Employee benefit options guide

              Employee Benefit
Options Guide
Plan Year 2012
January 1 through December 31, 2012
Health
Dental
Life
Vision
www.sib.ok.gov or www.healthchoiceok.com
State Bird, Scissortailed Flycatcher
State Animal, Buffalo
State Wild Flower, Indian Blanket
State Reptile, Mountain Boomer
Update to Printed Version of This Guide
Update to the HMO ZIP Code List on pages 13 and 15:
CommunityCare HMO is available in ZIP Code areas 73141 and 74464.
Oklahoma State and Education Employees Group Insurance Board
A Division of the Office of State Finance
Monthly Premiums for Current Employees
Plan Year January 1, 2012 - December 31, 2012
HEALTH PLANS MEMBER SPOUSE CHILD CHILDREN
HealthChoice High $$449.48 $$ 668.10 $$228.20 $$352.08
HealthChoice High Alternative $$449.48 $$ 668.10 $$228.20 $$352.08
HealthChoice Basic $$391.64 $$ 571.84 $$201.82 $$310.80
HealthChoice Basic Alternative $$391.64 $$ 571.84 $$201.82 $$310.80
HealthChoice S-Account $$382.56 $$ 542.52 $$190.18 $$291.90
HealthChoice USA $$688.82 $$ 688.82 $$226.22 $$348.86
CommunityCare Standard HMO $$803.22 $$1,148.58 $$401.60 $$642.56
CommunityCare Alternative HMO $$553.96 $$ 792.14 $$276.98 $$443.16
CommunityCare Wellness Alternative Plus HMO $$528.96 $$ 792.14 $$276.98 $$443.16
GlobalHealth Standard HMO $$402.84 $$ 660.72 $$212.27 $$338.44
GlobalHealth Alternative HMO $$366.24 $$ 600.68 $$193.00 $$307.70
GlobalHealth Wellness Alternative Plus HMO $$341.24 $$ 600.68 $$193.00 $$307.70
UnitedHealthcare Standard HMO (formerly
PacifiCare) $$768.80 $$1,105.36 $$384.12 $$614.72
UnitedHealthcare Alternative HMO $$530.20 $$ 762.32 $$264.90 $$423.94
UnitedHealthcare Wellness Alternative Plus HMO $$505.20 $$ 762.32 $$264.90 $$423.94
DISABILITY (Employee only) $9.10 (Limited county participation only)
DENTAL PLANS MEMBER SPOUSE CHILD CHILDREN
HealthChoice Dental $$30.20 $$30.20 $$25.18 $$65.32
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 $$33.64 $$33.62 $$29.26 $$74.04
Delta Dental Premier $$38.36 $$38.36 $$33.38 $$84.46
Delta Dental PPO - Choice $$15.06 $$34.18 $$34.44 $$83.60
Before choosing a plan, it is very important that you review the list of network providers
available in your area for that plan. Although a plan may be available in your area, the
number of network providers may be limited. See the network provider listing on each plan’s
website or contact their customer service. See Help Lines on page 28 for contact information.
– IMPORTANT – IMPORTANT – IMPORTANT – IMPORTANT –
– IMPORTANT – IMPORTANT – IMPORTANT – IMPORTANT –
This publication was printed by the Oklahoma State and Education Employees Group Insurance Board, a division of the Office of
State Finance, as authorized by 74 O.S. Section 1301, et seq. 20,000 copies have been printed at a cost of $0.47 each. Copies
have been deposited with the Publications Clearinghouse of the Oklahoma Department of Libraries.
A text version of the Employee Benefit Options Guide is available on the OSEEGIB website at www.sib.
ok.gov or www.healthchoiceok.com. This Guide is also available in CD format at the Oklahoma Library for
the Blind and Physically Handicapped (OLBPH). Contact the OLBPH at 1-405-521-3514, toll-free 1-800-523-
0288, or TDD 1-405-521-4672.
The participating carriers reviewed and approved the information in this Guide. There is no guarantee that a
provider will remain within a plan’s network or have open patient slots throughout the year. Please verify your
provider’s participation in your plan’s network.
LIFE
HealthChoice Basic Life ($20,000) $4.00 First $20,000 of Supplemental Life $4.00
Age-Rated Supplemental Life – Cost Per $20,000
< 30 ---------- $0.60 45 - 49 ------- $2.00 65 - 69 ------- $10.20
30 - 34 ------- $0.60 50 - 54 ------- $3.40 70 - 74 ------- $17.40
35 - 39 ------- $0.80 55 - 59 ------- $5.40 75+ ----------- $27.00
40 - 44 ------- $1.20 60 - 64 ------- $6.20
Dependent Life Low Option $2.60 Standard Option $4.32 Premier Option $8.64
Spouse $$6,000 of coverage $$10,000 of coverage $$20,000 of coverage
Child (age 6 months to 26) $$3,000 of coverage $$ 5,000 of coverage $$10,000 of coverage
Child (live birth to 6 months) $$1,000 of coverage $$ 1,000 of coverage $$ 1,000 of coverage
VISION PLANS MEMBER SPOUSE CHILD CHILDREN
Humana/CompBenefits VisionCare Plan $$6.76 $$5.06 $$3.57 $$ 4.46
Primary Vision Care Services $$9.25 $$8.00 $$8.50 $$10.75
Superior Vision Plan $$7.14 $$7.10 $$6.72 $$13.80
UnitedHealthcare Vision $$8.18 $$5.79 $$4.59 $$ 6.98
Vision Service Plan (VSP) $$8.76 $$5.87 $$5.62 $$12.64
Oklahoma State and Education Employees Group Insurance Board
A Division of the Office of State Finance
Monthly Premiums for Current Employees
Plan Year January 1, 2012 - December 31, 2012
Table of Contents
2012 Plan Changes ............................................................................................ 1
Introduction ....................................................................................................... 4
General Enrollment Information ....................................................................... 5
Health Plans ...................................................................................................... 5
Dental Plans ...................................................................................................... 5
Vision Plans ...................................................................................................... 6
HealthChoice Life Insurance Plan .................................................................... 6
HealthChoice Disability Insurance Plan ........................................................... 7
American Fidelity Health Services Administration........................................... 8
Enrollment Periods ........................................................................................... 10
Eligibility .......................................................................................................... 10
HMO ZIP Code List .......................................................................................... 13
Comparison of Benefits for Health Plans ......................................................... 16
Comparison of Benefits for Dental Plans ......................................................... 24
Comparison of Benefits for Vision Plans .......................................................... 26
Help Lines ......................................................................................................... 28
This information is only a brief summary of the plans. All benefits and limitations of these plans are
governed in all cases by the relevant plan documents, insurance contracts, handbooks, and Rules of
the Oklahoma State and Education Employees Group Insurance Board, a division of the Office of State
Finance. 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.
www.sib.ok.gov or www.healthchoiceok.com
2012 PLAN CHANGES
Plan changes are indicated by bold text in the Comparison of Benefits charts.
Health Plan Changes
HealthChoice Health Plans
Each year, tobacco use costs the HealthChoice health plans and their members approximately $52
million. Because these costs affect the premiums of all health plan members, HealthChoice is encouraging
our members to stay or become tobacco-free by freezing the deductibles and out-of-pocket limits of the
HealthChoice High and Basic Plans at 2011 amounts for non-tobacco users. The HealthChoice High
Alternative and HealthChoice Basic Alternative Plans are being introduced for tobacco users. The individual
deductibles and out-of-pocket limits for these two plans are $250 higher than the High and Basic Plans.
To enroll or remain enrolled in the HealthChoice High or Basic Plan for Plan Year 2012, you must attest
that you and your covered dependents are tobacco-free by completing the HealthChoice High and Basic
Plans Tobacco-Free Attestation for Plan Year 2012 by November 15, 2011. The Attestation is available to you:
♦♦ Online at www.sib.ok.gov or www.healthchoiceok.com
♦♦ From your Insurance Coordinator
♦♦ By calling HealthChoice 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.
If you cannot complete the tobacco-free Attestation because you and/or your covered dependents are not
tobacco-free, you can still qualify for the HealthChoice High or HealthChoice Basic plan if you can show
proof of an attempt to quit using tobacco or provide a letter from your doctor. To qualify for the tobacco-free
plans, you must provide one of the following:
♦♦ A letter from Alere Wellbeing indicating you and/or your covered dependents have enrolled in the quit tobacco
program available through the Oklahoma Tobacco Settlement Endowment Trust (TSET) and Alere Wellbeing
within the previous 90 days.
♦♦ A letter from Alere Wellbeing indicating you and/or your covered dependents have completed the quit tobacco
program available through the Oklahoma Tobacco Settlement Endowment Trust (TSET) and Alere Wellbeing
within the previous 90 days.
♦♦ A letter from your doctor indicating it is not medically advisable for you or your covered dependents to quit
tobacco.
The letter from Alere Wellbeing or your doctor must be provided to HealthChoice, 3545 N.W. 58 Street, Suite
110, Oklahoma City, OK 73112 by November 15, 2011. Be sure to write your name and member ID number located
in Section A of your pre-printed Option Period Enrollment/Change Form on your letter. If you do not or cannot
complete the tobacco-free Attestation or provide one of the letters described previously, you and your covered
dependents will be enrolled in the new HealthChoice High Alternative Plan or Basic Alternative Plan.
HealthChoice High, High Alternative, Basic, Basic Alternative, S-Account, and USA Plans
♦♦ No limit on visits and treatment days for mental health and substance abuse.
♦♦ Non-Network emergency room visits will be covered at the Network benefit level; however, you are still
responsible for non-covered services and amounts over Allowed Charges.
♦♦ As an enhanced benefit for HealthChoice members, preventive procedures and many other services will be
covered at 100% of Allowed Charges with no out-of-pocket costs when using a Network Provider. This means
no-cost access to:
●● Blood pressure, diabetes, and cholesterol tests
●● Breast, cervical, prostate, and colorectal cancer screenings
●● Osteoporosis screening
●● Counseling from your health care provider on topics including quitting tobacco, losing weight, eating
healthy, treating depression, and reducing alcohol use
●● Prescription tobacco cessation products
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●● Vaccines for children and adults
●● Flu and pneumonia shots
●● Screening for obesity and counseling from your doctor and other health professionals to promote sustained
weight loss, including dietary counseling from your doctor
●● Screening for conditions that can harm pregnant women or their babies, including iron deficiency, hepatitis
B, a pregnancy related immune condition called Rh incompatibility, and a bacterial infection called
bacteriuria
●● Special, pregnancy-tailored counseling from a doctor to help pregnant women quit smoking and avoid
alcohol use
●● Counseling to support breast-feeding and help nursing mothers
See the HealthChoice website at www.sib.ok.gov or www.healthchoiceok.com for more details.
