, and $60 for Tier 3
prescriptions. For prescriptions in the Specialty Tier, you pay 33% of the discounted network
price. You can find a complete formulary listing on www.UnitedhealthRxforGroups.com. If
the formulary changes, you are notified in writing before the change. Only Medicare Part D
covered drugs impact your Medicare prescription drug plan annual out-of-pocket spending.
Certain prescription drugs have maximum quantity limits. Your provider must get prior
authorization from UnitedHealthcare for certain prescription drugs.
Once you are out-of-pocket $2,840 (the gap) in copays and/or specialty prescriptions, you are
responsible for 100% of the discounted network price for all prescriptions except for Tier 1
drugs. After you are out-of-pocket $4,550, you pay 5% or a minimum of $2.50 for generics and
a minimum of $6.30 for brand-name prescriptions.
Additionally, a mail order benefit is available. You can receive a 90-day supply of prescriptions
for two copays. The coverage, during and after the gap, also applies.
28 2011 Plan Year
Section IV
2011 Plan Year 29 .
Medicare Advantage
Prescription Drug Plans
(MA-PD Plans)
Medicare Advantage Prescription Drug
(MA-PD) Plans
An MA-PD plan offers a combination of health and prescription drug benefits within a specified
service area.
Plan Premiums
The monthly premiums in the chart below are per person:
CommunityCare Senior Health Plan $220.00 per enrolled person
CommunityCare Senior Health Plan Alternate $180.00 per enrolled person
Generations Healthcare by GlobalHealth $186.07 per enrolled person
Secure Horizons Medicare Complete Retiree Plan $219.50 per enrolled person
Eligibility in an MA-PD Plan
This option is available to eligible retired, vested, and non-vested former employees, your
survivors, your covered dependents, and COBRA participants. You must be currently enrolled
in Medicare and participating in the health insurance coverage offered through OSEEGIB.
The following additional requirements also apply:
• You must be a permanent resident of the MA-PD plan's service area.
• You must be enrolled in both Medicare Part A (Hospital) and Part B (Medical) and
continue to pay your monthly Medicare Part B premium. If you are already enrolled in
a Medicare Managed Care Plan and have only Medicare Part B, you can stay with your
current plan.
If you have been diagnosed with End-Stage Renal Disease (ESRD), you are not eligible to
enroll in an MA-PD plan. If you are currently enrolled in an MA-PD plan and develop ESRD
or undergo a transplant, you can remain with your plan. Please contact the MA-PD plan of your
choice for further information.
Service Area
You must reside in the MA-PD plan's service area. This is a federally qualified area where the
MA-PD provides coverage. Check the MA-PD Plan Service Areas in this section to make sure
your county is in the MA-PD plan's service area.
30 2011 Plan Year
Note: Not all ZIP Codes in every county fall within the MA-PD plan's service area. If you are
unsure, check with each MA-PD plan to verify your address is in its service area.
Plan Guidelines
• While the MA-PD plans market to the general public throughout the year, the options
available to you are a result of your status as a former state, education, or local
government employee or dependent. If you enroll in another MA-PD plan, such as one
offered to the general public, you may lose your benefits through OSEEGIB as well as
any retirement system contribution toward your insurance premium.
• When you enroll with an MA-PD plan, that plan becomes your Medicare benefits
administrator. Your MA-PD plan replaces Medicare and administers all your healthcare
benefits.
• If you permanently move out of your plan's service area or are absent from the service
area for more than six consecutive months, you must disenroll from your MA-PD plan
and select another plan that provides coverage in your new area.
Primary Care Physician (PCP)
• When you join an MA-PD plan, you agree that the Primary Care Physician (PCP) you
select will coordinate all your medical services. There are exceptions in cases of out-of-network
emergency or urgent care.
• If you do not use your PCP for routine care, you are financially responsible for any
charges related to those services.
• You may change doctors for any reason as long as the physician you select participates
in your MA-PD plan's provider network. To change your PCP, please contact the MA-PD
plan's customer service. See Help Lines on pages 51 and 52 of this Guide. If your
provider leaves your plan, you must select another provider within your plan's network.
You cannot change plans until the next annual Option Period.
