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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
Object Description
Description
Title | Plan Guide 2011 |
OkDocs Class# | E3610.5 P699m 2011 |
Digital Format | PDF, Adobe Reader required |
ODL electronic copy | Deposited by agency in print; scanned by Oklahoma Department of Libraries 9/2011 |
Rights and Permissions | This Oklahoma state government publication is provided for educational purposes under U.S. copyright law. Other usage requires permission of copyright holders. |
Language | English |
Full text | E 3610.5 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 |
Date created | 2011-09-09 |
Date modified | 2011-09-09 |