HealthChoice High, High Alternative, and USA Plans
♦♦ HealthChoice is implementing a family out-of-pocket limit for the HealthChoice High, High Alternative,
and USA Plans. The family out-of-pocket limit for the High and USA Plans will be $8,400 when using a
Network Provider and $9,900 when using a non-Network Provider. The family out-of-pocket limit for the
High Alternative Plan will be $9,150 when using a Network Provider and $10,650 when using a non-Network
provider.
HealthChoice S-Account Plan
♦♦ The out-of-pocket limits are being lowered to $3,000/individual and $6,000/family.
♦♦ Proof of a Health Savings Account (HSA) is not required to enroll.
♦♦ HealthChoice has contracted with American Fidelity Health Services Administration to make establishing
and keeping a Health Savings Account easier and more convenient for S-Account members. HSA deposits
are invested in a money market account and all interest is applied to your account. The monthly maintenance
fee is waived as long as you continue to be an employee of the state of Oklahoma. See pages 8-9 for more
information.
HealthChoice Pharmacy Benefit
♦♦ Two 90-day courses of certain prescription tobacco cessation products will be covered at 100% with no cost to
members.
♦♦ HealthChoice is introducing a mail order pharmacy benefit and changing the quantity of medication you can get
per copay. A 30-day supply of medication will be covered, when purchased at a retail pharmacy, for one copay.
A 90-day supply of a maintenance medication will be covered for one copay when purchased through Medco’s
mail order service or one of the Network Retail Maintenance Pharmacies. See the Comparison of Benefits for
Health Plans for copay amounts.
HMOs
CommunityCare Wellness Alternative Plus, GlobalHealth Wellness Alternative Plus, and UnitedHealthcare
Wellness Alternative Plus HMO Plans
♦♦ To be eligible for one of the Wellness Alternative Plus plans, you must complete the Health Risk Assessment
(HRA) available at www.sib.ok.gov or www.healthchoiceok.com. After completing the HRA, print the last
screen, which states you have completed it, and give it to your Insurance Coordinator with your Option Period
Enrollment/Change Form. If you completed the HRA as a HealthChoice member after July 1, 2011, you do not
have to complete it again, but you will have to give your enrollment/change form to your Insurance Coordinator
indicating which Wellness Alternative Plus plan you choose.
���♦ If you are a new employee and wish to enroll in one of the HMO Wellness Alternative Plus plans, you must first
enroll in the HMO’s Alternative plan. You then have until the end of your 30-day enrollment period to complete
the HRA, print the last screen, and return it to your Insurance Coordinator. Your enrollment in the Wellness
Alternative Plus plan will be effective the first of the month following the date you complete this process. If you
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Plan changes are indicated by bold text
in the Comparison of Benefits charts.
If you have questions about any of the plans,
contact each plan directly. See Help Lines
on page 28 of this Employee Benefit Options
Guide for contact information.
do not complete the process during this 30-day period, you will remain enrolled in the HMO Alternative plan
for the remainder of the plan year.
♦♦ HMO service areas have changed. See the HMO ZIP Code List on pages 13-15 to check your eligibility.
Life Plan Changes
HealthChoice Life Insurance
♦♦ You must submit a Life Insurance Application to enroll in or increase the amount of your life insurance.
♦♦ The maximum amount of Supplemental Life insurance you can carry is being increased to $500,000 regardless
of your salary.
Vision Plan Changes
Superior Vision Plan
♦♦ For in-Network services, there is a $25 fitting fee copay for standard and specialty fitting of contact lenses.
The Plan then pays 100% for standard fitting and up to $50 for specialty fitting. The fitting fee is not a covered
benefit when out-of-network.
UnitedHealthcare Vision
♦♦ UV coating and tinting will be covered in full when using in-Network providers.
Vision Service Plan (VSP)
♦♦ After a copay of up to $60, a contact lens exam is covered in full when using in-Network providers.
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There are no dental plan changes for 2012.
INTRODUCTION
The Oklahoma State and Education Employees Group Insurance Board (OSEEGIB), a division of the Office of
State Finance, produced this Employee Benefit Options Guide to help you select your benefits. It is a summary of the
available plans. The insurance benefits explained in this Guide are:
♦♦ Health
♦♦ Dental
♦♦ Vision
♦♦ Life
♦♦ Disability
See the Monthly Premium Chart and Comparison of Benefits charts to determine your costs under each plan.
Helpful Hints For Option Period
♦♦ Review Section B of your pre-printed Option Period Enrollment/Change Form. This is the coverage you will
have effective January 1, 2012, if you do not make changes during Option Period.
♦♦ Contact your Insurance Coordinator if you have questions about your current coverage.
♦♦ Review the plan changes for 2012 starting on page 1 of this Guide.
♦♦ Ask your Insurance Coordinator about returning your form even if you are not making changes.
♦♦ Use the following resources to help you decide on coverage for you and your dependents for 2012:
♦♦ Complete your Option Period Enrollment/Change Form and return it to your Insurance Coordinator by the
deadline set by your coordinator.
♦♦ Review your Confirmation Statement when you receive it in the mail to verify your coverage is correct.
♦♦ Contact your Insurance Coordinator right away if your Confirmation Statement is incorrect. If you do not make
changes to your coverage and you are not automatically enrolled in one of the HealthChoice alternative
plans (see page 1), you will not receive a Confirmation Statement from OSEEGIB. Keep a copy of your
Option Period Enrollment/Change Form as verification of your insurance coverage.
Helpful Hints For New Employees
♦♦ Use the following resources to help you decide on coverage for you and your dependents:
♦♦ Complete your Insurance Enrollment Form and return it to your Insurance Coordinator by the deadline set by
your coordinator.
♦♦ Review your Confirmation Statement when you receive it in the mail to verify your coverage is correct.
♦♦ Contact your Insurance Coordinator right away if your Confirmation Statement is incorrect.
●● This Guide ●● Provider Directories
●● Plan Websites ●● OSEEGIB Member Services
●● Customer Service Telephone Numbers ●● Your Insurance Coordinator
●● This Guide ●● Provider Directories
●● Plan Websites ●● OSEEGIB Member Services
●● Customer Service Telephone Numbers ●● Your Insurance Coordinator
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GENERAL ENROLLMENT INFORMATION
Your employer determines which benefits are available to you and may not participate in all the benefits
explained in this Guide. Ask your Insurance Coordinator which benefits are available to you.
The benefits you select will be in effect from January 1, 2012, or for new employees, the effective date of
your coverage, through December 31, 2012.
After enrollment, the plans you have selected will provide more information about your benefits.
Once enrolled in any of the plans, it is your responsibility to review your benefits carefully so you know
what is covered, as well as the plan’s policies and procedures, before you use your benefits.
HEALTH PLANS
There are 15 health plans available:
●● HealthChoice High and High Alternative
Plans
●● CommunityCare Standard, Alternative, and
Wellness Alternative Plus HMO
●● HealthChoice Basic and Basic Alternative
Plans
●● GlobalHealth Standard, Alternative, and Wellness
Alternative Plus HMO
●● HealthChoice S-Account Plan ●● UnitedHealthcare Standard, Alternative, and
●● HealthChoice USA Plan* Wellness Alternative Plus HMO
See Comparison of Benefits for Health Plans on pages 16-23 for specific benefit information.
♦♦ There are no preexisting condition exclusions or limitations applied to any of the health plans.
♦♦ To be eligible for the HealthChoice High or Basic Plan, you must complete the tobacco-free Attestation
located on the OSEEGIB website.
♦♦ You must live or work within an HMO’s ZIP Code service area to be eligible. Post Office Box
addresses cannot be used to determine your HMO eligibility. See pages 13-15 for the HMO ZIP Code
List.
♦♦ If you select an HMO, you must use the provider network designated by your plan for Oklahoma.
♦♦ You must complete the HRA through the OSEEGIB website to enroll in an HMO Wellness Alternative
Plus plan.
♦♦ All health plans coordinate benefits with other group insurance plans you have in force. For more
information, check with each health plan.
♦♦ All plans have toll-free numbers for customer service. See Help Lines on page 28.
♦♦ Check with the individual health plan if you have benefit questions.
*The HealthChoice USA Plan is designed for employees who receive a work assignment of more than 90 consecutive days outside of
Oklahoma and Arkansas. Call HealthChoice Member Services for more details.
DENTAL PLANS
Verify your employer offers dental coverage through OSEEGIB.
There are eight dental plans available:
●● HealthChoice Dental ●● CIGNA Dental Care Plan (Prepaid)
●● Assurant Freedom Preferred ●● Delta Dental PPO
●● Assurant Heritage Plus with SBA (Prepaid) ●● Delta Dental Premier
●● Assurant Heritage Secure (Prepaid) ●● Delta Dental PPO – Choice
See Comparison of Benefits for Dental Plans on pages 24-25 for specific benefit information.
♦♦ All dental plans have toll-free numbers for customer service. See Help Lines on page 28.
♦♦ Check with the individual dental plan if you have benefit questions.
VISION PLANS
Verify your employer offers vision coverage through OSEEGIB.
There are five vision plans available:
●● Humana/CompBenefits VisionCare Plan ●● UnitedHealthcare Vision
●● Primary Vision Care Services (PVCS) ●● Vision Service Plan (VSP)
●● Superior Vision Plan
See Comparison of Benefits for Vision Plans on pages 26-27 for specific benefit information.
♦♦ Verify your vision provider participates in a vision plan’s network by contacting the plan, visiting the
plan’s website, or calling your provider.
♦♦ All vision plans have limited coverage for services provided by out-of-network providers.
♦♦ All plans have toll-free numbers for customer service. See Help Lines on page 28.
♦♦ Check with the individual vision plan if you have benefit questions.
Thinking About Retirement?
If you are a current employee who is retiring before January 1, 2012, please contact OSEEGIB Member
Services and request the appropriate materials. You will select your benefits from either the former pre-Medicare
Option Period guide or the Medicare Option Period guide. To contact Member Services, refer to Help Lines on
page 28.
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If your provider leaves your health, dental, or vision plan, you cannot change plans
until the next annual Option Period; however, you may change providers within your
plan’s Network as needed.
HEALTHCHOICE LIFE INSURANCE PLAN
Verify your employer offers HealthChoice Life Insurance through OSEEGIB.
♦♦ As a new employee, you can elect life insurance coverage within 30 days of your employment date or
the date you become eligible. You can enroll in a limited amount of coverage, known as Guaranteed
Issue, without an approved Life Insurance Application. All requests for coverage above Guaranteed
Issue require an approved Life Insurance Application.