Enrolling in an MA-PD Plan
If you are interested in enrolling in one of the MA-PD plans, contact the plan directly. Be sure
to indicate that you are with the State of Oklahoma account and an enrollment packet will
be mailed to you. Follow the instructions enclosed in your packet and return your completed
enrollment form directly to the MA-PD plan.
2011 Plan Year 31
Confirming Enrollment
You will receive a letter from your MA-PD plan confirming your enrollment and effective date.
Just before your effective date, you will receive your plan ID card and member handbook.
When a Covered Family Member is Not Yet Eligible for Medicare
All covered family members must enroll in the same plan. For example, if you are enrolled in the
CommunityCare MA-PD plan, your pre-Medicare spouse or dependents must enroll in one of the
CommunityCare HMO options.
Creditable Coverage Notice
The Medicare Advantage Plans offered through OSEEGIB qualify as Medicare Prescription Drug
Plans (MA-PD plans). All MA-PD plans available through OSEEGIB offer Creditable Coverage.
This means that if you elect a different Medicare plan the next year, you will not have a penalty.
Limiting Charge
Under Medicare guidelines, the highest amount you can be charged for a covered service by
doctors and other health care providers who don't accept assignment is known as the limiting
charge. The limiting charge is 15% over Medicare's approved amount. The limiting charge only
applies to certain services and not to supplies or equipment.
Enrollment Periods
There are three time periods when you can enroll in or disenroll from an MA-PD plan.
• The Initial Enrollment Period - The Initial Enrollment Period refers to the time period
when you first become eligible for enrollment. This seven-month period begins three
months prior to your month of eligibility and extends three months beyond your month
of eligibility. Your coverage is effective the first of the month in which you become
Medicare eligible, or the first of the month following your election, whichever is later.
• The Annual Enrollment Period - The annual Option Period (Annual Enrollment
Period) occurs during the fall of each year; however, your plan selection may be changed
up until December 7. After December 7, plan changes cannot be made until the next
annual Option Period.
• Special Enrollment Periods - Special Enrollment Periods can be allowed under certain
situations. Your coverage is effective following the processing of your paperwork.
Extra Help Paying For Part D (Medicare Low Income Subsidy Information)
32 2011 Plan Year
If you have limited income and resources, you may be able to get help paying your monthly
premiums, deductibles, and copays. This extra help, known as a low income subsidy, is offered
through the Social Security Administration. If you are interested in applying for the Medicare
Part D subsidy, you can apply online or contact the Social Security Administration office. See
page 2 for contact information.
Grievance and Appeals Procedures
Under Medicare guidelines, each plan has a process in place to handle grievances and appeals
regarding member complaints. Contact each plan for details regarding its procedures.
2011 Plan Year 33
Comparison of Benefits for
Medicare Advantage Prescription Drug Plans (MA-PD)
All Benefits are Based on Medicare Approved Amounts
CommunityCare Secure Horizons
Services Senior Health and Generations Medicare
or Items CommunityCare Senior Healthcare Complete Retiree
Health-Alternate Plans Plan (HMO)
Hospitalization: Senior Health Plan: $195 copay per $300 copay per
Semiprivate room or $50 each day for days 1-5 admission admission
private room if $0 each day for days 6-90 for
medically necessary a Medicare-covered stay in a
network hospital
Laboratory tests,
X-rays, and other Senior Health Plan -
radiology services Alternate:
$100 each day for days 1-5
Inpatient physician $0 each day for days 6-90 for
and surgical services, a Medicare-covered stay in a
including anesthesia network hospital
Necessary medical Both Plans:
supplies and Prior authorization is
appliances required, except in the case of
Blood and its
an emergency
administration
Organ Transplants: Both Plans: $195 copay per Plan covers organ
At a Medicare The following types of admission transplants the
approved transplant transplants are covered- same as any other
facility cornea, kidney, lung, heart- inpatient illness/
lung, bone marrow, intestinal admission; there is
and multivisceral, and stem no separate copay
cell for transplants
Heart, liver, lung, heart-lung,
and intestinal multivisceral
transplants are only covered
