The Oklahoma State and Education Employees Group Insurance Board
EMPLOYEE BENEFIT OPTIONS GUIDE FOR CURRENT EMPLOYEES
For Plan Year January 1, 2011 through December 31, 2011
This information is only a brief summary of the plans. All benefits and limitations of these plans are governed in all cases by the relevant plan document, insurance contracts, handbooks, and Rules of the Oklahoma State and Education Employees Group Insurance Board. The Rules of the Oklahoma Administrative Code, Title 360, are controlling in all aspects of Plan benefits. No oral statement of any person shall modify or otherwise affect the benefits, limitations, or exclusions of any plan.
www.sib.ok.gov/ and www.healthchoiceok.com
FORMS ARE BEING MAILED SEPARATELY
THE DEADLINE FOR TURNING IN YOUR OPTION PERIOD FORM IS DETERMINED BY YOUR INSURANCE COORDINATOR.
TABLE OF CONTENTS
Monthly Premiums for Current Employees
2011 Plan Changes
Introduction
General Enrollment Information
HealthChoice Disability Insurance
Comparison of Benefits for Health Plans – All Plans
HealthChoice High Option Plan Benefits
HealthChoice Basic Plan Benefits
HealthChoice S-Account Plan Benefits
CommunityCare Alternative HMO Benefits
GlobalHealth Alternative HMO Benefits
PacifiCare Alternative HMO Benefits
Comparison of Benefits for Dental Plans – All Plans
HealthChoice Dental Plan Benefits
Assurant Freedom Preferred Benefits
Assurant Prepaid Plans - Heritage Plus with SBA and Heritage Secure Benefits
Cigna Dental Care Plan (Prepaid) Benefits
Delta Dental PPO In-Network and Out-of-Network
Delta Dental Premier In-Network and Out-of-Network
Delta Dental PPO – Choice PPO Network
Comparison of Benefits for Vision Plans – All Plans
Humana/CompBenefits VisionCare Plan
Primary Vision Care Services, Inc.
How to Access the Online Provider Networks
If you have any questions concerning anything in this guide, please refer to Help Lines for contact information for each plan.
The participating carriers reviewed and approved the information in this Guide. There is no guarantee that a provider will remain within a plan’s network or have open patient slots throughout the year. Please verify your provider’s participation in your plan’s network.
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.
MONTHLY PREMIUMS FOR CURRENT EMPLOYEES
For Plan Year January 1, 2011 through December 31, 2011
HEALTH PLANS
HealthChoice High Option
Member $449.48
Spouse $682.74
Child $228.20
Children $352.08
HealthChoice Basic Plan
Member $391.64
Spouse $598.48
Child $201.82
Children $310.80
HealthChoice S-Account
Member $382.56
Spouse $562.74
Child $190.18
Children $291.90
HealthChoice USA Plan
Member $688.82
Spouse $688.82
Child $226.22
Children $348.86
CommunityCare Standard HMO
Member $772.34
Spouse $1,104.42
Child $386.16
Children $617.86
CommunityCare Alternative HMO
Member $532.66
Spouse $761.68
Child $266.34
Children $426.12
GlobalHealth Standard HMO
Member $366.56
Spouse $601.22
Child $193.12
Children $307.96
GlobalHealth Alternative HMO
Member $333.26
Spouse $546.58
Child $175.62
Children $279.98
PacifiCare Standard HMO
Member $686.42
Spouse $986.94
Child $342.96
Children $548.86
PacifiCare Alternative HMO
Member $473.39
Spouse $680.63
Child $236.51
Children $378.51
DISABILITY PLAN (Employee only) (Limited county participation only)
Member $9.10
DENTAL PLANS
HealthChoice Dental
Member $29.84
Spouse $29.84
Child $24.88
Children $64.56
Assurant Freedom Preferred
Member $28.83
Spouse $28.67
Child $21.50
Children $57.80
Assurant Heritage Plus with SBA Prepaid
Member $11.74
Spouse $8.86
Child $7.60
Children $15.20
Assurant Heritage Secure Prepaid
Member $7.20
Spouse $5.98
Child $5.20
Children $10.38
CIGNA Dental Care Plan Prepaid
Member $9.26
Spouse $6.06
Child $7.08
Children $15.32
Delta Dental PPO
Member $31.14
Spouse $31.14
Child $27.10
Children $68.56
Delta Dental Premier
Member $35.52
Spouse $35.52
Child $30.90
Children $78.20
Delta Dental PPO - Choice
Member $13.94
Spouse $31.64
Child $31.90
Children $77.42
VISION PLANS
Humana/CompBenefits Vision Care Plan
Member $6.76
Spouse $5.06
Child $3.57
Children $4.46
Primary Vision Care Services
Member $9.25
Spouse $8.00
Child $8.50
Children $10.75
Superior Vision Plan
Member $6.98
Spouse $6.90
Child $6.60
Children $6.60
UnitedHealthcare Vision
Member $8.18
Spouse $5.79
Child $4.59
Children $6.98
Vision Service Plan (VSP)
Member $8.76
Spouse $5.87
Child $5.62
Children $12.64
LIFE
Member
HealthChoice Basic Life ($20,000) $4.56
First $20,000 of Supplemental Life $4.56
Age-rated Supplemental Life per $20,000
Under 30 $1.00
30 – 34 $1.00
35 – 39 $1.60
40 – 44 $2.40
45 – 49 $3.80
50 – 54 $6.40
55 – 59 $10.40
60 – 64 $12.00
65 - 69 $19.80
70 – 74 $33.40
75 and older $52.00
Dependent Life
Low Option $2.60
Spouse coverage of $6,000
Children over 6 months coverage of $3,000
Birth to 6 months $1,000
Standard Option $4.32
Spouse coverage of $10,000
Children over 6 months coverage of $5,000
Birth to 6 months $1,000
Premier Option $8.64
Spouse coverage of $20,000
Children over 6 months coverage of $10,000
Birth to 6 months $1,000
2011 PLAN CHANGES
Notice of Eligibility to Age 26
Your children are now eligible up to age 26, whether married or unmarried. Your election to re-enroll a dependent terminated due to turning age 25 must be made on your Option Period Enrollment/ Change Form and submitted to your Insurance Coordinator by the due date.
Health Plan Changes
HealthChoice Plans
Patient Protection and Affordable Care Act Disclosure of Grandfather Status – HealthChoice believes it is a grandfathered plan under the Patient Protection and Affordable Care Act (the Affordable Care Act). As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when the law was enacted. Being a grandfathered health plan means that your HealthChoice health plan may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of certain preventive health services without any cost sharing. However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits.
Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to HealthChoice, 3545 NW 58th, Ste 110, OKC, OK, 73112, or call 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. You may also contact the US Department of Health and Human Services at http://www.healthreform.gov.
HealthChoice High Option and USA Plans
Copays are being decreased to $30 for primary care physician office visits and other copay-related services received from a primary care physician; however, the copay for specialist office visits and other copay-related services received from a specialist will remain $50. The following are considered primary care physician: General Practitioners, Internal Medicine physicians, OB/GYNs, Pediatricians, Physician Assistants, and Nurse Practitioners. HealthChoice members do not need to designate a primary care physician and can change physicians at any time.
Preventive service visits for members and dependents under age 20 will be available with no copay through a Network Provider according to the following schedule:
Age 0 to 12 months – 8 visits
Age 1 through 2 years – 4 visits
Age 3 through 5 years – 2 visits
Age 6 through 19 years – 1 visits
One preventive service visit per calendar year, including one metabolic panel and one lipid panel, will be covered at 100% with no copay through a Network Provider for members and dependents age 20 and older.
HealthChoice Basic and S-Account Plans
All Plan provisions including deductibles, copays, and out-of-pocket maximums remain the same as Plan Year 2010; the above schedule of well child care visits applies.
HealthChoice Pharmacy Benefit
The $2 million lifetime limit on pharmacy benefits is being eliminated.
HealthChoice offers certain prescription tobacco cessation medications for a $5 copay. Additionally, HealthChoice partners with the Tobacco Settlement Endowment Trust (TSET) and Free and Clear to provide members with over-the counter nicotine replacement therapy products (patches, gum, and lozenges) and telephone coaching at no charge to HealthChoice health plan members.
HMOs
Attention current Aetna members – Aetna is not a participating HMO for Plan Year 2011. If you are currently enrolled in Aetna Standard or Alternative HMO, you must choose another health plan.