♦ As a current employee, if you did not enroll when first eligible, you can enroll:
●● During the annual Option Period. An approved Life Insurance Application is required to enroll in or
increase life insurance coverage.
●●Within 30 days of a midyear qualifying event. An approved Life Insurance Application is required.
●●Within 30 days of the loss of other group life coverage. You can enroll in the amount of coverage
you lost, rounded up to the next $20,000 unit, without a Life Insurance Application. Proof of loss is
required.
Basic Life Insurance. . . For You
♦♦ Basic Life pays a benefit of $20,000 to your beneficiary in the event of your death.
♦♦ Basic Life includes Accidental Death and Dismemberment (AD&D) coverage. This coverage pays an
additional $20,000 to your beneficiary if your death is due to an accident. It also pays benefits if you lose
your sight or a limb due to an accident.
Supplemental Life Insurance . . . For You
♦♦ At the time of initial enrollment, you can purchase Supplemental Life coverage in an amount equal to
two times your annual salary, rounded up to the next $20,000. This amount, known as Guaranteed
Issue, is available without an approved Life Insurance Application.
Dependent Life Insurance . . . For Your Family
♦♦ If you enroll in Basic Life insurance, you can purchase Dependent Life insurance for your spouse and
eligible dependents during your initial enrollment, during the annual Option Period, or within 30 days of
the loss of other group life insurance or other midyear qualifying event.
♦♦ Dependent Life does not include AD&D coverage.
♦♦ There are three options for Dependent Life coverage: Low, Standard, or Premier Option. Regardless of
the number of dependents, the monthly premium is the same. Each eligible dependent must be enrolled
in Dependent Life.
♦♦ A Life Insurance Application is not required for Dependent Life coverage.
DEPENDENT LOW OPTION STANDARD OPTION PREMIER OPTION
Spouse $6,000 of coverage $10,000 of coverage $20,000 of coverage
Child (age 6 months to 26) $3,000 of coverage $ 5,000 of coverage $10,000 of coverage
Child (live birth to 6 months) $1,000 of coverage $ 1,000 of coverage $ 1,000 of coverage
Beneficiary Designation
Benefits are paid to your beneficiary in a lump sum. You must name your beneficiary or beneficiaries when
you enroll. Your beneficiary designation can be changed at any time. For a Beneficiary Designation Form or
more information, contact your Insurance Coordinator. This form is also available on the HealthChoice website
at www.sib.ok.gov or www.healthchoiceok.com. Be aware that life insurance benefits for covered dependents
are always paid to the member.
HEALTHCHOICE DISABILITY INSURANCE PLAN
Verify your employer offers HealthChoice Disability Insurance through OSEEGIB (limited
county participation only).
The HealthChoice Disability Insurance Plan provides partial replacement income if you are unable to work
due to an illness or injury. Disability coverage is not available to dependents.
Eligibility
Enrollment in the disability plan begins the first day of the month following your employment date or the
date you become eligible. You become eligible for disability benefits after 31 consecutive days of employment.
During that time, you must continuously perform all of the material duties of your regular occupation. Any
claim for disability benefits must be filed within one year of the date your disability began.
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♦♦ You may purchase Supplemental Life in units of $20,000. The maximum amount of Supplemental
Life coverage available is $500,000, regardless of your salary. You must complete a Life Insurance
Application to apply for coverage.
♦♦ The first $20,000 unit of Supplemental Life provides an additional $20,000 of AD&D coverage.
♦♦ A Life Insurance Application is available from your Insurance Coordinator.
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HEALTH SAVINGS ACCOUNTS
A Health Savings Account (HSA) is an individually owned savings account that allows you to set aside money
for health care tax-free whenever you select an HSA qualified High Deductible Health Plan (HDHP). Money left in
the account can accumulate interest tax-free and money used to pay for qualified medical expenses can be paid tax-free.
Through your employer’s Section 125 plan, you can make HSA contributions on a pre-tax basis up to the yearly
maximum allowed.
SOME HIGHLIGHTS OF HSAs
♦♦ HSA contributions are tax-free.
♦♦ Interest accrues tax-free.
♦♦ Interest earned is applied to your account starting with the first dollar contribution.
♦♦ Withdrawals are not taxed when funds are used for qualified medical expenses.
♦♦ You decide when and how to use your money.
♦♦ No “use it or lose it” requirement meaning whatever deposits you make each year can be left in the HSA to earn
interest and to be available to pay for future medical expenses.
♦♦ You can pay for qualified medical expenses on yourself, your spouse, or your tax dependents regardless of
whether or not they are covered by your health plan.
♦♦ No matter where you go, your account follows you. Even if you change jobs, change medical coverage, become
unemployed, move to another state, or change your marital status, your HSA goes with you. You own it!
♦♦ If you do not remain a qualified individual, you can continue to earn interest and pay for qualified medical
expenses as long as there are funds in your account.
CONTRIBUTIONS
You can contribute up to the annual maximum amount allowed by law in any given tax-year. The IRS establishes
the maximum amounts on an annual basis. The 2011 maximum allowable is $3,050 for an individual or $6,150 for a
family. Effective January 1st 2012 the maximum allowable will increase to $3,100 for an individual or $6,250 for a
family. If your HDHP is effective on a date other than January 1 and you wish to make the maximum contribution, you
must meet certain requirements. Visit www.afhsa.com for more information.
If you are age 55 and older, you are eligible to make an additional catch-up contribution of $1,000 per year. An
HSA is owned by one individual, so if you and your spouse are covered under the family HDHP and both of you
are age 55 or older, only you as the owner of the account can make the catch up contribution. Your spouse would be
required to establish his or her own HSA to make catch-up contributions.
QUALIFIED MEDICAL EXPENSES
There are many expenses that qualify for tax-free distributions. For a listing, you can refer to the HSA Eligible
Expenses listed on www.afhsa.com. If you use funds for any expenses that are not eligible, then the funds withdrawn
are subject to income taxes and a 20% additional tax penalty. The non-qualified distributions must be reported on your
annual income tax return.
Additional information on eligible expenses can be found in IRS Publication 502 at www.irs.gov. Even though
Publication 502 is a valuable resource on what qualifies as a medical expense, it addresses only what expenses are
deductible.
MAKING WITHDRAWALS FROM YOUR HSA
You can withdraw funds from your account in three ways:
1. HSA Debit Card
2. On-Line Distribution Request
3. Distribution Form
SB-22136(State of Oklahoma)-0811
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You can use the money from your HSA as follows:
1. You can only use the funds that have been deposited.
2. You can withdraw funds for qualified medical expenses incurred after the date your account is established.
3. You may elect to make withdrawals from your HSA when expenses are incurred, or you may make
withdrawals for these expenses anytime in the future. There is no time limit.
In order to receive the tax benefit, the IRS requires that you keep records to prove that your HSA funds were used
to pay for qualified medical expenses and that the qualified expense was not reimbursed from another source. Although
you are not required to send your receipts with your tax returns, keeping your receipts with your tax information is an
excellent way to ensure proper documentation. You will receive two forms each year as a result of having an HSA: 1) a
1099-SA which shows the total distributions from your account will be mailed by January 31, and 2) a 5498-SA which
shows total contributions to your account will be mailed by May 31. Each of these forms will also be sent to the IRS.
ELIGIBILITY REQUIREMENTS
To be eligible to establish and contribute to an HSA, you must meet the following requirements:
1. You must be covered by an HSA-qualified HDHP.
2. You cannot be claimed as a dependent on anyone else’s tax return.
3. You cannot be covered under a non-HDHP coverage other than “permitted coverage” or “permitted
insurance” and/or preventative care. Products such as Cancer, Accident, Long Term Care, and Disability
Income are usually considered permitted coverage/insurance. Check with your employer or visit www.irs.
gov to be sure.
4. You cannot have a general purpose Health FSA-Medical Reimbursement Account. However, you can have a
Limited Purpose Health FSA which allows for dental and vision reimbursement only should your employer
offer this benefit. Note: If you are covered under your spouse’s general purpose Health FSA, then you are not
eligible to establish and contribute to an HSA.
5. You cannot be enrolled in Medicare.
INTEREST & ACCOUNT FEES
HSA deposits are invested in a money market account and all interest is applied to your account. The monthly
maintenance fee is waived as long as you continue to be employed by the State of Oklahoma. This fee covers unlimited
account withdrawals, the debit card, and other investment funds for balances above the minimum $2,500 required in the
money market account. A $15 fee will also apply for an additional or replacement debit card.
SUMMARY
HSAs give you the savings potential, flexibility, portability, and tax savings unlike any other savings account.
By enrolling in a qualified HDHP, you save on premiums. By investing those savings into an HSA, you can save for
medical expenses in the future.
Individuals who elect an HSA with us will receive a welcome packet outlining all the information associated with
the account. This flyer is meant to provide you high level information on HSAs. For more information on HSAs visit
our website at www.afhsa.com. There you will find an overview specific to employees/individuals along with other
helpful information. You can also find additional information about HSAs in the IRS Publication 969 at www.irs.gov.
CONTACT INFORMATION
American Fidelity Health Services Administration Toll-Free - 1-866-326-3600
2000 N. Classen Blvd, Suite G16 Fax - (405) 523-5072
Oklahoma City, OK 73125 Web site - www.afhsa.com
(405) 523-5699 – Local Number email - HSA-Suppost@af-group.com
American Fidelity Health Services Administration and its affiliates do not provide legal or tax advice. The information provided here is general in nature and
should not be considered legal or tax advice. We recommend you consult with your tax or legal counsel about your personal situation.
SB-22136(State of Oklahoma)-0811
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ENROLLMENT PERIODS
Option Period Enrollment – Coverage effective January 1, 2012
This is the time when eligible employees can:
●● Enroll in plans
●● Change plans or drop coverage
●● Increase or decrease life insurance coverage
●● Add or drop eligible family members from coverage
♦♦ You can enroll in health, dental, life, and/or vision coverage for yourself and/or your dependent(s) during the
annual Option Period, as long as you have not dropped that coverage within the past 12 months. If you have
dropped coverage within the past 12 months, limitations and/or exceptions may apply.
Initial Enrollment – Coverage effective the first of the month following your employment
date or the date set by your employer
This is the time when new employees are eligible to:
●● Enroll in plans
●● Enroll eligible dependents
●● Apply for life insurance coverage above Guaranteed Issue
♦♦ As a new employee, you have 30 days from your employment date, or the date you become eligible, to enroll in
coverage. If you do not enroll within 30 days, you cannot enroll until the next annual Option Period unless you
experience a qualifying event. Check with your Insurance Coordinator for more information.