if performed in a Medicare
approved transplant center
34 2011 Plan Year
CommunityCare Secure Horizons
Services Senior Health and Generations Medicare
or Items CommunityCare Senior Healthcare Complete Retiree
Health-Alternate Plans Plan (HMO)
In-Area Urgent Senior Health Plan: $0 copay for PCP $35 copay
Care Services: $10 to $50 for each visits
Contact Primary Care Medicare-covered urgent care
Physician (PCP) first visit $10 copay per
visit for all other
Senior Health Plan - providers
Alternate:
$20 to $50 for each
Medicare-covered urgent care
visit
Skilled Nurse Both Plans: $195 per $75 per day for
Facility (Inpatient $0 for days 1-20 admission days 1-40
Services): $50 for days 21-100 for each
Semiprivate benefit period in a skilled $0 per day for days
room and regular nursing facility 41-100 . . nursmg services
You pay the inpatient
hospital copay for each
benefit period; no prior
hospital stay is required;
Physical, prior authorization is required
occupational, and
speech therapy $20 for each Medicare-covered
occupational,
Drugs furnished by physical, speech, and
the facility language therapy visit; prior
Necessary medical authorization is required
equipment and
supplies
Blood and its $0 for blood services
administration
Inpatient radiology $0 for each Medicare-covered
and pathology radiation therapy service
Use of appliances $0 to $50 or 20% for each
such as wheelchairs Medicare-covered DME item;
prior authorization is required
2011 Plan Year 35
CommunityCare Secure Horizons
Services Senior Health and Generations Medicare
or Items CommunityCare Senior Healthcare Complete Retiree
Health-Alternate Plans Plan (HMO)
Physical, Both Plans: $0 copay $25 copay
occupational, and $20 for each occupational,
speech therapy physical, speech, and
services language therapy visit
Prior authorization is required
Chiropractic: Senior Health Plan: $10 copay per 50% coinsurance
Limited to manual $15 per visit visit
manipulation Prior authorization is required Limited to 12 visits
of the spine per year
Senior Health Plan -
Alternate:
$15 per visit
Prior authorization is required
X-Ray Services: Both Plans: $0 copay $0 copay for
Including annual $0 per visit standard film
mammography $0 per screening mammogram x-rays
screening, if
medically indicated
Professional Senior Health Plan: $0 copay per PCP $15 PCP copay
Services: $10 per PCP visit visits
Office visit; $20 per specialist visit $10 copay per $30 specialist
consultati on, specialist visit copay
diagnosis, and Prior authorization is required
treatment by a for specialty care $10 per visit
specialist; medical for testing and
and surgical care; Senior Health Plan - treatment, no
allergy tests and Alternate: copay for serum
treatment (serum); $20 per PCP visit
diagnostic tests and $30 per specialist visit $0 copay for
treatments; medical other professional
supplies including Prior authorization is required services
casts, dressings, and for specialty care
splints
36 2011 Plan Year
CommunityCare Secure Horizons
Services Senior Health and Generations Medicare
or Items CommunityCare Senior Healthcare Complete Retiree
Health-Alternate Plans Plan (HMO)
Hearing Senior Health Plan: $10 capay per $15 capay per
Examinations $10 for routine hearing tests visit Medicare-covered
$20 for Medicare-covered visit
benefits
You pay 100% for hearing aids $30 capay per
routine exam
Senior Health Plan - Alternate:
$20 for routine hearing tests Limited to one per
$30 for Medicare-covered year
benefits
You pay 100% for hearing aids
Immunizations: Senior Health Plan: $0 capay for $0 capay
Includes flu $0 for annual flu vaccine Medicare Part
shots and all $0 for pneumonia vaccine B covered
Medicare approved No referral is necessary immunizations
immunizations $0 copay for Hepatitis B
vaccine
Senior Health Plan - Alternate:
$0 for annual flu vaccine
$0 for pneumonia vaccine
No referral is necessary
$0 copay for Hepatitis B
vaccine
Physical Senior Health Plan: $0 capay $0 capay
Examinations $0 for one routine physical exam Annual Routine
Limited to one per year Physical Exam
Senior Health Plan - Alternate:
$0 for one routine physical exam
Limited to one per year
2011 Plan Year 37
CommunityCare Secure Horizons
Services Senior Health and Generations Medicare
or Items CommunityCare Senior Healthcare Complete Retiree
Health-Alternate Plans Plan (HMO)
Well Female Exams Both Plans: $0 copay $0 copay
$0 for Pap test and pelvic
exam
Limited to one pap test and
one pelvic exam per year
Laboratory Services Both Plans: $0 copay $0 copay
$0 for each Medicare-covered
clinical/diagnostic
lab service with prior
approval
$0 to $100 for each clinical!