HMO service areas may have changed. Check the HMO ZIP Code List for your area.
A preventive office visit with a primary care physician will be covered at 100% for members age 19 and older.
HMO Standard Option plans are removing the copay for hearing screenings for members and dependents through age 21. Age 22 and over will have a $30 copay.
GlobalHealth Alternative HMO is removing the copay for well child care visits and hearing screenings for members and dependents to age 21 and decreasing the copay for mental health and substance abuse outpatient visits from $50 to $25.
PacifiCare Alternative HMO is removing the copay for hearing screenings, inpatient occupational or speech therapy, and inpatient physical therapy/physical medicine.
CommunityCare Alternative HMO is removing the copay for hearing screenings.
Dental Plan Change
DMOs/Prepaid Dental
Assurant Freedom Preferred is increasing the orthodontia lifetime maximum for members under age 19 to $2,000 and decreasing the orthodontia waiting period to 12 months.
CIGNA Dental is making the following changes:
Basic Care – The copay for amalgam, one surface, permanent teeth is increasing to $21.
Major Care – The copay for a root canal, anterior is increasing to $355.
Orthodontic Care – The out-of-pocket maximum for children through 18 is increasing to $2,280, and the out-of-pocket maximum for adults is increasing to $3,120.
Delta Dental is not offering the Delta Dental PPO – Point-of-Service plan for 2011. If you are currently enrolled in Delta Dental PPO – Point of Service, you must choose another dental plan for 2011.
Delta Dental is offering 3 plans, Delta Dental PPO, Delta Dental Premier, and Delta Dental PPO – Choice.
Delta Dental PPO is increasing the plan year maximum for Preventive, Basic, and Major Care to $2,500 and increasing the orthodontia lifetime maximum to $2,000.
Delta Dental Premier is lowering the annual deductible for Preventive, Basic, and Major Care to $50 and increasing the orthodontia lifetime maximum to $2,000.
Life Plan Changes
There are no plan changes for 2011.
Vision Plan Changes
There are no plan changes for 2011.
If you have questions about any of the plans, contact each plan directly. Contact information is located in the Help Lines section.
INTRODUCTION
The Oklahoma State and Education Employees Group Insurance Board (OSEEGIB) 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, and Disability.
Refer to the Monthly Premiums for Current Employees and Comparison of Benefits for each plan to determine your costs.
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, 2011, 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 2011 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 2011 – this guide, plan websites, customer service telephone numbers, provider directories, OSEEGIB Member Services, and your Insurance Coordinator.
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 not correct. If you do not make changes to your coverage, you will not receive a Confirmation Statement from OSEEGIB. Keep a copy of your Option Period Enrollment/Change Form as verification of insurance coverage.
Helpful Hints For New Employees
Use the following resources to help you decide on coverage for you and your dependents – this guide, plan websites, customer service telephone numbers, provider directories, OSEEGIB Member Services, and your Insurance Coordinator.
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 not correct.
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, 2011, or for new employees, the effective date of your coverage, through December 31, 2011.
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 10 health plans available – HealthChoice High Option Plan, HealthChoice Basic Plan, HealthChoice S-Account Plan, HealthChoice USA Plan*, CommunityCare Standard and Alternative HMO, GlobalHealth Standard and Alternative HMO, and PacifiCare Standard and Alternative HMO.
*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.
There are no preexisting condition exclusions or limitations applied to any of the health plans.
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. Refer to the HMO ZIP Code List to verify your eligibility.
To enroll in the HealthChoice S-Account Plan, you must provide OSEEGIB with proof you have a Health Savings Account at a bank or other financial institution. This proof must be submitted by December 15, 2010. Without proof, your health plan will default to the HealthChoice Basic 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. Refer to Help Lines at the end of this document.
Check with the individual health plan if you have benefit questions.
Dental Plans
Verify your employer offers dental coverage through OSEEGIB.
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, and Delta Dental PPO – Choice.
All dental plans have toll-free numbers for customer service. Refer to Help Lines at the end of this document.
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, Primary Vision Care Services, Superior Vision Plan, UnitedHealthcare Vision, and Vision Service Plan (VSP).
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. Refer to Help Lines at the end of this document.
Check with the individual vision plan if you have benefit questions.
For directions on how to access each health, dental, and vision plan’s provider network, refer to the How to Access the Online Provider Networks section. 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 as needed.
Thinking About Retirement?
If you are a current employee who will be retiring before January 1, 2011, 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 at the end of this document.
HEALTHCHOICE LIFE INSURANCE
Verify your employer offers HealthChoice Life Insurance through OSEEGIB.
As a new employee, you can elect life 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.
As a current employee, if you did not enroll when first eligible, you can enroll:
During the annual Option Period. If you are enrolled in one of the health plans offered through OSEEGIB, an approved Life Insurance Application is required only if you apply for more than $20,000 in coverage.
Within 30 days of a midyear qualifying event; however, 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…For You
You can enroll in Basic Life during Option Period without a Life Insurance Application as long as you are enrolled in one of the health plans offered through OSEEGIB. Mark the appropriate box on your Option Period Enrollment/Change Form.
Basic Life pays a benefit of $20,000 to your beneficiary in the event of your death.
Basic Life coverage 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 providing a Life Insurance Application.
You may purchase Supplemental Life coverage in units of $20,000. One $20,000 unit of life insurance may be purchased during Option Period without a Life Insurance Application as long as you are already enrolled in Basic Life and one of the health plans offered through OSEEGIB. You cannot apply for Supplemental Life coverage that exceeds the Plan maximum of five times your annual salary or $300,000, whichever is less. You must complete a Life Insurance Application to apply for coverage above $20,000.
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.
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 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 Option, Standard Option, or Premier Option. Regardless of your number of dependents, the monthly premium is the same. Each dependent must be enrolled in Dependent Life.
A Life Insurance Application is not required for Dependent Life coverage.
Amount of Coverage for Low Option
Spouse $6,000
Child (age 6 months to 26) $3,000
Child (live birth to 6 months) $1,000
Amount of Coverage for Standard Option
Spouse $10,000
Child (age 6 months to 26) $5,000
Child (live birth to 6 months) $1,000
Amount of Coverage for Premier Option
Spouse $20,000
Child (age 6 months to 26) $10,000
Child (live birth to 6 months) $1,000
Beneficiary Designation
Benefits are paid to your beneficiary in a lump sum. You must name your beneficiary when you enroll. Your beneficiary designation can be changed at any time. For a Beneficiary Designation Form or more information, contact your Insurance Coordinator. These forms are also available on the HealthChoice website at www.sib.ok.gov or www.healthchoiceok.com. Be aware that life insurance benefits for covered dependents are always paid to the member.
HEALTHCHOICE DISABILITY INSURANCE
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 the material duties of your regular occupation. Any claim for disability benefits must be filed within one year of the date your disability began.
ENROLLMENT PERIODS
Option Period Enrollment – Coverage effective January 1, 2011
This is the time when eligible employees can:
Enroll in plans
Change plans or drop coverage
Increase or decrease life insurance coverage
Add eligible family members or drop them from coverage
You can enroll in health, dental, life, and/or vision coverage for yourself and/or your dependents during the annual Option Period, as long as you have not dropped that coverage within the past 12 months. This does not include dependents who were dropped due to turning age 25. If you have dropped coverage, 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 insurance 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.
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. Contact 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 if 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. Contact 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 in order to enroll in dental and/or life insurance.
Dependents
If one eligible dependent is covered, all eligible dependents must be covered. You can elect 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 may be covered under only 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. It also does not apply for dependents who were dropped due to turning age 25.
Dependents can only be enrolled in the same types of coverage and in the same plans you have.
To enroll your newborn, a 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 will not be able to do so until the next annual Option Period. Direct notification to an HMO will not enroll your newborn, or any other dependents. The newborn’s Social Security Number is not required at the time of initial enrollment, but must be provided once it is received from the Social Security Administration. Insurance premiums for the month the child was born must be paid. Under the HealthChoice plans, a separate deductible and coinsurance may apply.
Without enrollment, newborns will be covered only for the first 48 hours following a vaginal birth or the first 96 hours following a cesarean section birth. Deductible and coinsurance may apply.
Excluding Dependents from Coverage
You can exclude your spouse from health and/or dental coverage. Your spouse must sign the Spouse Exclusion Certification section of the enrollment or change form.