♦♦ You have 30 days following your eligibility date to make changes to your original enrollment.
♦♦ You have 30 days following your eligibility date to complete the HRA if you want to enroll in one of the HMO
Wellness Alternative Plus plans.
♦♦ If you request life insurance coverage in an amount greater than two times your annual salary, known as
Guaranteed Issue, you must complete and submit a Life Insurance Application for approval. See your Insurance
Coordinator for an application.
♦♦ Keep a copy of your Insurance Enrollment Form for your records.
Midyear Changes – Coverage generally effective the first of the month following a
qualifying event
♦♦ Midyear plan changes are allowed only when a qualifying event such as birth, marriage, or loss of other
group coverage occurs. You must complete an Insurance Change Form within 30 days of the event. See your
Insurance Coordinator for more information.
ELIGIBILITY
Members
♦♦ Your employer must participate in the plans offered through OSEEGIB.
♦♦ You must be a current Education employee eligible to participate in the Oklahoma Teachers’ Retirement System
working a minimum of four hours per day or 20 hours per week, or a current State of Oklahoma or Local
Government employee regularly scheduled to work at least 1,000 hours a year and not classified as a temporary
or seasonal employee.
♦♦ You must be enrolled in a group health plan to enroll in dental and/or life insurance.
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Dependents
♦♦ If one eligible dependent is covered, all eligible dependents must be covered. You can choose not to cover
dependents who do not reside with you, are married, are not financially dependent on you for support, or have
other group coverage. Eligible dependents include:
●● Your legal spouse (including common-law).
●● Your daughter, son, stepdaughter, stepson, eligible foster child, adopted child, or child legally placed with
you for adoption up to age 26, whether married or unmarried.
●● A dependent, regardless of age, who is incapable of self-support due to a disability that was diagnosed prior
to age 26. Subject to medical review and approval.
●● Other unmarried dependent children up to age 26, upon completion of an Application for Coverage for
Other Dependent Children. Guardianship papers or a tax return showing dependency may be provided in
lieu of the application.
♦♦ If your spouse is enrolled separately in one of the OSEEGIB plans, your dependents can be covered under one
parent’s health, dental, and/or vision plan (but not both); however, both parents can cover dependents under
Dependent Life insurance.
♦�� Dependents who are not enrolled within 30 days of your eligibility date cannot be enrolled until the next annual
Option Period, unless a qualifying event such as birth, marriage, or loss of other group coverage occurs. If
eligible dependents are dropped from coverage, you cannot re-enroll them for a minimum of 12 months. The
12-month requirement does not apply when dependents lose other group health, dental, vision, and/or life
insurance coverage and are seeking reinstatement of coverage through OSEEGIB.
♦♦ Dependents can only be enrolled in the same types of coverage and in the same plans you enroll in.
♦♦ To enroll your newborn, an Insurance Change Form must be provided to your Insurance Coordinator within 30
days of the birth. If you do not enroll your newborn during this 30-day period, you cannot do so until the next
annual Option Period. Direct notification to a plan will not enroll your newborn or any other dependents. The
newborn’s Social Security number is not required at the time of initial enrollment, but must be provided once it
is received from the Social Security Administration. Insurance premiums for the month the child was born must
be paid. Under the HealthChoice plans, a separate deductible and coinsurance may apply.
♦♦ Without enrollment, newborns are covered only for the first 48 hours following a vaginal birth or the first 96
hours following a cesarean section birth. Deductible and coinsurance may apply.
Excluding Dependents From Coverage
♦ You can exclude your spouse from health and/or dental coverage while covering other dependents on these
benefits. Your spouse must sign the Spouse Exclusion Certification section of the enrollment or change form.
♦ You can exclude your spouse or other dependents who do not reside with you, are married, are not financially
dependent on you for support, have other group coverage, or are eligible for Indian or military health benefits.
Note: Your spouse cannot be excluded from vision coverage if your other dependents are covered unless your
spouse has proof of other group vision coverage.
Confirmation Statement
♦♦ You are mailed a Confirmation Statement (CS) when you enroll or make changes to your coverage. Your CS
lists the coverage you are enrolled in, the effective date of your coverage, and the premium amounts.
♦♦ Always review your CS to verify your coverage is correct. Corrections to your coverage must be submitted to
your Insurance Coordinator within 60 days of your election. Corrections reported after 60 days are effective the
first of the month following notification.
♦♦ Section B of your Option Period Enrollment/Change Form lists the coverage you will have effective January
1, 2012, if you don’t make changes during Option Period and you are not automatically enrolled in one of the
HealthChoice alternative plans (see page 1). If you don’t make changes and you are not automatically enrolled
in one of the HealthChoice alternative plans, you will not receive a CS from OSEEGIB. Keep a copy of your
Option Period Enrollment/Change Form as verification of your coverage.
12
Transfer Employee
♦♦ You can keep your coverage continuous when you move from one participating employer to another as long as
there is no break in coverage that lasts longer than 30 days. Premiums must be paid upon reporting to work.
♦♦ Benefit options vary from employer to employer. Changes to your coverage must be made within the first 30
days of your transfer. See your Insurance Coordinator for more information.
Termination of Coverage
♦♦ Coverage will end the last day of the month in which a termination event occurs. Examples of termination
events include:
●● Loss of employment
●● Loss of dependent eligibility
●● Non-payment of premiums
●● Death
COBRA – Temporary Continuation of Coverage
♦♦ The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) allows you and/or your dependents
to continue health, dental, and/or vision insurance coverage after your employment terminates or after your
dependent loses eligibility. Certain time limits apply to enrollment. Contact your Insurance Coordinator
immediately upon termination of your employment, or when changes to your family status occur, to find out
more about your COBRA rights. Be aware, dropping dependent coverage during Option Period is not a
COBRA qualifying event.
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HMO ZIP Code List
C = CommunityCare G = GlobalHealth U = UnitedHealthCare
continued on next page
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72761 C G 73039 G U 73079 G U 73118 C G U 73160 C G U 73437 G U 73528 G U
73001 G U 73040 G U 73080 G U 73119 C G U 73162 C G U 73438 G U 73529 G U
73002 G U 73041 G U 73081 G U 73120 C G U 73163 C G U 73439 G U 73530 G U
73003 C G U 73042 G U 73082 G U 73121 C G U 73164 C G U 73440 G U 73531 G U
73004 G U 73043 G U 73083 C G U 73122 C G U 73165 C G U 73441 G U 73532 G U
73005 G U 73044 C G U 73084 C G U 73123 C G U 73167 C G U 73442 G U 73533 G U
73006 G U 73045 C G U 73085 C G U 73124 C G U 73169 C G U 73443 G U 73534 G U
73007 C G U 73046 G U 73086 G U 73125 C G U 73170 C G U 73444 G U 73536 G U
73008 C G U 73047 G U 73087 G U 73126 C G U 73172 C G U 73446 G U 73537 G U
73009 G U 73048 G U 73088 G U 73127 C G U 73173 C G U 73447 G U 73538 G U
73010 G U 73049 C G U 73089 G U 73128 C G U 73175 G 73448 G U 73539 G U
73011 G U 73050 C G U 73090 C G U 73129 C G U 73177 C G U 73449 G U 73540 G U
73012 G U 73051 C G U 73091 G U 73130 C G U 73178 C G U 73450 G U 73541 G U
73013 C G U 73052 G U 73092 G U 73131 C G U 73179 C G U 73451 G 73542 G U
73014 C G U 73053 G U 73093 G U 73132 C G U 73180 C G U 73453 G U 73543 G U
73015 G U 73054 C G U 73094 G U 73134 C G U 73184 C G U 73455 G U 73544 G U
73016 G U 73055 G U 73095 G U 73135 C G U 73185 C G U 73456 G U 73546 G U
73017 G U 73056 C G U 73096 G U 73136 C G U 73189 C G U 73458 G U 73547 G U
73018 G U 73057 G U 73097 C G U 73137 C G U 73190 C G U 73459 G U 73548 G U
73019 C G U 73058 C G U 73098 G U 73139 C G U 73193 C G U 73460 G U 73549 G U
73020 C G U 73059 G U 73099 C G U 73140 C G U 73194 C G U 73461 G U 73550 G U
73021 G U 73061 C G U 73100 C G U 73141 C G U 73195 C G U 73463 G U 73551 G U
73022 C G U 73062 G U 73101 C G U 73142 C G U 73196 C G U 73476 G U 73552 G U
73023 G U 73063 C G U 73102 C G U 73143 C G U 73197 C G U 73481 G U 73553 G U
73024 G U 73064 C G U 73103 C G U 73144 C G U 73198 C G U 73487 G U 73554 G U
73025 G U 73065 G U 73104 C G U 73145 C G U 73199 C G U 73488 G U 73555 G U