diagnostic lab service
$0 for each Medicare-covered
radiation therapy
service
Part- Time or Both Plans: $0 copay $0 copay
Intermittent Skilled $0 for home health visits;
Nursing Care: prior authorization is
Aide in conjunction required
with skilled care
Durable Medical Both Plans: 20% coinsurance 20% coinsurance
Equipment $0 to $50 copay or 20% for
each Medicare-covered item
Authorization rules may
apply for these items
Ambulance Services Both Plans: No copay $100 copay
(medically necessary $50 for Medicare-covered Covered 100%
services) ambulance services worldwide
for medically
This amount is waived if you necessary
are admitted to a medical transports
facility
38 2011 Plan Year
PHARMACY BENEFITS FOR
MEDICARE ADVANTAGE PRESCRIPTION DRUG PLANS
Services
or Items
CommunityCare
Senior
CommunityCare
Senior Alternate
Prescriptions:
Mandatory generic and
formulary options
Quantity limits apply to
certain drugs, also some
drugs require prior
authorization
Pharmacy programs
must meet the minimum
requirements for benefits
as outlined in the
Medicare Modernization
Act of2003
2011 Plan Year
This plan uses a formulary
You will be notified before
any changes are made to the
formulary
In-Network Benefits
30-day supply:
$0 capay for a select list of
Preferred generic drugs
$10 capay for Preferred generic
drugs
$30 capay for Preferred brand
drugs
$60 capay for non-Preferred
generic/non-Preferred brand
drugs
33% coinsurance for Specialty
drugs and non-Specialty
injectables
Mail order
90-day supply:
$0 capay for a select list of
Preferred generic drugs
$20 capay for Preferred
generic drugs
$60 capay for Preferred brand
drugs
$120 capay for non-Preferred
generic/non- Preferred brand
drugs
33% coinsurance for Specialty
drugs and non-Specialty
injectables
39
This plan uses a formulary
You will be notified before
any changes are made to the
formulary
In-Network Benefits
30-day supply:
$0 capay for a select list of
Preferred generic drugs
$10 capay for Preferred generic
drugs
$35 capay for Preferred brand
drugs
$90 capay for non-Preferred
generic/non-Preferred brand
drugs
33% coinsurance for Specialty
drugs and non-Specialty
injectables
Mail order
90-day supply:
$0 capay for a select list of
Preferred generic drugs
$20 capay for Preferred
generic drugs
$70 capay for Preferred brand
drugs
$180 capay for non-Preferred
generic/non-Preferred brand
drugs
33% coinsurance for Specialty
drugs and non-Specialty
injectables
1 .
PHARMACY BENEFITS FOR
MEDICARE ADVANTAGE PRESCRIPTION DRUG PLANS
Services
or Items
Generations
Healthcare
Secure Horizons Medicare
Complete Retiree Plan
(HMO)
Prescriptions:
Mandatory generic and
formulary options
Quantity limits apply
to certain drugs, also
some drugs require prior
authorization
Pharmacy programs
must meet the minimum
requirements for benefits
as outlined in the Medicare
Modernization Act of 2003
Part B:
No copay for Part B covered
chemotherapy drugs and other
Part B covered drugs.