You can exclude your spouse or other dependents if they are covered under another group health or dental plan, 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 will be 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, 2011, if you do not make changes to your coverage during Option Period. If you don’t make changes, you will not receive a CS from OSEEGIB. Keep a copy of your Option Period Enrollment/Change Form as verification of your coverage.
Transfer Employee
You can keep your coverage continuous when moving 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. Contact 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, and 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 a 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 coverage on dependents during Option Period is not a COBRA qualifying event.
HMO ZIP CODE LIST
If you do not live in the ZIP Code area for a plan, that plan is not available to you. PO Box addresses cannot be used to determine HMO enrollment eligibility. There is no guarantee that all providers remain with the plans or that they have open patient slots all year long. Please verify availability and physician status prior to scheduling an appointment.
GlobalHealth may not be available in all the ZIP Codes indicated. Please check the Employee Benefit Options Guide posted on OSEEGIB’s website or contact GlobalHealth. Refer to Help Lines for contact information.
Use your screen readers find command to search for a specific ZIP Code. Press the letter H to move to the heading that begins the next section.
73001 GlobalHealth
73002 GlobalHealth, PacifiCare
73003 CommunityCare, GlobalHealth, PacifiCare
73004 GlobalHealth, PacifiCare
73005 GlobalHealth
73006 GlobalHealth
73007 CommunityCare, GlobalHealth, PacifiCare
73008 CommunityCare, GlobalHealth, PacifiCare
73009 GlobalHealth
73010 GlobalHealth, PacifiCare
73011 GlobalHealth, PacifiCare
73012 CommunityCare, GlobalHealth, PacifiCare
73013 CommunityCare, GlobalHealth, PacifiCare
73014 CommunityCare, GlobalHealth, PacifiCare
73015 GlobalHealth
73016 GlobalHealth, PacifiCare
73017 GlobalHealth
73018 GlobalHealth, PacifiCare
73019 CommunityCare, GlobalHealth, PacifiCare
73020 CommunityCare, GlobalHealth, PacifiCare
73021 GlobalHealth
73022 CommunityCare, GlobalHealth, PacifiCare
73023 GlobalHealth
73024 GlobalHealth
73025 CommunityCare, GlobalHealth, PacifiCare
73026 CommunityCare, GlobalHealth, PacifiCare
73027 CommunityCare, GlobalHealth, PacifiCare
73028 CommunityCare, GlobalHealth, PacifiCare
73029 GlobalHealth
73030 GlobalHealth
73031 GlobalHealth, PacifiCare
73032 GlobalHealth
73033 GlobalHealth
73034 CommunityCare, GlobalHealth, PacifiCare
73036 CommunityCare, GlobalHealth, PacifiCare
73037 CommunityCare, PacifiCare
73038 GlobalHealth
73039 GlobalHealth
73040 GlobalHealth
73041 GlobalHealth
73042 GlobalHealth
73043 GlobalHealth
73044 CommunityCare, GlobalHealth, PacifiCare
73045 CommunityCare, GlobalHealth, PacifiCare
73047 GlobalHealth
73048 GlobalHealth
73049 CommunityCare, GlobalHealth, PacifiCare
73050 CommunityCare, GlobalHealth, PacifiCare
73051 CommunityCare, GlobalHealth, PacifiCare
73052 GlobalHealth
73053 GlobalHealth
73054 CommunityCare, GlobalHealth, PacifiCare
73055 GlobalHealth
73056 CommunityCare, GlobalHealth, PacifiCare
73057 GlobalHealth, PacifiCare
73058 CommunityCare, GlobalHealth, PacifiCare
73059 GlobalHealth, PacifiCare
73061 CommunityCare, GlobalHealth
73062 GlobalHealth
73063 CommunityCare, GlobalHealth, PacifiCare
73064 CommunityCare, GlobalHealth, PacifiCare
73065 GlobalHealth, PacifiCare
73066 CommunityCare, GlobalHealth, PacifiCare
73067 GlobalHealth, PacifiCare
73068 CommunityCare, GlobalHealth, PacifiCare
73069 CommunityCare, GlobalHealth, PacifiCare
73070 CommunityCare, GlobalHealth, PacifiCare
73071 CommunityCare, GlobalHealth, PacifiCare
73072 CommunityCare, GlobalHealth, PacifiCare
73073 CommunityCare, GlobalHealth, PacifiCare
73074 GlobalHealth
73075 GlobalHealth
73077 CommunityCare, GlobalHealth
73078 CommunityCare, GlobalHealth, PacifiCare
73079 GlobalHealth, PacifiCare
73080 GlobalHealth, PacifiCare
73082 GlobalHealth
73083 CommunityCare, GlobalHealth, PacifiCare
73084 CommunityCare, GlobalHealth, PacifiCare
73085 CommunityCare, GlobalHealth, PacifiCare
73086 GlobalHealth
73089 GlobalHealth, PacifiCare
73090 CommunityCare, GlobalHealth, PacifiCare
73092 GlobalHealth, PacifiCare
73093 GlobalHealth, PacifiCare
73094 GlobalHealth
73095 GlobalHealth, PacifiCare
73096 GlobalHealth
73097 CommunityCare, GlobalHealth, PacifiCare
73098 GlobalHealth
73099 CommunityCare, GlobalHealth, PacifiCare
73100 CommunityCare
73101 CommunityCare, GlobalHealth, PacifiCare
73102 CommunityCare, GlobalHealth, PacifiCare
73103 CommunityCare, GlobalHealth, PacifiCare
73104 CommunityCare, GlobalHealth, PacifiCare
73105 CommunityCare, GlobalHealth, PacifiCare
73106 CommunityCare, GlobalHealth, PacifiCare
73107 CommunityCare, GlobalHealth, PacifiCare
73108 CommunityCare, GlobalHealth, PacifiCare
73109 CommunityCare, GlobalHealth, PacifiCare
73110 CommunityCare, GlobalHealth, PacifiCare
73111 CommunityCare, GlobalHealth, PacifiCare
73112 CommunityCare, GlobalHealth, PacifiCare
73113 CommunityCare, GlobalHealth, PacifiCare
73114 CommunityCare, GlobalHealth, PacifiCare
73115 CommunityCare, GlobalHealth, PacifiCare
73116 CommunityCare, GlobalHealth, PacifiCare
73117 CommunityCare, GlobalHealth, PacifiCare
73118 CommunityCare, GlobalHealth, PacifiCare
73119 CommunityCare, GlobalHealth, PacifiCare
73120 CommunityCare, GlobalHealth, PacifiCare
73121 CommunityCare, GlobalHealth, PacifiCare
73122 CommunityCare, GlobalHealth, PacifiCare
73123 CommunityCare, GlobalHealth, PacifiCare
73124 CommunityCare, GlobalHealth, PacifiCare
73125 CommunityCare, GlobalHealth, PacifiCare
73126 CommunityCare, GlobalHealth, PacifiCare
73127 CommunityCare, GlobalHealth, PacifiCare
73128 CommunityCare, GlobalHealth, PacifiCare
73129 CommunityCare, GlobalHealth, PacifiCare
73130 CommunityCare, GlobalHealth, PacifiCare
73131 CommunityCare, GlobalHealth, PacifiCare
73132 CommunityCare, GlobalHealth, PacifiCare
73134 CommunityCare, GlobalHealth, PacifiCare
73135 CommunityCare, GlobalHealth, PacifiCare
73136 CommunityCare, GlobalHealth, PacifiCare
73137 CommunityCare, GlobalHealth, PacifiCare
73139 CommunityCare, GlobalHealth, PacifiCare
73140 CommunityCare, GlobalHealth, PacifiCare