73026 C G U 73066 C G U 73105 C G U 73146 C G U 73210 G 73491 G U 73556 G U
73027 C G U 73067 G U 73106 C G U 73147 C G U 73251 G 73501 G U 73557 G U
73028 C G U 73068 C G U 73107 C G U 73148 C G U 73401 G U 73502 G U 73558 G U
73029 G U 73069 C G U 73108 C G U 73149 C G U 73402 G U 73503 G U 73559 G U
73030 G U 73070 C G U 73109 C G U 73150 C G U 73403 G U 73505 G U 73560 G U
73031 G U 73071 C G U 73110 C G U 73151 C G U 73422 G 73506 G U 73561 G U
73032 G U 73072 C G U 73111 C G U 73152 C G U 73425 G U 73507 G U 73562 G U
73033 G U 73073 C G U 73112 C G U 73153 C G U 73430 G U 73520 G U 73564 G U
73034 C G U 73074 G U 73113 C G U 73154 C G U 73432 G U 73521 G U 73565 G U
73035 G U 73075 G U 73114 C G U 73155 C G U 73433 G U 73522 G U 73566 G U
73036 C G U 73076 G U 73115 C G U 73156 C G U 73434 G U 73523 G U 73567 G U
73037 C G 73077 C G U 73116 C G U 73157 C G U 73435 G U 73526 G U 73568 G U
73038 G U 73078 C G U 73117 C G U 73159 C G U 73436 G U 73527 G U 73569 G U
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HMO ZIP Code List
C = CommunityCare G = GlobalHealth U = UnitedHealthCare
73570 G U 73666 G U 73750 G U 73858 G U 74023 C G U 74070 C G U 74131 C G U
73571 G U 73667 G U 73753 G U 73859 G U 74026 G U 74071 C G U 74132 C G U
73572 G U 73668 G U 73754 G U 73860 G U 74027 C G U 74072 C G U 74133 C G U
73573 G U 73669 G U 73755 G U 73901 G U 74028 C G U 74073 C G U 74134 C G U
73575 G U 73673 G U 73756 G U 73931 G U 74029 C G U 74074 C G U 74135 C G U
73589 G 73701 G U 73757 C G U 73932 G U 74030 C G U 74075 C G U 74136 C G U
73601 G U 73702 G U 73758 G U 73933 G U 74031 C G U 74076 C G U 74137 C G U
73597 G 73703 G U 73759 G U 73937 G U 74032 C G U 74077 C G U 74138 G
73620 G U 73705 G U 73760 G U 73938 G U 74033 C G U 74078 C G U 74141 C G U
73622 G U 73707 G 73761 G U 73939 G U 74034 C G U 74079 G U 74145 C G U
73624 G U 73706 G U 73762 G U 73942 G U 74035 C G U 74080 C G U 74146 C G U
73625 G U 73716 G U 73763 G U 73944 G U 74036 C G U 74081 C G U 74147 C G U
73626 G U 73717 G U 73764 G U 73945 G U 74037 C G U 74082 C G U 74148 C G U
73627 G U 73718 G U 73766 G U 73946 G U 74038 C G U 74083 C G U 74149 C G U
73628 G U 73719 G U 73768 G U 73947 G U 74039 C G U 74084 C G U 74150 C G U
73632 G U 73720 G U 73770 G U 73949 G U 74041 C G U 74085 C G U 74152 C G U
73637 G 73722 G U 73771 G U 73950 G U 74042 C G U 74100 G U 74153 C G U
73638 G U 73724 G U 73772 G U 73951 G U 74043 C G U 74101 C G U 74155 C G U
73639 G U 73725 GU 73773 G U 74001 C G U 74044 C G U 74102 C G U 74156 C G U
73641 G U 73726 G U 73801 G U 74002 C G U 74045 C G U 74103 C G U 74157 C G U
73642 G U 73727 G U 73802 G U 74003 C G U 74046 C G U 74104 C G U 74158 C G U
73644 G U 73728 G U 73820 G 74004 C G U 74047 C G U 74105 C G U 74159 C G U
73645 G U 73729 G U 73832 G U 74005 C G U 74048 C G U 74106 C G U 74169 C G U
73646 G U 73730 G U 73834 G U 74006 C G U 74050 C G U 74107 C G U 74170 C G U
73647 G U 73731 G U 73835 G U 74008 C G U 74051 C G U 74108 C G U 74171 C G U
73648 G U 73733 G U 73838 G U 74009 C G U 74052 C G U 74110 C G U 74172 C G U
73650 G U 73734 G U 73840 G U 74010 C G U 74053 C G U 74112 C G U 74182 C G U
73651 G U 73735 G U 73841 G U 74011 C G U 74054 C G U 74114 C G U 74183 C G U
73654 G U 73736 G U 73842 G U 74012 C G U 74055 C G U 74115 C G U 74184 C G U
73655 G U 73737 G U 73843 G U 74013 C G U 74056 C G U 74116 C G U 74186 C G U
73656 G U 73738 G U 73844 G U 74014 C G U 74058 C G U 74117 C G U 74187 C G U
73657 G 73739 G U 73847 G U 74015 C G U 74059 C G U 74119 C G U 74189 C G U
73658 G U 73741 G U 73848 G U 74016 C G U 74060 C G U 74120 C G U 74192 C G U
73659 G U 73742 G U 73849 G U 74017 C G U 74061 C G U 74121 C G U 74193 C G U
73660 G U 73743 G U 73851 G U 74018 C G U 74062 C G U 74126 C G U 74194 C G U
73661 G U 73744 G U 73852 G U 74019 C G U 74063 C G U 74127 C G U 74301 C G U
73662 G U 73746 G U 73853 G U 74020 C G U 74066 C G U 74128 C G U 74306 G
73663 G U 73747 G U 73855 G U 74021 C G U 74067 C G U 74129 C G U 74317 G
73664 G U 73749 G U 73857 G U 74022 C G U 74068 C G U 74130 C G U 74330 C G U
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C = CommunityCare G = GlobalHealth U = UnitedHealthCare
74331 G U 74421 C G U 74466 C G U 74559 C G U 74722 G U 74825 G U 74877 C G
74332 C G U 74422 C G U 74467 C G U 74560 C G U 74723 G U 74826 C G U 74878 C G U
74333 C G U 74423 C G U 74468 C G U 74561 C G U 74724 G U 74827 G U 74880 C G U
74335 C G U 74425 C G U 74469 C G U 74562 C G U 74726 G U 74829 G U 74881 G U
74336 C G 74426 C G U 74470 C G U 74563 C G U 74727 C G U 74830 C G U 74883 G U
74337 C G U 74427 C G U 74471 C G U 74565 C G U 74728 G U 74831 G U 74884 C G U
74338 C G 74428 C G U 74472 C G U 74567 C G U 74729 G U 74832 G U 74901 C G
74339 C G U 74429 C G U 74477 C G U 74569 G U 74730 G U 74833 G U 74902 C G
74340 C G U 74430 C G U 74501 C G U 74570 C G U 74731 G U 74834 G U 74930 C G
74342 C G 74431 C G U 74502 C G U 74571 C G U 74733 G U 74836 G U 74931 C G
74343 C G U 74432 C G U 74521 C G U 74572 G U 74734 G U 74837 C G U 74932 C G
74344 C G 74434 C G U 74522 C G U 74574 C G U 74735 C G U 74838 C G 74935 C G
74345 G 74435 C G 74523 C G U 74576 C G U 74736 G U 74839 G U 74936 C G
74346 C G 74436 C G U 74525 G U 74577 C G 74737 G U 74840 C G U 74937 C G
74347 C G 74437 C G U 74526 C G U 74578 C G U 74738 C G U 74842 G U 74939 C G
74349 C G U 74438 C G U 74528 C G U 74601 G U 74740 G U 74843 G U 74940 C G
74350 C G U 74439 G U 74529 C G U 74602 G U 74741 G U 74844 G U 74941 C G U
74352 C G U 74440 C G U 74530 G U 74603 G U 74743 C G U 74845 C G U 74942 C G
74353 C G U 74441 C G U 74531 G U 74604 G U 74745 G U 74848 G U 74943 C G U
74354 C G U 74442 C G U 74533 G U 74630 C G U 74747 G U 74849 C G U 74944 C G U
74355 C G U 74444 C G U 74534 G U 74631 G U 74748 G U 74850 G U 74945 C G
74358 C G U 74445 C G U 74535 G U 74632 G U 74750 G U 74851 C G U 74946 C G
74359 C G 74446 C G U 74536 C G U 74633 C G U 74752 G U 74852 C G U 74947 C G
74360 C G U 74447 C G U 74538 G U 74636 G U 74753 G U 74854 C G U 74948 C G
74361 C G U 74450 C G U 74540 G U 74637 C G U 74754 G U 74855 G U 74949 C G
74362 C G U 74451 C G U 74542 G U 74640 G U 74755 G U 74856 G U 74951 C G
74363 C G U 74452 C G U 74543 C G U 74641 G U 74756 G C U 74857 C G U 74953 C G
74364 C G U 74454 C G U 74545 C G U 74643 G U 74759 C G U 74859 G U 74954 C G
74365 C G U 74455 C G U 74546 C G U 74644 C G U 74760 C G U 74860 G U 74955 C G
74366 C G U 74456 C G U 74547 C G U 74646 G U 74761 C G U 74864 G U 74956 C G
74367 C G U 74457 C G 74548 C G U 74647 G U 74764 G U 74865 G U 74957 C G U
74368 C G 74458 C G U 74549 C G 74650 C G U 74766 G U 74866 C G U 74959 C G
74369 C G U 74459 C G U 74552 C G U 74651 C G U 74801 C G U 74867 C G U 74960 C G
74370 C G U 74460 C G U 74553 C G U 74652 C G U 74802 C G U 74868 C G U 74962 C G
74401 C G U 74461 C G U 74554 C G U 74653 C G U 74804 C G U 74869 G U 74963 G U
74402 C G U 74462 C G U 74555 G U 74701 G U 74818 C G U 74871 G U 74964 C G
74403 C G U 74463 C G U 74556 G U 74702 G U 74820 G U 74872 G U 74965 C G
74406 G 74464 C G U 74557 C G U 74720 G U 74821 G U 74873 C G U 74966 C G
74408 G 74465 C G U 74558 C G U 74721 G U 74824 G U 74875 G U
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Plan Year 2012 Comparison Chart 16
COMPARISON OF BENEFITS FOR HEALTH PLANS
Your Costs
for Network
Services
HealthChoice
High, High Alternative,
and USA Plans
HealthChoice
Basic and Basic
Alternative Plans
HealthChoice
S-Account Plan
Calendar Year
Deductibles
High and USA Plans
$500 individual
$1,500 family
Basic Plan
$500 individual
$1,000 family
Applies after Plan pays first $500
of Allowed Charges
$1,500 individual
$3,000 family
The combined medical and
pharmacy deductible must be
High Alternative Plan met before benefits are paid
$750 individual
$2,250 family
Basic Alternative Plan
$750 individual
$1,500 family
Applies after Plan pays first
$250 of Allowed Charges
Calendar Year
Out-of-Pocket
Limit
High and USA Plans
$2,800 Network individual
$8,400 Network family
$3,300 non-Network individual
$9,900 non-Network family, plus
amounts over Allowed Charges
Basic Plan
$5,500 individual
$11,000 family
$3,000 individual
$6,000 family
Non-Network charges do not
apply
High Alternative Plan
$3,050 Network individual
$9,150 Network family
$3,550 non-Network individual
$10,650 non-Network family, plus
amounts over Allowed Charges
Basic Alternative Plan
$5,750 individual
$11,500 family
Office Visit
(Professional
Services)
$30 copay/physician office visit*
$50 copay/specialist office visit
•Copays do not apply
•All services, benefits, exceptions,
limitations, and conditions are
identical to the HealthChoice
High Plan
Basic Plan
•$0 the first $500 of Allowed
Charges
•100% of the next $500 of
Allowed Charges (deductible)
Only Allowed Charges apply to
the deductible
Basic Alternative Plan
•$0 the first $250 of Allowed
Charges
•100% of the next $750 of
Allowed Charges (deductible)
Only Allowed Charges apply to
the deductible
Both Basic Plans
•50% of the next $10,000 of
Allowed Charges
•$0 of Allowed Charges over the
individual or family out-of-pocket
limit
•No deductible for well child
care visit.