Part D:
Retail- 1 month supply
$5 - Formulary Tier 1
$30 - Formulary Tier 2
$50 - Formulary Tier 3
20% Coinsurance .Spccialty
Drugs Tier 4
Retail - 3 month supply
$10 - Formulary Tier 1
$60 - Formulary Tier 2
$100 - Formulary Tier 3
20% - Coinsurance Tier 4
Includes Tier 1, Plavix, and
insulin coverage during the
Medicare coverage gap
40
Retail
Up to 30-day supply:
Tier 1: $ 4 copay
Tier 2: $25 copay
Tier 3: $50 copay
Tier 4: $50 copay
Mail Order
Up to 90-day supply:
Tier 1: $ 8 copay
Tier 2: $ 65 copay
Tier 3: $140 copay
Tier 4: $150 copay
Includes full coverage in the
coverage gap
2011 Plan Year
E = Entire County Service Area P= Partial County Service Area
MA-PD Plan Service Areas
CommunityCare Generations Secure Horizons Medicare
Counties Senior Health Plans Healthcare Complete Retiree Plan
Canadian - E E
Cleveland - E E
Creek E E E
Grady - E -
Lincoln - E -
Logan - E -
McClain - E -
Mayes - E E
Oklahoma - E E
Osage P* E P**
Pottowatomie - E E
Rogers E E E
Seminole - E -
Tulsa E E E
Wagoner E E E
Washington P* - -
*Community Care Senior Health Plans
Osage County - Service Area includes the following ZIP Codes ONLY:
74002, 74035, 74054, 74060, 74063, 74070, 74084, 74126, 74127
Washington County - Service Area includes the following ZIP Codes ONLY:
74003, 74005, 74006, 74029, 74051, 74061, 74070
**Secure Horizons Medicare Complete Retiree Plan (HMO)
Osage County - Service Area includes the following ZIP Codes ONLY:
74003, 74022, 74051, 74063, 74070, 74073, 74106, 74126, 74127, 74604, 74650
2011 Plan Year 41
Section V
Dental and Vision Plan Options
There are eight 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
• Delta Dental Premier
• Delta Dental PPO - Choice
See Comparison of Benefits for Dental Plans to determine your costs under each plan.
There are five vision plans available:
• Humana/CompBenefits Vision Care Plan
• Primary Vision Care Services (PVCS)
• Superior Vision Plan
• UnitedHealthcare Vision
• Vision Service Plan (VSP)
See Comparison of Benefits for Vision Plans to determine your costs under each plan.
42 2011 Plan Year
Comparison of Benefits For Dental Plans
Your Costs HealthChoice CIGNA Dental Care Assurant
forSeNrevtiwceosrk Dental Plan (Prepaid) PFrreefeedrroemd
Network: $25 Basic No deductible or plan $25 per person, per
and Major services maximum calendar year, waived
combined $5 office copay applies for preventive services
ANNUAL Non-Network: $25 in-network
DEDUCTIBLE Preventive, Basic,
and Major services
combined
PREVENTIVE
Network: $0 Sealant: $15 per tooth $0 with no deductible
Non-Network: $0 of No charge for routine when in-network
CARE Allowed Charges after cleaning once every 6
Ex: cleaning,
deductible months
No charge for topical
routine oral fluoride application
exam (through age 18)
Allowed Charges
No charge for periodic
oral evaluations
apply
BASIC CARE
Network: 15% Amalgam: One surface, Network: 15%
Non-Network: 30% permanent teeth $21 Non-Network: 30%
Ex: extractions,
Deductible applies Plan pays 85% of usual
oral surgery iann-dnectuwsotormk,ary when
Allowed Charges Deductible applies
apply
Network: 40% Root canal, anterior: Network: 40%
MAJOR CARE Non-Network: 50% $355 Non-Network: 50%
Deductible applies Periodontal/scaling/ Plan pays 60% of usual
Ex: dentures, root planing 1-3 teeth and customary when
bridge work (per quadrant): $65 in-network
Deductible applies
Allowed Charges
apply
2011 Plan Year 43
Comparison of Benefits For Dental Plans
AHsesruitraagnet PPlruespwaiidthPSlaBnAs DIenl-tNaeDtwenotrakl PanPdO InD-NePletrtawemDorieeknrtaalnd PDPeOlt-aCDhoeincteal
and Heritage Secure Out-of-Network Out-of-Network PPO Network
No deductibles $25 per person, $50 per person, $100 per person, per
per year applies to per year applies year applies to Major
Basic and Major to diagnostic, Care only (Level 4)
Care only Preventive, Basic,
and Major Care
No charge for routine $0 of allowable $0 of allowable Schedule of covered
cleaning (once every 6 amounts amounts after services and copays
months) No deductible deductible Copay examples:
No charge for topical applies Routine cleaning $5
fluoride application (up to Includes diagnostic Periodic oral
age 18) Includes diagnostic evaluation $5
No charge for periodic Topical fluoride
oral evaluations application (up to age
19) $5
Includes diagnostic
Fillings 15% of allowable 30% of allowable Schedule of covered
Minor oral surgery amounts after amounts after services and copays
Refer to the copayment deductible deductible Copay example:
schedule for each plan Amalgam - One
surface, primary or
permanent tooth $12
Root canal 40% of allowable 50% of allowable Schedule of covered
Periodontal amounts after amounts after services and copays
Crowns deductible deductible Copay examples:
Refer to the copayment Crown - porcelain!