73141 CommunityCare, GlobalHealth, PacifiCare
73142 CommunityCare, GlobalHealth, PacifiCare
73143 CommunityCare, GlobalHealth, PacifiCare
73144 CommunityCare, GlobalHealth, PacifiCare
73145 CommunityCare, GlobalHealth, PacifiCare
73146 CommunityCare, GlobalHealth, PacifiCare
73147 CommunityCare, GlobalHealth, PacifiCare
73148 CommunityCare, GlobalHealth, PacifiCare
73149 CommunityCare, GlobalHealth, PacifiCare
73150 CommunityCare, GlobalHealth, PacifiCare
73151 CommunityCare, GlobalHealth, PacifiCare
73152 CommunityCare, GlobalHealth, PacifiCare
73153 CommunityCare, GlobalHealth, PacifiCare
73154 CommunityCare, GlobalHealth, PacifiCare
73155 CommunityCare, GlobalHealth, PacifiCare
73156 CommunityCare, GlobalHealth, PacifiCare
73157 CommunityCare, GlobalHealth, PacifiCare
73159 CommunityCare, GlobalHealth, PacifiCare
73160 CommunityCare, GlobalHealth, PacifiCare
73162 CommunityCare, GlobalHealth, PacifiCare
73163 CommunityCare, GlobalHealth, PacifiCare
73164 CommunityCare, GlobalHealth, PacifiCare
73165 CommunityCare, GlobalHealth, PacifiCare
73167 CommunityCare, GlobalHealth, PacifiCare
73169 CommunityCare, GlobalHealth, PacifiCare
73170 CommunityCare, GlobalHealth, PacifiCare
73172 CommunityCare, GlobalHealth, PacifiCare
73173 CommunityCare, GlobalHealth, PacifiCare
73177 CommunityCare, PacifiCare
73178 CommunityCare, GlobalHealth, PacifiCare
73179 CommunityCare, GlobalHealth, PacifiCare
73180 CommunityCare, PacifiCare
73184 CommunityCare, GlobalHealth, PacifiCare
73185 CommunityCare, GlobalHealth, PacifiCare
73189 CommunityCare, GlobalHealth, PacifiCare
73190 CommunityCare, GlobalHealth, PacifiCare
73193 CommunityCare, PacifiCare
73194 CommunityCare, GlobalHealth, PacifiCare
73195 CommunityCare, GlobalHealth, PacifiCare
73196 CommunityCare, GlobalHealth, PacifiCare
73197 CommunityCare, PacifiCare
73198 CommunityCare, GlobalHealth, PacifiCare
73199 CommunityCare, PacifiCare
73401 GlobalHealth
73402 GlobalHealth
73403 GlobalHealth
73425 GlobalHealth
73430 GlobalHealth
73432 GlobalHealth
73433 GlobalHealth
73434 GlobalHealth
73435 GlobalHealth
73436 GlobalHealth
73437 GlobalHealth
73438 GlobalHealth
73441 GlobalHealth
73442 GlobalHealth
73443 GlobalHealth
73444 GlobalHealth
73447 GlobalHealth
73448 GlobalHealth
73449 GlobalHealth
73450 GlobalHealth
73453 GlobalHealth
73455 GlobalHealth
73456 GlobalHealth
73458 GlobalHealth
73459 GlobalHealth
73460 GlobalHealth
73461 GlobalHealth
73463 GlobalHealth
73481 GlobalHealth
73487 GlobalHealth
73488 GlobalHealth
73491 GlobalHealth
73501 GlobalHealth
73502 GlobalHealth
73503 GlobalHealth
73505 GlobalHealth
73506 GlobalHealth
73507 GlobalHealth
73520 GlobalHealth
73521 GlobalHealth
73522 GlobalHealth
73523 GlobalHealth
73526 GlobalHealth
73527 GlobalHealth
73528 GlobalHealth
73529 GlobalHealth
73530 GlobalHealth
73532 GlobalHealth
73533 GlobalHealth
73534 GlobalHealth
73536 GlobalHealth
73537 GlobalHealth
73538 GlobalHealth
73539 GlobalHealth
73540 GlobalHealth
73541 GlobalHealth
73542 GlobalHealth
73543 GlobalHealth
73544 GlobalHealth
73546 GlobalHealth
73548 GlobalHealth
73549 GlobalHealth
73550 GlobalHealth
73551 GlobalHealth
73552 GlobalHealth
73553 GlobalHealth
73555 GlobalHealth
73556 GlobalHealth
73557 GlobalHealth
73558 GlobalHealth
73559 GlobalHealth
73560 GlobalHealth
73561 GlobalHealth
73564 GlobalHealth
73565 GlobalHealth
73566 GlobalHealth
73567 GlobalHealth
73569 GlobalHealth
73570 GlobalHealth
73571 GlobalHealth
73573 GlobalHealth
73601 GlobalHealth
73620 GlobalHealth
73622 GlobalHealth
73624 GlobalHealth
73625 GlobalHealth
73626 GlobalHealth
73627 GlobalHealth
73632 GlobalHealth
73639 GlobalHealth
73641 GlobalHealth
73644 GlobalHealth
73645 GlobalHealth
73647 GlobalHealth
73648 GlobalHealth
73651 GlobalHealth
73655 GlobalHealth
73661 GlobalHealth
73662 GlobalHealth
73664 GlobalHealth
73668 GlobalHealth
73669 GlobalHealth
73701 GlobalHealth
73702 GlobalHealth
73703 GlobalHealth
73705 GlobalHealth
73706 GlobalHealth
73718 GlobalHealth
73720 GlobalHealth
73724 GlobalHealth
73727 GlobalHealth
73729 GlobalHealth
73730 GlobalHealth
73733 GlobalHealth
73734 GlobalHealth
73735 GlobalHealth
73736 GlobalHealth
73737 GlobalHealth
73738 GlobalHealth
73742 GlobalHealth
73743 GlobalHealth
73744 GlobalHealth
73747 GlobalHealth
73750 GlobalHealth
73753 GlobalHealth
73754 GlobalHealth
73755 GlobalHealth
73756 GlobalHealth
73757 CommunityCare, GlobalHealth
73758 GlobalHealth
73759 GlobalHealth
73760 GlobalHealth
73761 GlobalHealth
73762 GlobalHealth, PacifiCare
73763 GlobalHealth
73764 GlobalHealth
73766 GlobalHealth
73768 GlobalHealth
73770 GlobalHealth
73771 GlobalHealth
73772 GlobalHealth
73773 GlobalHealth
73834 GlobalHealth
73838 GlobalHealth
73848 GlobalHealth
73851 GlobalHealth
73855 GlobalHealth
73901 GlobalHealth
73939 GlobalHealth
73942 GlobalHealth
73944 GlobalHealth
73945 GlobalHealth
73951 GlobalHealth
74001 CommunityCare, GlobalHealth
74002 CommunityCare, GlobalHealth, PacifiCare
74003 CommunityCare, GlobalHealth
74004 CommunityCare, GlobalHealth
74005 CommunityCare, GlobalHealth
74006 CommunityCare, GlobalHealth
74008 CommunityCare, GlobalHealth, PacifiCare
74009 CommunityCare
74010 CommunityCare, GlobalHealth, PacifiCare
74011 CommunityCare, GlobalHealth, PacifiCare
74012 CommunityCare, GlobalHealth, PacifiCare
74013 CommunityCare, GlobalHealth, PacifiCare
74014 CommunityCare, GlobalHealth, PacifiCare
74015 CommunityCare, GlobalHealth, PacifiCare
74016 CommunityCare, GlobalHealth, PacifiCare
74017 CommunityCare, GlobalHealth, PacifiCare
74018 CommunityCare, GlobalHealth, PacifiCare
74019 CommunityCare, GlobalHealth, PacifiCare
74020 CommunityCare, GlobalHealth, PacifiCare
74021 CommunityCare, GlobalHealth, PacifiCare
74022 CommunityCare, GlobalHealth
74023 CommunityCare, GlobalHealth, PacifiCare
74026 GlobalHealth, PacifiCare
74027 CommunityCare, GlobalHealth
74028 CommunityCare, GlobalHealth, PacifiCare
74029 CommunityCare, GlobalHealth
74030 CommunityCare, GlobalHealth, PacifiCare
74031 CommunityCare, GlobalHealth, PacifiCare
74032 CommunityCare, GlobalHealth, PacifiCare
74033 CommunityCare, GlobalHealth, PacifiCare
74034 CommunityCare, GlobalHealth
74035 CommunityCare, GlobalHealth, PacifiCare
74036 CommunityCare, GlobalHealth, PacifiCare
74037 CommunityCare, GlobalHealth, PacifiCare
74038 CommunityCare, GlobalHealth, PacifiCare
74039 CommunityCare, GlobalHealth, PacifiCare
74041 CommunityCare, GlobalHealth, PacifiCare