•You may use non-Network
providers, but it will be more
costly
You pay 100% of Allowed
Charges until deductible is met
$50 office visit copay applies
after deductible
Diagnostic X-ray
and Lab
20% of Allowed Charges after
deductible
20% of Allowed Charges after
deductible
Hospital
Inpatient
Admission
20% of Allowed Charges after
deductible
Additional $300 deductible per
non-Network admission
20% of Allowed Charges after
deductible
Additional $300 deductible
per non-Network admission
Hospital
Outpatient Visit
20% of Allowed Charges after
deductible
20% of Allowed Charges after
deductible
Well Child
Care Visit
$0 copay; no deductible $0 copay; no deductible
applies
Immunizations
No charge for well child and adult
immunizations
$30/$50 office visit copay and/or
administration fee may apply
No charge for well child and
adult immunizations
$50 office visit copay and/or
administration fee may apply
*The $30 copay applies to general practioners, internal medicine physicians, OB/GYNs, pediatricians, physician assistants,
and nurse practitioners. Plan changes are indicated by bold text.
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17 Plan Year 2012 Comparison Chart
COMPARISON OF BENEFITS FOR HEALTH PLANS
HMO Standard
Option
CommunityCare
Alternative
& Wellness
Alternative Plus
HMO
GlobalHealth
Alternative
and Wellness
Alternative Plus
HMO
UnitedHealthcare
Alternative
and Wellness
Alternative Plus
HMO
Your Costs
for Network
Services
No deductible No deductible No deductible No deductible
Calendar Year
Deductibles
Wellness Alternative
Plus
To be eligible for
this Plan, you must
complete a Health
Risk Assessment.
For instructions, see
page 2
Wellness Alternative
Plus
To be eligible for
this Plan, you must
complete a Health
Risk Assessment.
For instructions, see
page 2
Wellness Alternative
Plus
To be eligible for
this Plan, you must
complete a Health
Risk Assessment.
For instructions, see
page 2
$2,500 individual
$5,000 family
$3,000 individual
$6,000 family
$3,000 individual
$5,000 family
$2,500 individual
$5,000 family
Calendar Year
Out-of-Pocket
Limit
$30 copay/PCP
$40 copay/specialist
$35 copay/PCP
$50 copay/specialist
$25 copay/PCP
$50 copay/specialist
$35 copay/PCP
$50 copay/specialist Office Visit
(Professional
Services)
No copay for laboratory
services or outpatient
radiology
$150 copay per MRI,
CAT, MRA, or PET
scan
No additional copay for
laboratory services or
outpatient radiology
$200 copay per MRI,
CAT, MRA, or PET
scan
$0 copay
$250 copay per MRI,
MRA, PET, CAT, or
nuclear scan
$0 copay for standard
lab and radiology
$200 copay per MRI,
MRA, PET, CAT, or
nuclear scan
Diagnostic X-ray
and Lab
$350 copay
Preauthorization
required
$500 copay
Preauthorization
required
$250 copay per day
$750 maximum per
admission
Preauthorization
required
$1,000 copay/admission
Hospital
Inpatient
Admission
$250 copay
Preauthorization
required
$300 copay $250 copay
Preauthorization
required
$500 copay Hospital
Outpatient Visit
$0 copay $0 copay $0 copay ages 0 – 21 $0 copay
Well Child
Care Visit
$0 copay ages birth
through age 18
$0 copay ages 19 and
over
$0 copay ages birth
through age 18 years
$0 copay ages 19 and
over
When medically
necessary
$0 copay
Office visit copay may
apply
$0 copay
In accordance with the
US Preventive Services
Task Force and other
health organizations
required guidelines
Immunizations
Plan changes are indicated by bold text.
This is only a sample of the services covered by each plan. For services that are not listed in this comparison
chart, contact each plan. See Help Lines on page 28 for contact information.
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Plan Year 2012 Comparison Chart 18
COMPARISON OF BENEFITS FOR HEALTH PLANS
Your Costs
for Network
Services
HealthChoice
High, High Alternative
and USA Plans
HealthChoice
Basic and Basic
Alternative Plans
HealthChoice
S-Account Plan
Periodic Health
Exams
$0 copay for one preventive
service office visit per
calendar year for members and
dependents age 20 and older
One mammogram per year at no
charge for women age 40 and
older
$0 copay for one preventive
service office visit per calendar
year for members and
dependents age 20 and older
One mammogram per year at no
charge for women age 40 and
over
•Copays do not apply
•All services, benefits,
exceptions, limitations, and
conditions are identical to the
HealthChoice High Plan
Basic Plan
•$0 the first $500 of Allowed
Charges
•100% of the next $500 of
Allowed Charges (deductible)
Only Allowed Charges apply to
the deductible
Basic Alternative Plan
•$0 the first $250 of Allowed
Charges
•100% of the next $750 of
Allowed Charges (deductible)
Only Allowed Charges apply to
the deductible
Both Basic Plans
•50% of the next $10,000 of
Allowed Charges
•$0 of Allowed Charges over
the individual or family out-of-pocket
limit
•You may use non-Network
providers, but it will be more
costly
$0 copay for one preventive
service office visit per calendar
year for members and
dependents age 20 and older
One mammogram per year at no
charge for women age 40 and
older
Allergy
Treatment and
Testing
20% of Allowed Charges after
deductible
Limit: 60 tests every 24 months
20% of Allowed Charges after
deductible
Limit: 60 tests every 24 months
Emergency
Health Care
Facility
Visit
20% of Allowed Charges after
deductible
Additional $100 ER deductible
– waived if admitted
20% of Allowed Charges after
deductible
Additional $100 ER deductible
– waived if admitted
After Hours
Urgent Care
20% of Allowed Charges after
deductible
20% of Allowed Charges after
deductible
Mental Health or
Substance Abuse
Inpatient
Admission
20% of Allowed Charges after
deductible
No limit on the number of
days per year
20% of Allowed Charges after
deductible
No limit on the number of
days per year
Mental Health or
Substance Abuse
Outpatient
Visit
20% of Allowed Charges after
deductible
No limit on the number of
visits per year
20% of Allowed Charges after
deductible
No limit on the number of
visits per year
Durable Medical
Equipment (DME)
20% of Allowed Charges after
deductible for purchase, rental,
repair, or replacement
20% of Allowed Charges after
deductible for purchase, rental,
repair, or replacement
This is only a sample of the services covered by each plan. For services that are not listed in this comparison
chart, contact the plan. See Help Lines on page 28 of this guide for contact information.
Plan changes are indicated by bold text.
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19 Plan Year 2012 Comparison Chart
COMPARISON OF BENEFITS FOR HEALTH PLANS
HMO Standard
Option
CommunityCare
Alternative
& Wellness
Alternative Plus
HMO
GlobalHealth
Alternative
and Wellness
Alternative Plus
HMO
UnitedHealthcare
Alternative
and Wellness
Alternative Plus
HMO
Your Costs
for Network
Services
$0 copay per visit for
routine physicals
$0 copay $0 copay/PCP
Limit: One per year
$0 copay
In accordance with the
US Preventive Services
Task Force and other
health organizations
required guidelines
Periodic Health
Exams
$30 copay/PCP
$40 copay/specialist
$30 serum and shots
including a 6-week
supply of antigen
$35 copay/PCP
$50 copay/specialist
$30 serum and shots
including a 6-week
supply of antigen
$25 copay/PCP
$50 copay/specialist
$30 serum and shots
including a 6-week
supply of antigen
$35 copay/PCP
$50 copay/specialist
$35 serum and shots
including a 6-week
supply of antigen
Allergy
Treatment and
Testing
$150 copay; waived if
admitted
$200 copay; waived if
admitted
$150 copay; waived if
admitted
$200 copay; waived if
admitted Emergency
Health Care
Facility
Visit
$40 copay per visit $50 copay per visit
Preauthorization
required
$25 copay/PCP
$50 copay/all others
Must use Network
facilities
$50 copay per visit
After Hours
Urgent Care
$350 copay $500 copay
Must be preauthorized
and approved through
CCOK Behavioral
Health Services
$250 per day
$750 maximum per
admission
Must be preauthorized
$1,000 copay per
admission Mental Health or
Substance Abuse
Inpatient
Admission
$30 copay/PCP
$40 copay/specialist
$35 copay/PCP
$50 copay/specialist
Must be preauthorized
and approved through
CCOK Behavioral
Health Services
$25 copay
Must be preauthorized
$35 copay/PCP and
specialist Mental Health or
Substance Abuse
Outpatient
Visit
20% coinsurance initial
device
20% coinsurance repair
and replacement
20% coinsurance initial
device
20% coinsurance repair
and replacement
20% coinsurance 20% coinsurance
$10,000 maximum
benefit per calendar
year
Durable Medical
Equipment (DME)
This is only a sample of the services covered by each plan. For services that are not listed in this comparison
chart, contact the plan. See Help Lines on page 28 for contact information.
Plan changes are indicated by bold text.
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Plan Year 2012 Comparison Chart 20
COMPARISON OF BENEFITS FOR HEALTH PLANS
Your Costs
for Network
Services
HealthChoice
High, High Alternative,
and USA Plans
HealthChoice
Basic and Basic
Alternative Plans
HealthChoice
S-Account Plan
Occupational and
Speech Therapy
Visits
20% of Allowed Charges after
deductible
Occupational therapy*
Limit: 20 visits per year without
certification
Speech therapy*
Certification not required for
age 18 and older
*Maximum of 60 visits per year
•Copays do not apply
•All services, benefits,
exceptions, limitations, and
conditions are identical to the
HealthChoice High Plan
Basic Plan
•$0 the first $500 of Allowed
Charges
•100% of the next $500 of
Allowed Charges (deductible)
Only Allowed Charges apply to
the deductible
Basic Alternative Plan
•$0 the first $250 of Allowed
Charges
•100% of the next $750 of
Allowed Charges (deductible)
Only Allowed Charges apply to
the deductible
Both Basic Plans
•50% of the next $10,000 of
Allowed Charges
•$0 of Allowed Charges over
the individual or family out-of-pocket
limit
•You may use non-Network
providers, but it will be more
costly
20% of Allowed Charges after
deductible
Occupational therapy*
Limit: 20 visits per year without
certification
Speech therapy*
Certification not required for
age 18 and older
*Maximum of 60 visits per year
Physical Therapy/
Physical Medicine
Visit
20% of Allowed Charges after
deductible
Limit: 20 visits per year without
certification
Maximum of 60 visits per year
20% of Allowed Charges after
deductible
Limit: 20 visits per year without
certification
Maximum of 60 visits per year
Chiropractic and
Manipulative
Therapy
Visit
Chiropractic services:
20% of Allowed Charges after
deductible
Limit: 20 visits per year without
certification
Maximum of 60 visits per year
Manipulative therapy: see
Physical Therapy/Physical
Medicine
Chiropractic services:
20% of Allowed Charges after
deductible
Limit: 20 visits per year without
certification
Maximum of 60 visits per year
Manipulative therapy: see
Physical Therapy/Physical
Medicine
Maternity
Pre and Post
Natal Care
20% of Allowed Charges after
deductible
Includes one postpartum home
visit - criteria must be met
20% of Allowed Charges after
deductible
Includes one postpartum home
visit - criteria must be met
Hearing
Screening and
Hearing Aids
$50 copay/specialist
$30 copay/primary care
physician**
Basic hearing screening
Limit: one per year
Hearing aids are covered as
durable medical equipment for
children up to age 18
$50 copay after deductible
Basic hearing screening
Limit: one per year
Hearing aids are covered as
durable medical equipment for
children up to age 18
Plan changes are indicated by bold text.