schedule for each plan ceramic substrate
$241
Complete denture -
maxillary $320
44 2011 Plan Year
Comparison of Benefits For Dental Plans
Your Costs for HealthChoice
CIGNADental Assurant
Care Plan Freedom
Network Services Dental
(Prepaid) Preferred
Network: 50% $2,280 out-of-pocket Network: 40%
Non-Network: 50% for children through Non-Network: 50%
12-month waiting age 18 Up to $2,000 lifetime
period may apply $3,120 out-of-pocket maximum for members
No lifetime orthodontic for adults under age 19*
maximum for Network
ORTHODONTIC or non-Network 24-month treatment 12-month waiting
CARE excludes orthodontic period may apply
Covered for members treatment plan and
Allowed Charges under age 19 and banding *Increase in
apply members age 19 and orthodontic maximum
older with TMD applies to treatment
beginning on or after
January 1,2011
Network and non- No maximum $2,000
PLAN YEAR
Network $2,000 per
person, per year
MAXIMUM
Network: No claims to No claims to file Member/provider must
file file claims
Non-Network: You file
FILING CLAIMS claims
2011 Plan Year 45
Comparison of Benefits For Dental Plans
HAsesruitraagnet PPlruespwaiidthPSlaBnAs DIenl-tNaeDtwenotrakl PanPdO InD-NePletrtawemDorieeknrtaalnd PDPeOlt-aCDhoenicteal
and Heritage Secure Out-of-Network Out-of-Network PPONetwork
25% discount 40% of allowable 40% of allowable You pay amounts in
Adults and children amounts, up to amounts, up to excess of $50 per
lifetime maximum lifetime maximum of month
of$2,000 $2,000 Lifetime maximum up
No deductible No deductible to $1,800
No waiting period No waiting period No deductible
No waiting period
Orthodontic Orthodontic benefits
benefits are are available to the Orthodontic benefits
available to the member and his/her are available to the
member and his/her lawful spouse and member and his/her
lawful spouse and eligible dependent lawful spouse and
eligible dependent children eligible dependent
children children
No annual maximum for $2,500 per person, $3,000 per person, $2,000 per person, per
general dentist per year per year year
No claims to file Claims are filed Claims are filed by Claims are filed by
by participating participating dentists participating dentists
dentists
46 2011 Plan Year
Comparison of Benefits for Vision Plans
Humana/CompBenefits Primary Vision
VisionCare Plan Care Services, Inc.
Covered
In-Network
Out-of-
In-Network
Out-of-
Services Network Network*
Eye $10 copay Copays do not apply $0 copay Plan pays up to
Exams
One exam for eyeglasses Plan pays up to $35; No limit on exams $40
or contacts per year One exam per year per year One exam per
year
$25 material copay Plan pays up to: You pay wholesale You pay normal
applies to lenses and! $25 single cost with no limit doctor's fee,
or frames (single, $40 bifocals on number of pairs reimbursed up
lined bifocal, trifocal, $60 trifocals to $60 for one
Lenses lenticular are covered at $100 lenticular set of lenses
100%) One pair of lenses and frames per
Each Pair A discount applies to per year year
progressive lenses
One pair of lenses per
year
$25 material copay $25 copay You pay wholesale You pay normal
applies to lenses and/or Plan pays up to $45 cost with no limit doctor's fee,
frames; One pair of frames on number of pairs reimbursed up
Frames $45 wholesale frame per year to $60 for one
allowance; set of lenses
One pair of frames per and frames per
year year
$130 allowance $130 allowance for You pay wholesale Limit of one set
for conventional or exam, contacts, and cost for contacts annually in lieu
disposable lenses and fitting fee in lieu of $50 fee applies to of eyeglasses
fitting fee in lieu of all all other benefits all soft contact lens You pay normal
Contact other benefits Medically necessary fittings; $75 to rigid doctor's fees,
Lenses Medically necessary, Plan pays $210 or gas permeable reimbursed up
Plan pays 100% One set of contacts lens fittings; $150 to to $60
One set of contacts per per year hybrid contact lens
year fittings Replacement
lenses do not have
these fees
$895 copay conventional No benefit Discount No benefit
$1,295 copay custom nationwide at
Laser $1,895 copay custom The Laser Center
Vision plus bladeless when (TLC)
Correction services are rendered by
a TLC Network Provider
*Out-of-Network limited to one eye exam and one set of eyeglasses or contact lenses annually.