74042 CommunityCare, GlobalHealth
74043 CommunityCare, GlobalHealth, PacifiCare
74044 CommunityCare, GlobalHealth, PacifiCare
74045 CommunityCare, GlobalHealth
74046 CommunityCare, GlobalHealth, PacifiCare
74047 CommunityCare, GlobalHealth, PacifiCare
74048 CommunityCare, GlobalHealth
74050 CommunityCare, GlobalHealth, PacifiCare
74051 CommunityCare, GlobalHealth
74052 CommunityCare, GlobalHealth, PacifiCare
74053 CommunityCare, GlobalHealth, PacifiCare
74054 CommunityCare, GlobalHealth, PacifiCare
74055 CommunityCare, GlobalHealth, PacifiCare
74056 CommunityCare, GlobalHealth
74058 CommunityCare, GlobalHealth
74059 CommunityCare, GlobalHealth, PacifiCare
74060 CommunityCare, GlobalHealth, PacifiCare
74061 CommunityCare, GlobalHealth, PacifiCare
74062 CommunityCare, GlobalHealth, PacifiCare
74063 CommunityCare, GlobalHealth, PacifiCare
74066 CommunityCare, GlobalHealth, PacifiCare
74067 CommunityCare, GlobalHealth, PacifiCare
74068 CommunityCare, GlobalHealth, PacifiCare
74070 CommunityCare, GlobalHealth, PacifiCare
74071 CommunityCare, GlobalHealth, PacifiCare
74072 CommunityCare, GlobalHealth
74073 CommunityCare, GlobalHealth, PacifiCare
74074 CommunityCare, GlobalHealth, PacifiCare
74075 CommunityCare, GlobalHealth, PacifiCare
74076 CommunityCare, GlobalHealth, PacifiCare
74077 CommunityCare, GlobalHealth
74078 CommunityCare, GlobalHealth
74079 GlobalHealth, PacifiCare
74080 CommunityCare, GlobalHealth, PacifiCare
74081 CommunityCare, GlobalHealth, PacifiCare
74082 CommunityCare, GlobalHealth, PacifiCare
74083 CommunityCare, GlobalHealth
74084 CommunityCare, GlobalHealth
74085 CommunityCare, GlobalHealth, PacifiCare
74100 CommunityCare
74101 CommunityCare, GlobalHealth, PacifiCare
74102 CommunityCare, GlobalHealth, PacifiCare
74103 CommunityCare, GlobalHealth, PacifiCare
74104 CommunityCare, GlobalHealth, PacifiCare
74105 CommunityCare, GlobalHealth, PacifiCare
74106 CommunityCare, GlobalHealth, PacifiCare
74107 CommunityCare, GlobalHealth, PacifiCare
74108 CommunityCare, GlobalHealth, PacifiCare
74110 CommunityCare, GlobalHealth, PacifiCare
74112 CommunityCare, GlobalHealth, PacifiCare
74114 CommunityCare, GlobalHealth, PacifiCare
74115 CommunityCare, GlobalHealth, PacifiCare
74116 CommunityCare, GlobalHealth, PacifiCare
74117 CommunityCare, GlobalHealth, PacifiCare
74119 CommunityCare, GlobalHealth, PacifiCare
74120 CommunityCare, GlobalHealth, PacifiCare
74121 CommunityCare, GlobalHealth, PacifiCare
74126 CommunityCare, GlobalHealth, PacifiCare
74127 CommunityCare, GlobalHealth, PacifiCare
74128 CommunityCare, GlobalHealth, PacifiCare
74129 CommunityCare, GlobalHealth, PacifiCare
74130 CommunityCare, GlobalHealth, PacifiCare
74131 CommunityCare, GlobalHealth, PacifiCare
74132 CommunityCare, GlobalHealth, PacifiCare
74133 CommunityCare, GlobalHealth, PacifiCare
74134 CommunityCare, GlobalHealth, PacifiCare
74135 CommunityCare, GlobalHealth, PacifiCare
74136 CommunityCare, GlobalHealth, PacifiCare
74137 CommunityCare, GlobalHealth, PacifiCare
74141 CommunityCare, GlobalHealth, PacifiCare
74145 CommunityCare, GlobalHealth, PacifiCare
74146 CommunityCare, GlobalHealth, PacifiCare
74147 CommunityCare, GlobalHealth, PacifiCare
74148 CommunityCare, GlobalHealth, PacifiCare
74149 CommunityCare, GlobalHealth, PacifiCare
74150 CommunityCare, GlobalHealth, PacifiCare
74152 CommunityCare, GlobalHealth, PacifiCare
74153 CommunityCare, GlobalHealth, PacifiCare
74155 CommunityCare, GlobalHealth, PacifiCare
74156 CommunityCare, GlobalHealth, PacifiCare
74157 CommunityCare, GlobalHealth, PacifiCare
74158 CommunityCare, GlobalHealth, PacifiCare
74159 CommunityCare, GlobalHealth, PacifiCare
74169 CommunityCare, GlobalHealth, PacifiCare
74170 CommunityCare, GlobalHealth, PacifiCare
74171 CommunityCare, GlobalHealth, PacifiCare
74172 CommunityCare, GlobalHealth, PacifiCare
74182 CommunityCare, GlobalHealth, PacifiCare
74183 CommunityCare, PacifiCare
74184 CommunityCare
74186 CommunityCare, GlobalHealth, PacifiCare
74187 CommunityCare, GlobalHealth, PacifiCare
74189 CommunityCare, PacifiCare
74192 CommunityCare, GlobalHealth, PacifiCare
74193 CommunityCare, GlobalHealth, PacifiCare
74194 CommunityCare, PacifiCare
74301 CommunityCare, GlobalHealth, PacifiCare
74330 CommunityCare, GlobalHealth, PacifiCare
74331 CommunityCare, GlobalHealth
74332 CommunityCare, GlobalHealth
74333 CommunityCare, GlobalHealth
74335 CommunityCare, GlobalHealth
74337 CommunityCare, GlobalHealth, PacifiCare
74338 CommunityCare, GlobalHealth
74339 CommunityCare, GlobalHealth
74340 CommunityCare, GlobalHealth, PacifiCare
74342 CommunityCare, GlobalHealth
74343 CommunityCare, GlobalHealth
74344 CommunityCare, GlobalHealth
74345 CommunityCare, GlobalHealth
74346 CommunityCare, GlobalHealth
74347 CommunityCare, GlobalHealth
74349 CommunityCare, GlobalHealth, PacifiCare
74350 CommunityCare, GlobalHealth, PacifiCare
74352 CommunityCare, GlobalHealth, PacifiCare
74353 CommunityCare, PacifiCare
74354 CommunityCare, GlobalHealth
74355 CommunityCare, GlobalHealth
74358 CommunityCare, GlobalHealth
74359 CommunityCare, GlobalHealth
74360 CommunityCare, GlobalHealth
74361 CommunityCare, GlobalHealth, PacifiCare
74362 CommunityCare, GlobalHealth, PacifiCare
74363 CommunityCare, GlobalHealth
74364 CommunityCare, GlobalHealth, PacifiCare
74365 CommunityCare, GlobalHealth, PacifiCare
74366 CommunityCare, GlobalHealth, PacifiCare
74367 CommunityCare, GlobalHealth, PacifiCare
74368 CommunityCare, GlobalHealth
74369 CommunityCare, GlobalHealth
74370 CommunityCare, GlobalHealth
74401 CommunityCare, GlobalHealth
74402 CommunityCare, GlobalHealth
74403 CommunityCare, GlobalHealth
74421 CommunityCare, GlobalHealth, PacifiCare
74422 CommunityCare, GlobalHealth, PacifiCare
74423 CommunityCare, GlobalHealth
74425 CommunityCare, GlobalHealth
74426 CommunityCare, GlobalHealth
74427 CommunityCare, GlobalHealth
74428 CommunityCare, GlobalHealth
74429 CommunityCare, GlobalHealth, PacifiCare
74430 CommunityCare, GlobalHealth
74431 CommunityCare, GlobalHealth, PacifiCare
74432 CommunityCare, GlobalHealth
74434 CommunityCare, GlobalHealth
74435 CommunityCare, GlobalHealth
74436 CommunityCare, GlobalHealth, PacifiCare
74437 CommunityCare, GlobalHealth, PacifiCare
74438 CommunityCare, GlobalHealth
74439 CommunityCare, GlobalHealth
74440 CommunityCare, GlobalHealth
74441 CommunityCare, GlobalHealth
74442 CommunityCare, GlobalHealth
74444 CommunityCare, GlobalHealth