**The $30 copay applies to general practioners, internal medicine physicians, OB/GYNs, pediatricians, physician
assistants, and nurse practitioners.
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21 Plan Year 2012 Comparison Chart
COMPARISON OF BENEFITS FOR HEALTH PLANS
HMO Standard
Option
CommunityCare
Alternative
& Wellness
Alternative Plus
HMO
GlobalHealth
Alternative
and Wellness
Alternative Plus
HMO
UnitedHealthcare
Alternative
and Wellness
Alternative Plus
HMO
Your Costs
for Network
Services
No copay inpatient
$30 copay/PCP
$40 copay/specialist
Limit: 60 treatment
days per illness
No copay inpatient
$50 copay outpatient
therapy
Limit: 60 days per
illness
No copay inpatient
$50 copay per
outpatient therapy
Limit: 60 consecutive
days per illness
$0 copay inpatient
$35 copay/PCP
$50 copay/specialist
Limit: 60 days per
medical episode
Occupational or
Speech Therapy
Visit
No copay inpatient
$30 copay/PCP
$40 copay/specialist
Limit: 60 treatment
days per illness
No copay inpatient
$50 copay outpatient
therapy
Limit: 60 days per
illness
No copay inpatient
$50 copay per
outpatient visit
Limit: 60 consecutive
days per illness
$0 copay inpatient
$35 copay/PCP
$50 copay/specialist
Limit: 60 days per
medical episode
Physical Therapy/
Physical Medicine
Visit
$40 copay
Limit: 15 visits per
year
PCP referral required
$50 copay
Limit: 15 visits per
year
PCP referral required
$50 copay
Must be preauthorized
$50 copay
Limit: 15 visits per
year - referral required
Limited to treatment
of neurological and
orthopedic conditions
Chiropractic and
Manipulative
Therapy
Visit
$30 copay for initial
visit
$350 copay per hospital
admission
$35 copay for initial
visit
$500 copay per hospital
admission
$25 copay for initial
visit only
$250 copay per hospital
admission per day
$750 maximum per
admission
$35 copay/PCP
$50 copay/specialist
for initial visit once
diagnosis of pregnancy
is confirmed
$1,000 copay per
hospital admission
Maternity
Pre and Post
Natal Care
$0 copay children birth
– age 21
$30 copay age 22 and
over
Limit: One per year
Hearing aids – 20%
coinsurance for children
up to age 18
$0 copay
Limit: One per year
Hearing aids – 20%
coinsurance for children
up to age 18
$0 copay children birth
– age 21
$25 copay age 22 and
over
Limit: One per year
Hearing aids – 20%
coinsurance
For children up to age
18
$0 copay/PCP ages 0-17
20% coinsurance ages
18 and over
Limited to a single
hearing aid every 3
years – maximum
benefit of $5,000 per
calendar year
Hearing
Screening and
Hearing Aids
This is only a sample of the services covered by each plan. For services that are not listed in this comparison
chart, contact each plan. See Help Lines on page 28 for contact information.
Plan changes are indicated by bold text.
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Plan Year 2012 Comparison Chart 22
COMPARISON OF BENEFITS FOR HEALTH PLANS
Plan changes are indicated by bold text.
Your Costs
for Network
Services
HealthChoice High, High Alternative,
Basic, Basic Alternative, and USA
Plans
HealthChoice
S-Account Plan
Pharmacy
Benefits
NETWORK
Retail Pharmacy
•Up to a 30-day supply
•Generic medication – $10 copay or cost of
medication if less
•Preferred brand-name medication – cost of
medication up to $15 or a maximum copay of
$30
•Non-Preferred brand-name medication – cost
of medication up to $30 or a maximum copay
of $60
•Maintenance medication – 50% of ingredient
cost plus dispensing fee for fourth and all
subsequent fills; minimum copay of $10 for
generics, $15 for Preferred brand-name, and
$30 for non-Preferred brand-name medication
Mail Order and
Retail Maintenance Pharmacies
•Up to a 90-day supply
•Generic medication – $25 or cost of
medication if less
•Preferred brand-name medication – cost of
medication up to $30 or a maximum copay of
$60
•Non-preferred brand-name medication – cost
of medication up to $60 or a maximum copay
of $120
•Specialty medication covered only when
ordered through Accredo Health Group
●● Preferred medication $60 per 30-day
supply
●● Non-Preferred $120 per 30-day supply
Pharmacy out-of-pocket maximum - $2,500
per person using Preferred products at Network
pharmacies, then you pay $0
After combined medical and pharmacy
deductible ($1,500 individual/$3,000 family)
has been met, the pharmacy benefits are:
NETWORK
Retail Pharmacy
•Up to a 30-day supply
•Generic medication – $10 copay or cost of
medication if less
•Preferred brand-name medication – cost of
medication up to $15 or a maximum copay of
$30
•Non-Preferred brand-name medication – cost
of medication up to $30 or a maximum copay
of $60
•Maintenance medication – 50% of ingredient
cost plus dispensing fee for fourth and all
subsequent fills; minimum copay of $10 for
generics, $15 for Preferred brand-name, and
$30 for non-Preferred brand-name medication
Mail Order and
Retail Maintenance Pharmacies
•Up to a 90-day supply
•Generic medication – $25 or cost of
medication if less
•Preferred brand-name medication – cost of
medication up to $30 or a maximum copay of
$60
•Non-preferred brand-name medication – cost
of medication up to $60 or a maximum copay
of $120
•Specialty medication covered only when
ordered through Accredo Health Group per
30-day supply
●● Preferred medication $60 per 30-day
supply
●● Non-Preferred $120 per 30-day supply
23 Plan Year 2012 Comparison Chart
COMPARISON OF BENEFITS FOR HEALTH PLANS
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HMO Standard
Option
CommunityCare
Alternative
& Wellness
Alternative Plus
HMO
GlobalHealth
Alternative
and Wellness
Alternative Plus
HMO
UnitedHealthcare
Alternative
and Wellness
Alternative Plus
HMO
Your Costs
for Network
Services
Up to $5 generic
formulary
Up to $30 brand
formulary (when no
generic is available)
Up to $60 brand
formulary (when
generic is available)
30-day supply
Certain medications
have restricted
quantities
Mail order may be
available, contact Plans
for details
Please note: Tier
categories will be
determined by each
HMO based on its
formulary design
Tier 1: $10
Tier 2: $40
Tier 3: $65
$0 copay for selected
generics
Up to $65 non-formulary
(non-
Preferred)
These copays do not
apply to the maximum
out-of-pocket
30-day supply
Certain medications
have restricted
quantities
Convenient mail-order
is available. Contact
Plan for details
Tier 1: $10
Tier 2: $50
Tier 3: $75
$4 copay for selected
generics
30-day supply
Certain medications
may have restricted
quantities
These copays do not
apply to the maximum
out-of-pocket
$5 copay for formulary
generic drugs
$30 copay for formulary
brand-name drugs
$60 copay non-formulary
generic and
non-formulary brand
drugs
Lesser of a 30-day
supply or 100 units
Certain medications
have restricted
quantities
Pharmacy
Benefits
Plan changes are indicated by bold text.
COMPARISON OF BENEFITS FOR DENTAL PLANS
Your Costs
for Network
Services
HealthChoice
Dental
CIGNA Dental Care
Plan (Prepaid)
Assurant
Freedom
Preferred
Annual
Deductible
Network: $25 Basic and
Major services combined
Non-Network: $25
Preventive, Basic, and Major
services combined plus
amounts above Allowed
Charges
No deductible or plan
maximum
$5 office copay applies
$25 per person, per year,
waived for preventive services
in-network
Preventive
Care
ex: cleaning,
routine oral exam
Allowed Charges
apply
Network: $0
Non-Network: $0 of Allowed
Charges after deductible
Sealant: $15 per tooth
No charge for routine cleaning
once every 6 months
No charge for topical fluoride
application (through age 18)
No charge for periodic oral
evaluations
$0 with no deductible when
in-network
Basic Care
ex: extractions,
oral surgery
Allowed Charges
apply
Network: 15%
Non-Network: 30% plus
amounts above Allowed
Charges
Deductible applies
Amalgam: One surface,
permanent teeth $21
Network: 15%
Non-Network: 30%
Plan pays 85% of usual and
customary when in-network
Deductible applies
Major Care
ex: dentures,
bridge work
Allowed Charges
apply
Network: 40%
Non-Network: 50% plus
amounts above Allowed
Charges
Deductible applies
Root canal, anterior: $355
Periodontal/scaling/root
planing 1-3 teeth (per
quadrant): $71
Network: 40%
Non-Network: 50%
Plan pays 60% of usual and
customary when in-network
Deductible applies
Orthodontic Care
Allowed Charges
apply
Network: 50%
Non-Network: 50% plus
amounts above Allowed
Charges
12-month waiting period may
apply
No lifetime maximum for
Network or non-Network
Covered for members under
age 19 and members age 19
and older with TMD
$2,280 out-of-pocket for
children through age 18
$3,120 out-of-pocket for adults
24-month treatment excludes
orthodontic treatment plan and
banding
Network: 40%
Non-Network: 50%
Up to $2,000 lifetime
maximum for members under
age 19
12-month waiting period may
apply
Plan Year
Maximum
Network and non-Network:
$2,000 per person, per year
No maximum $2,000
Filing Claims
Network: No claims to file
Non-Network: You file claims
No claims to file Member/provider must file
claims
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Plan Year 2012 Comparison Chart 24
Assurant Prepaid Plans
Heritage Plus with SBA
and Heritage Secure
Delta Dental PPO
In-Network and
Out-of-Network
Delta Dental Premier
In-Network and
Out-of-Network
Delta Dental
PPO – Choice
PPO Network
No deductibles $25 per person, per year,
applies to Basic and Major
Care only
$50 per person, per year,
applies to Diagnostic,
Preventive, Basic, and Major
Care
$100 per person, per year,
applies to Major Care only
(Level 4)
No charge for routine cleaning
(once every 6 months)
No charge for topical fluoride
application (up to age 18)
No charge for periodic oral
evaluations
$0 of allowable amounts
No deductible applies
Includes diagnostic
$0 of allowable amounts after
deductible
Includes diagnostic
Schedule of covered services
and copays
Copay examples:
Routine cleaning $5
Periodic oral evaluation $5
Topical fluoride application
(up to age 19) $5
Includes diagnostic
Fillings
Minor oral surgery
Refer to the copayment schedule
for each plan
15% of allowable amounts
after deductible
30% of allowable amounts
after deductible
Schedule of covered services
and copays
Copay example:
Amalgam - one surface,
primary or permanent tooth
$12
Root canal
Periodontal
Crowns
Refer to the copayment schedule
for each plan
40% of allowable amounts
after deductible
50% of allowable amounts
after deductible
Schedule of covered services
and copays
Copay examples:
Crown - porcelain/ceramic
substrate $241
Complete denture - maxillary
$320
25% discount
Adults and children
40% of allowable amounts,
up to lifetime maximum of
$2,000
No deductible
No waiting period
Orthodontic benefits are
available to the employee
and their lawful spouse and
eligible dependent children
40% of allowable amounts, up
to lifetime maximum of $2,000
No deductible
No waiting period
Orthodontic benefits are
available to the employee and
their lawful spouse and eligible
dependent children
You pay amounts in excess of
$50 per month
Lifetime maximum up to
$1,800
No deductible
No waiting period
Orthodontic benefits are
available to the employee and
their lawful spouse and eligible
dependent children
No annual maximum for general
dentist
$2,500 per person, per year $3,000 per person, per year $2,000 per person, per year
No claims to file Claims are filed by
participating dentists
Claims are filed by
participating dentists
Claims are filed by
participating dentists
COMPARISON OF BENEFITS FOR DENTAL PLANS
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Plan Year 2012 Comparison Chart 26
COMPARISON OF BENEFITS FOR VISION PLANS
Humana/CompBenefits
VisionCare Plan
Primary Vision
Care Services, Inc.