Cannot be used with In-Network services.
2011 Plan Year 47
Comparison of Benefits for Vision Plans
Superior Vision Plan UnitedHealthcare Vision Vision Service Plan (VSP)
In-Network Out-of- In-Network Out-of- In-Network Out-of-
Network Network Network
$10 copay OD-$26 max $10 copay Plan pays up $10 copay $10 copay
One exam MD-$34 max One exam per to $40 One exam per Plan pays up
per year year year to $35
$25 copay Plan pays up $25 copay Plan pays up $25 copay* $25 copay*
One pair of to: One pair of to: One set of lenses Plan pays up
lenses per $26 single lenses per year $40 single per year to:
year $39 bifocals $60 bifocals Polycarbonate $25 single
$49 trifocals $80 trifocals lenses covered in $40 bifocals
$78 lenticular $80 full for dependent $55 trifocals
lenticular children $80
Average 35-40% lenticular
savings on all
non-covered lens
options
$25 copay Plan pays up $25 copay Plan pays up $25 copay* $25 copay*
Plan pays up to $68 $130 allowance to $45 $120 allowance Plan pays up
to $125 One pair of 20% off any to $45
One set of frames per year out-of-pocket
frames per costs above the
year allowance
One pair of
frames per year
$0 copay $0 copay $25 copay Plan pays up $0 copay $0 copay
Plan pays up Plan pays up covers fitting/ to $150 $120 allowance Plan pays up
to $120 to $100 evaluation For applied to the cost to $105 for
Medically For medically fees, contacts medically of your contact disposable or
necessary necessary (including necessary lens exam and the conventional
contacts are contacts, Plan disposables ), contacts, contact lenses contact
covered in pays up to and up to 2 Plan pays up 15% discount on lenses
full $210 follow-up visits to $210 contact lens exam (in lieu of
(in lieu of (in lieu of (in lieu of (in lieu of (in lieu of glasses) glasses)
glasses) glasses) glasses) glasses)
20% off No benefit Members have No benefit Laser vision No benefit
retail price access to correction
discounted services (PRK,
refractive eye LASIK, and
surgery from Custom LASIK)
numerous at a reduced cost
provider locations through VSP's
throughout the contracted laser
U.S. surgery centers
*Benefit includes an annual $25 materials copay on lenses or frames, but not both.
48 2011 Plan Year
How to Access the Online Provider Networks
Medicare Supplement Plans
HealthChoice Employer PDP Medicare Supplement Plans With Part D and HealthChoice
Medicare Supplement Plans Without Part D
You are not limited to the HealthChoice Provider Network but you are encouraged to use
providers who accept Medicare assignment.
UnitedHealthcare Senior Supplement Plans
You are not limited to the UnitedHealthcare provider network but you are encouraged to use
providers who accept Medicare assignment.
Medicare Advantage Prescription Drug Plans
CommunityCare Senior Health Plans
Visit www.ccok.com
Click on Find a Provider, then select Senior Health Plan
Generations Healthcare by Global Health
Visit www.generationshealthcare.cc
Click on Find a doctor covered under my plan
Click on Find A Primary Care or Specialist Physician under For Prospective members
Secure Horizons Medicare Complete Retiree Plan
Visit www.UHCRetiree.com
Click on Look up a provider now and enter your ZIP Code
Select 2011 United Healthcare Group Medicare Advantage (PPO)
Dental Plans
HealthChoice Dental
Visit www.healthchoiceok.com
Click on Find a Provider, then select Medical and Dental Providers
Follow the on-screen instructions
Assurant Freedom Preferred (Options for PPO)
Visit www.assurantemployeebenefits.com
Click on Find a Dentist
Select DHA Network
2011 Plan Year 49
Assurant Heritage Plus with SBA and Heritage Secure (Options for Prepaid)