74445 CommunityCare, GlobalHealth, PacifiCare
74446 CommunityCare, GlobalHealth, PacifiCare
74447 CommunityCare, GlobalHealth, PacifiCare
74450 CommunityCare, GlobalHealth
74451 CommunityCare, GlobalHealth
74452 CommunityCare, GlobalHealth
74454 CommunityCare, GlobalHealth, PacifiCare
74455 CommunityCare, GlobalHealth
74456 CommunityCare, GlobalHealth, PacifiCare
74457 CommunityCare, GlobalHealth
74458 CommunityCare, GlobalHealth, PacifiCare
74459 CommunityCare, GlobalHealth
74460 CommunityCare, GlobalHealth, PacifiCare
74461 CommunityCare, GlobalHealth
74462 CommunityCare, GlobalHealth
74463 CommunityCare, GlobalHealth
74464 CommunityCare, GlobalHealth
74465 CommunityCare, GlobalHealth
74466 CommunityCare, PacifiCare
74467 CommunityCare, GlobalHealth, PacifiCare
74468 CommunityCare, GlobalHealth
74469 CommunityCare, GlobalHealth
74470 CommunityCare, GlobalHealth
74471 CommunityCare, GlobalHealth
74472 CommunityCare, GlobalHealth
74477 CommunityCare, GlobalHealth, PacifiCare
74501 CommunityCare, GlobalHealth
74502 CommunityCare, GlobalHealth
74521 CommunityCare, GlobalHealth
74522 CommunityCare, GlobalHealth
74523 CommunityCare, GlobalHealth
74526 CommunityCare
74528 CommunityCare, GlobalHealth
74529 CommunityCare, GlobalHealth
74530 GlobalHealth
74531 GlobalHealth
74536 CommunityCare, GlobalHealth
74543 CommunityCare, GlobalHealth
74545 CommunityCare
74546 CommunityCare, GlobalHealth
74547 CommunityCare, GlobalHealth
74548 CommunityCare
74549 CommunityCare, GlobalHealth
74552 CommunityCare, GlobalHealth
74553 CommunityCare, GlobalHealth
74554 CommunityCare, GlobalHealth
74557 CommunityCare, GlobalHealth
74558 CommunityCare, GlobalHealth
74559 CommunityCare
74560 CommunityCare, GlobalHealth
74561 CommunityCare, GlobalHealth
74562 CommunityCare, GlobalHealth
74563 CommunityCare
74565 CommunityCare, GlobalHealth
74567 CommunityCare, GlobalHealth
74570 CommunityCare, GlobalHealth
74571 CommunityCare
74574 CommunityCare, GlobalHealth
74576 CommunityCare, GlobalHealth
74577 CommunityCare, GlobalHealth
74578 CommunityCare
74601 GlobalHealth
74602 GlobalHealth
74604 CommunityCare, GlobalHealth
74630 CommunityCare, GlobalHealth
74631 GlobalHealth
74632 GlobalHealth
74633 CommunityCare, GlobalHealth
74636 GlobalHealth
74637 CommunityCare, GlobalHealth
74640 GlobalHealth
74641 GlobalHealth
74643 GlobalHealth
74644 CommunityCare, GlobalHealth
74646 GlobalHealth
74647 GlobalHealth
74650 CommunityCare, GlobalHealth
74651 CommunityCare, GlobalHealth
74652 CommunityCare, GlobalHealth
74653 GlobalHealth
74701 GlobalHealth
74702 GlobalHealth
74720 GlobalHealth
74721 GlobalHealth
74722 GlobalHealth
74723 GlobalHealth
74724 GlobalHealth
74726 GlobalHealth
74727 CommunityCare, GlobalHealth
74728 GlobalHealth
74729 GlobalHealth
74730 GlobalHealth
74731 GlobalHealth
74733 GlobalHealth
74734 GlobalHealth
74735 CommunityCare, GlobalHealth
74736 GlobalHealth
74737 GlobalHealth
74738 CommunityCare, GlobalHealth
74740 GlobalHealth
74741 GlobalHealth
74743 CommunityCare, GlobalHealth
74745 GlobalHealth
74747 GlobalHealth
73748 GlobalHealth
74750 GlobalHealth
74752 GlobalHealth
74753 GlobalHealth
74754 GlobalHealth
74755 GlobalHealth
74756 CommunityCare, GlobalHealth
74759 CommunityCare, GlobalHealth
74760 CommunityCare, GlobalHealth
74761 CommunityCare, GlobalHealth
74764 GlobalHealth
74766 GlobalHealth
74801 GlobalHealth, PacifiCare
74802 GlobalHealth, PacifiCare
74804 GlobalHealth, PacifiCare
74818 CommunityCare, GlobalHealth, PacifiCare
74820 GlobalHealth
74821 GlobalHealth
74824 GlobalHealth, PacifiCare
74825 GlobalHealth
74826 GlobalHealth, PacifiCare
74827 GlobalHealth
74829 GlobalHealth, PacifiCare
74830 CommunityCare, GlobalHealth, PacifiCare
74831 GlobalHealth, PacifiCare
74832 GlobalHealth, PacifiCare
74833 GlobalHealth, PacifiCare
74834 GlobalHealth, PacifiCare
74835 PacifiCare
74836 GlobalHealth
74837 CommunityCare, GlobalHealth, PacifiCare
74838 PacifiCare
74839 GlobalHealth
74840 GlobalHealth, PacifiCare
74842 GlobalHealth
74843 GlobalHealth
74844 GlobalHealth
74845 CommunityCare, GlobalHealth
74848 GlobalHealth
74849 CommunityCare, GlobalHealth, PacifiCare
74850 GlobalHealth
74851 GlobalHealth, PacifiCare
74852 GlobalHealth, PacifiCare
74854 GlobalHealth, PacifiCare
74855 GlobalHealth, PacifiCare
74856 GlobalHealth
74857 GlobalHealth, PacifiCare
74859 GlobalHealth, PacifiCare
74860 GlobalHealth, PacifiCare
74862 PacifiCare
74864 GlobalHealth, PacifiCare
74865 GlobalHealth
74866 GlobalHealth, PacifiCare
74867 CommunityCare, GlobalHealth, PacifiCare
74868 GlobalHealth, PacifiCare
74869 GlobalHealth, PacifiCare
74871 GlobalHealth
74872 GlobalHealth
74873 GlobalHealth, PacifiCare
74875 GlobalHealth, PacifiCare
74878 GlobalHealth, PacifiCare
74880 CommunityCare, GlobalHealth, PacifiCare
74881 GlobalHealth, PacifiCare
74882 PacifiCare
74883 GlobalHealth
74884 CommunityCare, GlobalHealth, PacifiCare
74901 CommunityCare, GlobalHealth
74902 CommunityCare, GlobalHealth
74930 CommunityCare, GlobalHealth
74931 CommunityCare, GlobalHealth
74932 CommunityCare, GlobalHealth
74935 CommunityCare, GlobalHealth
74936 CommunityCare, GlobalHealth
74937 CommunityCare, GlobalHealth
74939 CommunityCare, GlobalHealth
74940 CommunityCare, GlobalHealth
74941 CommunityCare, GlobalHealth
74942 CommunityCare, GlobalHealth
74943 CommunityCare, GlobalHealth
74944 CommunityCare, GlobalHealth
74945 CommunityCare, GlobalHealth
74946 CommunityCare, GlobalHealth
74947 CommunityCare, GlobalHealth
74948 CommunityCare, GlobalHealth
74949 CommunityCare, GlobalHealth
74951 CommunityCare, GlobalHealth
74953 CommunityCare, GlobalHealth
74954 CommunityCare, GlobalHealth
74955 CommunityCare, GlobalHealth
74956 CommunityCare, GlobalHealth
74957 GlobalHealth
74959 CommunityCare, GlobalHealth
74960 CommunityCare, GlobalHealth
74962 CommunityCare, GlobalHealth
74963 GlobalHealth
74964 CommunityCare, GlobalHealth
74965 CommunityCare, GlobalHealth
74966 CommunityCare, GlobalHealth
COMPARISON OF BENEFITS FOR HEALTH PLANS – ALL PLANS
This is only a sample of the services covered by each plan. For services that are not listed in this comparison chart, contact each plan. Refer to the Help Lines at the end of this document for contact information.
HealthChoice members do not need to designate a primary care physician and can change physicians at any time.
This chart reflects your cost for the listed Network services.