Covered Services In-Network
Out-of-
Network
In-Network
Out-of-
Network*
Eye Exams
$10 copay
One exam for
eyeglasses or contacts
per year
Copays do not apply
Plan pays up to $35
One exam per year
$0 copay
No limit on exams per
year
Plan pays up to $40
One exam per year
Lenses Each Pair
$25 material copay
applies to lenses and/
or frames (single,
lined bifocal, trifocal,
lenticular are covered
at 100%)
A discount applies to
progressive lenses
One pair of lenses per
year
Plan pays up to:
$25 single
$40 bifocals
$60 trifocals
$100 lenticular
One pair of lenses per
year
You pay wholesale
cost with no limit on
number of pairs
You pay normal
doctor’s fee,
reimbursed up to $60
for one set of lenses
and frames per year
Frames
$25 material copay
applies to lenses and/
or frames
$45 wholesale frame
allowance
One pair of frames per
year
$25 copay
Plan pays up to $45
One pair of frames per
year
You pay wholesale
cost.
No limit on number of
frames
You pay normal
doctor’s fee,
reimbursed up to $60
for one set of lenses
and frames per year
Contact Lenses
$130 allowance
for conventional or
disposable contact
lenses and fitting fee
In lieu of all other
benefits
Medically necessary,
Plan pays 100%
One set of contacts per
year
$130 allowance for
exam, contacts, and
fitting fee
In lieu of all other
benefits
Medically necessary,
Plan pays $210
One set of contacts
per year
You pay wholesale
cost for an annual
supply of contacts
$50 service fee applies
to all soft contact lens
fittings; $75 to rigid
or gas permeable lens
fittings, $150 to hybrid
contact lens fittings
Replacement lenses do
not have these fees
Limit of one set
annually in lieu of
eyeglasses
You pay normal
doctor’s fee,
reimbursed up to $60
Laser Vision
Correction
$895 copay
conventional
$1,295 copay custom
$1,895 copay custom
plus bladeless when
services are rendered
by a TLC Network
Provider
No benefit Discount nationwide
at The Laser Center
(TLC)
No benefit
For information on limitations/exclusions,
please contact PVCS. See Help Lines on page 28
*Out-of-Network limited to one eye exam and
one set of eyeglasses or contact lenses annually.
Cannot be used with In-Network services.
Vision benefits apply from January 1 through
December 31, 2012
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27 Plan Year 2012 Comparison Chart
COMPARISON OF BENEFITS FOR VISION PLANS
Superior Vision Plan UnitedHealthcare Vision
Vision Service Plan
(VSP)
In-Network
Out-of-
Network
In-Network
Out-of-
Network
In-Network
Out-of-
Network
$10 copay
One exam per year
OD-$26 max
MD-$34 max
$10 copay
One exam per year
Plan pays up to $40 $10 copay
One exam per year
$10 copay
Plan pays up to $35
$25 copay
One pair of lenses
per year
Plan pays up to:
$26 single
$39 bifocals
$49 trifocals
$78 lenticular
$25 copay
One pair of lenses
per year
Lens options
covered in full:
•UV coating
•Tints
Plan pays up to:
$40 single
$60 bifocals
$80 trifocals
$80 lenticular
$25 copay*
One set of lenses
per year
Polycarbonate
lenses covered in
full for dependent
children
Average 35-40%
savings on non-covered
lens
options
$25 copay*
Plan pays up to:
$25 single
$40 bifocals
$55 trifocals
$80 lenticular
$25 copay
Plan pays up to
$125
One pair of frames
per year
Plan pays up to $68 $25 copay
$130 allowance
One pair of frames
per year
Plan pays up to $45 $25 copay*
$120 allowance
20% off any out-of-pocket
costs above
the allowance
One pair of frames
per year
$25 copay*
Plan pays up to $45
$25 fitting copay
for standard fitting
After copay, Plan
pays 100%
$25 fitting copay
for specialty fitting
After copay, Plan
pays up to $50
Plan pays up to
$120 for elective
contacts
Medically
necessary contacts
are covered in full
(in lieu of glasses)
Fitting fee is not a
covered benefit
Plan pays up to
$100 for elective
contacts
Plan pays up to
$210 for medically
necessary contacts
(in lieu of glasses)
$25 copay
covers fitting/
evaluation fees,
contacts (including
disposables), and
up to 2 follow-up
visits
(in lieu of glasses)
Plan pays up to
$150
For medically
necessary contacts,
Plan pays up to
$210
(in lieu of glasses)
$0 copay
$120 allowance
applied to the cost
of your contact
lenses (in lieu of
glasses)
Contact lens exam
is covered in full
after a copay of up
to $60
$0 copay
Plan pays up to
$105 for disposable
or conventional
contact lenses
(in lieu of glasses)
20% to 50%
savings on LASIK
surgery
No benefit Members
have access
to discounted
refractive eye
surgery from
numerous
provider locations
throughout the U.S.
No benefit Laser vision
correction services
(PRK, LASIK, and
Custom LASIK)
are provided at
a reduced cost
through VSP’s
contracted laser
surgery centers
No benefit
*Benefit includes an annual $25 materials
copay for lenses or frames, but not both.
Contact VSP at 1-800-877-7195 for
additional information regarding in-network
added value discounts.
Vision benefits apply from January 1 through
December 31, 2012
HealthChoice (OSEEGIB)
Help Lines
Health, Dental, and Life Claims, Benefits,
Verification of Coverage, and ID Cards
Oklahoma City Area 1-405-416-1800
All Other Areas 1-800-782-5218
TDD Oklahoma City Areas 1-405-416-1525
TDD All Other Areas 1-800-941-2160
Website www.sib.ok.gov or www.healthchoiceok.com
Pharmacy Claims/Pharmacy ID Cards
All Areas 1-800-903-8113
TDD All Areas 1-800-825-1230
Member Services/Provider Directory
Oklahoma City Area 1-405-717-8780
All Other Areas 1-800-752-9475
TDD 1-405-949-2281 or All Areas 1-866-447-0436
HealthChoice USA
Customer Service & Claims 1-800-782-5218
Provider Information 1-877-877-0715 ext. 4059
TDD All Areas 1-800-941-2160
Website www.choicecarenetwork.com
American Fidelity Health Services
Administration
Health Savings Account (HSA)
Oklahoma City Area 1-405-523-5699
All Areas 1-866-326-3600
Website www.afhsa.com
HMO Plans’ Help Lines
CommunityCare
All Areas 1-800-777-4890
TDD All Areas 1-800-722-0353
Website www.ccok.com
GlobalHealth, Inc.
Oklahoma City Area 1-405-280-5600
All Other Areas 1-877-280-5600
TDD All Areas 1-800-522-8506
Website www.globalhealth.com
UnitedHealthcare
All Areas 1-800-825-9355
TDD All Areas 1-800-557-7595
Website www.UHCwest.com
Dental Plans’ Help Lines
Assurant, Inc. Dental
Prepaid Plan 1-800-443-2995
Indemnity Plan 1-800-442-7742
Website www.assurantemployeebenefits.com
CIGNA Prepaid Dental
All Areas 1-800-244-6224
Toll-free Hearing Impaired Relay Svc 1-800-654-5988
Website www.cigna.com
Delta Dental
Oklahoma City Area 1-405-607-2100
All Other Areas 1-800-522-0188
Website www.DeltaDentalOK.org
Vision Plans’ Help Lines
Humana/CompBenefits
All Areas 1-800-865-3676
TDD All Areas 1-877-553-4327
Website www.compbenefits.com/custom/stateofoklahoma
Primary Vision Care Services (PVCS)
All Areas 1-888-357-6912
TDD All Areas 1-800-722-0353
Website www.pvcs-usa.com
Superior Vision Plan
All Areas 1-800-507-3800
TDD 1-916-852-2382
Website www.superiorvision.com
UnitedHealthcare Vision
All Areas 1-800-638-3120
TDD All Areas 1-800-524-3157
Website www.myuhcvision.com
Vision Service Plan (VSP)
All Areas 1-800-877-7195
TDD All Areas 1-800-428-4833
Website www.vsp.com
28
HealthChoice
OPTION PERIOD GUIDE
PLAN YEAR 2012
Oklahoma State and Education
Employees Group Insurance Board
3545 NW 58 Street, Suite 110
Oklahoma City, OK 73112