Visit www.assurantemployeebenefits.com
Click on Find a Dentist
Select The Heritage Series
CIGNA Dental
Visit www.cigna.com
Click on Provider Directory
Click Dentist for the type of provider
Select CIGNA Dental Care (HMO)
Delta Dental
Visit www.deltadentalok.org
Click on Click here under Welcome State of Oklahoma Employees
Click here on the 3 NEW Dental Plans for 2011 and select your dental plan
Delta Dental PPO, Delta Premier, or Delta Dental PPO - Choice
Vision Plans
Humana/CompBenefits Vision Care Plan
Visit www.compbenefits.com/custom/stateofoklahoma
Click on Search for Providers
Primary Vision Care Services (PVCS)
Visit www.pvcs-usa.com
Click on Find a Doctor
Superior Vision Plan
Visit www.superiorvision.com
Click on Locate a Provider
UnitedHealthcare Vision
Visit www.myuhcvision.com
Click on Provider Locator
Vision Services Plan (VSP)
Visit www.vsp.com
Click on Find the right doctor for you under the Members tab or Choose VSP through your
employer under the Prospective Members tab
Click on Find a VSP Doctor then select VSP Signature Network
50 2011 Plan Year
Help Lines
Contact Information for Participating Plans
HealthChoice
Certification Generations Healthcare
by GlobalHealth
Toll-free 1-800-848-8121 To11-r.c.ree 1-866-496-7817
Toll-free TDD 1-877-267-6367 Toll-free TTY/TDDNoice 1-866-958-2692
Member Services/Provider Directory Website www.generationshealthcare.cc
1-405-717-8780
1-800-752-9475
1-405-949-2281
1-866-447-0436
Health and Dental Claims, ID Cards, Benefits,
and Verification of Coverage
Oklahoma City Area 1-405-416-1800
Toll-free 1-800-782-5218
TDD Oklahoma City 1-405-416-1525
Toll-free TDD 1-800-941-2160
Website www.sib.ok.gov or
www.healthchoiceok.com
Pharmacy Claims/Pharmacy ID Cards
Plans With Part D:
Toll-free
Toll-free TDD
Plans Without Part D:
Toll-free
Toll-free TDD
1-800-590-6828
1-800-716-3231
1-800-903-8113
1-800-825-1230
Oklahoma City Area
Toll-free
TDD Oklahoma City
Toll-free TDD
UnitedHealthcare
Senior Supplement Plans
Toll-free
Toll-free TDD
Website
1-800-851-3802
1-800-557-7595
www.UHCRetiree.com
Medicare Advantage
Prescription Drug Plans
(MA-PD)
CommunityCare Senior
Health Plan
1-918-594-5323
1-800-642-8065
1-800-722-0353
www.ccok.com
Tulsa Area
Toll-free
Toll-free Relay Service
Website
Secure Horizons Medicare
Complete Retiree Plan (HMO)
Toll-free 1-888-635-2701
Toll-free TDD 1-800-387-1074
Website www.UHCRetiree.com
If a TDD or TTY number is not listed for a plan, hearing impaired members should use a relay service to contact
the plan.
2011 Plan Year 51
Dental Plans' Help Lines
Assurant, Inc. Dental
Prepaid plan, toll-free 1-800-443-2995
Indemnity plan, toll-free 1-800-442-7742
Website www.assurantemployeebenefits.com
CIGNA Dental Care Plan (prepaid)
Toll-free 1-800-244-6224
Toll-free Relay Service 1-800-654-5988
Website www.cigna.com
Delta Dental
Oklahoma City Area
Toll-free
Website
Vision Plans' Help Lines
Humana/CompBenefits Vision Care Plan
Toll-free 1-800-865-3676
Toll-free TDD 1-877-553-4327
Website
www.compbenefits.com/custom/stateofoklahoma
Primary Vision Care Services (PVCS)
Toll-free 1-888-357-6912
Toll-free TDD 1-800-722-0353
Website www.pvcs-usa.com
Superior Vision Plan
1-800-507-3800
1-916-852-2382
Toll-free
1-405-607-2100 Toll-free TDD
1-800-522-0188 Website
www.DeltaDentaIOK.org
www.superiorvision.com
UnitedHealthcare Vision
1-800-638-3120
1-800-524-3157
Toll-free
Toll-free TDD
Website www.myuhcvision.com
Vision Service Plan (VSP)
1-800-877-7195
1-800-428-4833
Toll-free
Toll-free TDD
Website www.vsp.com
If a TDD or TYY number is not listed for a plan, hearing impaired members should use a relay service to
contact the plan.
52 2011 Plan Year