Calendar Year Deductibles
HealthChoice High Option
$500 individual and $1,500 family
HealthChoice Basic Plan
$500 individual and $1,000 family; deductible applies after Plan pays first $500 of Allowed Charges
HealthChoice S-Account
$1,500 individual and $3,000 family; the combined medical and pharmacy deductible must be met before benefits are paid
HMO Standard Option
No deductible
CommunityCare Alternative HMO
No deductible
GlobalHealth Alternative HMO
No deductible
PacifiCare Alternative HMO
No deductible
Calendar Year Out-of-Pocket Maximum
HealthChoice High Option
$2,800 Network, individual and $3,300 non-Network individual, plus amounts over Allowed Charges
HealthChoice Basic Plan
$5,500 individual and $11,000 family
HealthChoice S-Account
$4,000 individual and $8,000 family; non-Network charges do not apply
HMO Standard Option
$2,500 individual and $5,000 family
CommunityCare Alternative HMO
$3,000 individual and $6,000 family
GlobalHealth Alternative HMO
$3,000 individual and $5,000 family
PacifiCare Alternative HMO
$2,500 individual and $5,000 family
Office Visit (Professional Services)
HealthChoice High Option
$30 copay/primary care physician office visit and $50 copay/specialist office visit
HealthChoice Basic Plan
Copays do not apply; refer to the HealthChoice Basic Plan Benefits for more specific plan information
HealthChoice S-Account
Member pays 100% of Allowed Charges until deductible is met; $50 copay applies after deductible
HMO Standard Option
$30 copay/PCP and $40 copay/specialist
CommunityCare Alternative HMO
$35 copay/PCP and $50 copay/specialist
GlobalHealth Alternative HMO
$25 copay/PCP and $50 copay/specialist
PacifiCare Alternative HMO
$35 copay/PCP and $50 copay/specialist
Diagnostic X-ray and Lab
HealthChoice High Option
20% of Allowed Charges after deductible
HealthChoice Basic Plan
Refer to the HealthChoice Basic Plan Benefits for more specific plan information
HealthChoice S-Account
20% of Allowed Charges after deductible
HMO Standard Option
No copay for laboratory services or outpatient radiology; $150 copay per MRI, CAT, MRA, or PET scan
CommunityCare Alternative HMO
No additional copay for laboratory services or outpatient radiology; $200 copay per MRI, CAT, MRA, or PET scan
GlobalHealth Alternative HMO
$0 copay; $250 copay per MRI, MRA, PET, CAT, or nuclear scan
PacifiCare Alternative HMO
$0 copay for standard lab and radiology; $200 copay per MRI, MRA, PET, or CAT scan
Hospital Inpatient Admission
HealthChoice High Option
20% of Allowed Charges after deductible; additional $300 deductible per non-Network admission
HealthChoice Basic Plan
Refer to the HealthChoice Basic Plan Benefits for more specific plan information
HealthChoice S-Account
20% of Allowed Charges after deductible; additional $300 deductible per non-Network admission
HMO Standard Option
$350 copay; preauthorization required
CommunityCare Alternative HMO
$500 copay; preauthorization required
GlobalHealth Alternative HMO
$250 copay per day; $750 maximum per admission; preauthorization required
PacifiCare Alternative HMO
$1,000 copay/admission
Hospital Outpatient Visit
HealthChoice High Option
20% of Allowed Charges after deductible
HealthChoice Basic Plan
Refer to the HealthChoice Basic Plan Benefits for more specific plan information
HealthChoice S-Account
20% of Allowed Charges after deductible
HMO Standard Option
$250 copay; preauthorization required
CommunityCare Alternative HMO
$300 copay
GlobalHealth Alternative HMO
$250 copay; preauthorization required
PacifiCare Alternative HMO
$500 copay
Well Child Care Visit
HealthChoice High Option
$0 copay; no deductible applies; according to the following schedule
Age 0 to 12 months – 8 visits
Age 1 through 2 years – 4 visits
Age 3 through 5 years – 2 visits
Age 6 through 19 years – 1 visits
HealthChoice Basic Plan
Refer to the HealthChoice Basic Plan Benefits for more specific plan information
HealthChoice S-Account
$50 copay; no deductible applies
HMO Standard Option
$0 copay
CommunityCare Alternative HMO
$0 copay
GlobalHealth Alternative HMO
$0 copay ages 0-21
PacifiCare Alternative HMO
$0 copay
Immunizations
HealthChoice High Option
No charge for well child and adult immunizations; $30/$50 office visit copay and/or administration fee may apply
HealthChoice Basic Plan
Refer to the HealthChoice Basic Plan Benefits for more specific plan information
HealthChoice S-Account
No charge for well child and adult immunizations; $50 office visit copay and/or administration fee may apply
HMO Standard Option
$0 copay ages birth through age 18; $0 copay ages 19 and over
CommunityCare Alternative HMO
$0 copay ages birth through age 18 years; $0 copay ages 19 and over; when medically necessary
GlobalHealth Alternative HMO
$0 copay; office visit copay may apply
PacifiCare Alternative HMO
$0 copay ages birth through age 18 (if no other service is rendered); $0 copay ages 19 and over
Periodic Health Exams
HealthChoice High Option
$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
HealthChoice Basic Plan
One mammogram per year at no charge for women age 40 and over; refer to the HealthChoice Basic Plan Benefits for more specific plan information
HealthChoice S-Account
$50 copay per exam, one mammogram per year at no charge for women age 40 and older
HMO Standard Option
$0 copay per visit for routine physicals
CommunityCare Alternative HMO
$0 copay
GlobalHealth Alternative HMO
$0 copay/PCP; Limit: one per year
PacifiCare Alternative HMO
$0 copay/PCP; $50 copay/specialist
Allergy Treatment and Testing
HealthChoice High Option
20% of Allowed Charges after deductible; Limit: 60 tests every 24 months
HealthChoice Basic Plan
Refer to the HealthChoice Basic Plan Benefits for more specific plan information
HealthChoice S-Account
20% of Allowed Charges after deductible; Limit: 60 tests every 24 months
HMO Standard Option
$30 copay/PCP; $40 copay/specialist; $30 serum and shots including a 6-week supply of antigen
CommunityCare Alternative HMO
$35 copay/PCP; $50 copay/specialist; $30 serum and shots including a 6-week supply of antigen
GlobalHealth Alternative HMO
$25 copay/PCP; $50 copay/specialist; $30 serum and shots including a 6-week supply of antigen
PacifiCare Alternative HMO
$35 copay/PCP; $50 copay/specialist; $35 serum and shots including a 6-week supply of antigen
Emergency Health Care Facility Visit
HealthChoice High Option
20% of Allowed Charges after deductible; Additional $100 ER deductible, waived if admitted
HealthChoice Basic Plan
Refer to the HealthChoice Basic Plan Benefits for more specific plan information
HealthChoice S-Account
20% of Allowed Charges after deductible; Additional $100 ER deductible, waived if admitted
HMO Standard Option
$150 copay; waived if admitted
CommunityCare Alternative HMO
$200 copay; waived if admitted
GlobalHealth Alternative HMO
$150 copay; waived if admitted
PacifiCare Alternative HMO
$200 copay; waived if admitted
After Hours Urgent Care
HealthChoice High Option
20% of Allowed Charges after deductible
HealthChoice Basic Plan
Refer to the HealthChoice Basic Plan Benefits for more specific plan information
HealthChoice S-Account
20% of Allowed Charges after deductible
HMO Standard Option
$40 copay per visit
CommunityCare Alternative HMO
$50 copay per visit; preauthorization required
GlobalHealth Alternative HMO
$25 copay/PCP; $50 copay/all others; must use Network facilities
PacifiCare Alternative HMO
$50 copay per visit
Mental Health or Substance Abuse Inpatient Admission
*Mental Health Parity provides that certain biological conditions for severe mental illness are not limited as other mental health conditions. This does not apply to substance abuse.
HealthChoice High Option
20% of Allowed Charges after deductible; Limit: 30 days per year*
HealthChoice Basic Plan
Refer to the HealthChoice Basic Plan Benefits for more specific plan information
HealthChoice S-Account
20% of Allowed Charges after deductible; Limit: 30 days per year*
HMO Standard Option
$350 copay
CommunityCare Alternative HMO
$500 copay; must be preauthorized and approved through CCOK Behavioral Health Services
GlobalHealth Alternative HMO
$250 per day; $750 maximum per admission; must be preauthorized
PacifiCare Alternative HMO
$1,000 copay per admission
Mental Health or Substance Abuse Outpatient Visit
*Mental Health Parity provides that certain biological conditions for severe mental illness are not limited as other mental health conditions. This does not apply to substance abuse.
HealthChoice High Option
20% of Allowed Charges after deductible; Limit: 26 visits per year*
HealthChoice Basic Plan
Refer to the HealthChoice Basic Plan Benefits for more specific plan information
HealthChoice S-Account
20% of Allowed Charges after deductible; Limit: 26 visits per year*
HMO Standard Option
$30 copay/PCP; $40 copay/specialist
CommunityCare Alternative HMO
$35 copay/PCP; $50 copay/specialist; must be preauthorized and approved through CCOK Behavioral Health Services
GlobalHealth Alternative HMO
$25 copay; must be preauthorized
PacifiCare Alternative HMO
$35 copay/PCP; $50 copay/specialist
Durable Medical Equipment (DME)
HealthChoice High Option
20% of Allowed Charges after deductible for purchase, rental, repair, or replacement
HealthChoice Basic Plan
Refer to the HealthChoice Basic Plan Benefits for more specific plan information
HealthChoice S-Account
20% of Allowed Charges after deductible for purchase, rental, repair, or replacement
HMO Standard Option
20% coinsurance initial device; 20% coinsurance repair and replacement
CommunityCare Alternative HMO
20% coinsurance initial device; 20% coinsurance repair and replacement
GlobalHealth Alternative HMO
20% coinsurance
PacifiCare Alternative HMO
20% coinsurance
Occupational or Speech Therapy Visits
HealthChoice High Option
20% of Allowed Charges after deductible; For each service – Limit: 20 visits per year without certification; maximum of 60 visits per year
HealthChoice Basic Plan
Refer to the HealthChoice Basic Plan Benefits for more specific plan information
HealthChoice S-Account
20% of Allowed Charges after deductible; For each service – Limit: 20 visits per year without certification; maximum of 60 visits per year
HMO Standard Option
No copay inpatient; $30 copay/PCP; $40 copay/specialist; Limit: 60 treatment days per illness
CommunityCare Alternative HMO
No copay inpatient; $50 copay outpatient therapy; Limit: 60 days per illness
GlobalHealth Alternative HMO
No copay inpatient; $50 copay per outpatient therapy; Limit: 60 consecutive days per illness
PacifiCare Alternative HMO
$0 copay inpatient; $35 copay/PCP; $50 copay/specialist; Limit: 60 days per illness
Physical Therapy/Physical Medicine Visit
HealthChoice High Option
20% of Allowed Charges after deductible; Limit: 20 visits per year without certification; maximum of 60 visits per year
HealthChoice Basic Plan
Refer to the HealthChoice Basic Plan Benefits for more specific plan information
HealthChoice S-Account
20% of Allowed Charges after deductible; Limit: 20 visits per year without certification; maximum of 60 visits per year
HMO Standard Option
No copay inpatient; $30 copay/PCP; $40 copay/specialist; Limit: 60 treatment days per illness
CommunityCare Alternative HMO
No copay inpatient; $50 copay outpatient therapy; Limit: 60 days per illness
GlobalHealth Alternative HMO
No copay inpatient; $50 copay per outpatient visit; Limit: 60 consecutive days per illness
PacifiCare Alternative HMO
$0 copay inpatient; $35 copay/PCP; $50 copay/specialist; Limit: 60 days per illness
Chiropractic and Manipulative Therapy Visit
HealthChoice High Option
Chiropractic services - 20% of Allowed Charges after deductible; Limit: 20 visits per year without certification; maximum of 60 visits per year
Manipulative therapy - Refer to Physical Therapy/Physical Medicine
HealthChoice Basic Plan
Refer to the HealthChoice Basic Plan Benefits for more specific plan information
HealthChoice S-Account
Chiropractic services - 20% of Allowed Charges after deductible; Limit: 20 visits per year without certification; maximum of 60 visits per year
Manipulative therapy - Refer to Physical Therapy/Physical Medicine
HMO Standard Option
$40 copay; Limit: 15 visits per year; PCP referral required
CommunityCare Alternative HMO
$50 copay; Limit: 15 visits per year; PCP referral required
GlobalHealth Alternative HMO
$50 copay; must be preauthorized
PacifiCare Alternative HMO
$50 copay; Limit: 15 visits per year – referral required; Limited to treatment of neurological and orthopedic conditions
Maternity Pre and Post Natal Care
HealthChoice High Option
20% of Allowed Charges after deductible; Includes one postpartum home visit – criteria must be met
HealthChoice Basic Plan
Refer to the HealthChoice Basic Plan Benefits for more specific plan information
HealthChoice S-Account
20% of Allowed Charges after deductible; Includes one postpartum home visit – criteria must be met
HMO Standard Option
$30 copay for initial visit; $350 copay per hospital admission
CommunityCare Alternative HMO
$35 copay for initial visit; $500 copay per hospital admission
GlobalHealth Alternative HMO
$25 copay for initial visit only; $250 copay per hospital admission per day; $750 maximum per admission
PacifiCare Alternative HMO
$35 copay/PCP; $50 copay/specialist for initial visit once diagnosis of pregnancy is confirmed; $1,000 copay per hospital admission
Hearing Screening and Hearing Aids
HealthChoice High Option
$30 copay/primary care physician; $50 copay/specialist basic hearing screening; Limit: one per year; Hearing aids are covered as durable medical equipment for children up to age 18
HealthChoice Basic Plan
Refer to the HealthChoice Basic Plan Benefits for more specific plan information
HealthChoice S-Account
$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
HMO Standard Option
$0 copay children birth through age 21; $30 copay age 22 and over; Limit: one per year; Hearing aids – 20% coinsurance for children up to age 18
CommunityCare Alternative HMO
$0 copay; Limit: one per year; Hearing aids – 20% coinsurance for children up to age 18
GlobalHealth Alternative HMO
$0 copay children birth through age 21; $25 copay age 22 and over; Limit: one visit per year; Hearing aids – 20% coinsurance; Covered for children up to age 18
PacifiCare Alternative HMO
$0 copay/PCP; Hearing aids – covered for children up to age 18
Pharmacy Benefits
HealthChoice High Option and HealthChoice Basic Plan
$5 copay per fill for certain prescription tobacco cessation products
NETWORK:
Generic Mandate
PREFERRED MEDICATION:
If the cost of medication is $100 or less – you pay up to $30 or actual cost if less
If the cost of medication is more than $100 – you pay 25% up to a $60 maximum
Out-of-pocket maximum - $2,500 per person using Preferred products at Network pharmacies, then you pay $0
NON-PREFERRED MEDICATION:
If the cost of medication is $100 or less – you pay up to $60 or actual cost if less
If the cost of medication is more than $100 – you pay 50% up to a $120 maximum
Out-of-pocket maximums do not apply to non-Preferred medications
NOTE:
Pharmacy benefits may cover up to a 34-day supply or 100 units, whichever is greater
Some medications may have a limit on quantity and/or duration of therapy
Some medications require prior authorization
Specialty medications are covered when ordered through Accredo Health Group
If you choose a brand-name medication when a generic is available, you will be responsible for the difference in cost, plus the copay
NON-NETWORK:
PREFERRED MEDICATION:
You pay the cost of medication up to $75 maximum plus a dispensing fee
NON-PREFERRED MEDICATION:
You pay the cost of medication up to $125 maximum plus a dispensing fee
HealthChoice S-Account
After the combined medical and pharmacy deductible - $1,500 individual or $3,000 family - has been met, the pharmacy benefits are:
NETWORK:
Generic Mandate
PREFERRED MEDICATION:
If the cost of medication is $100 or less – you pay up to $30 or actual cost if less
If the cost of medication is more than $100 – you pay 25% up to a $60 maximum
NON-PREFERRED MEDICATION:
If the cost of medication is $100 or less – you pay up to $60 or actual cost if less
If the cost of medication is more than $100 – you pay 50% up to a $120 maximum
NOTE:
Pharmacy benefits may cover up to a 34-day supply or 100 units, whichever is greater
Some medications may have a limit on quantity and/or duration of therapy
Some medications require prior authorization
Specialty medications are covered when ordered through Accredo Health Group
If you choose a brand-name medication when a generic is available, you will be responsible for the difference in cost, plus the copay
NON-NETWORK:
PREFERRED MEDICATION:
You pay the cost of medication up to $75 maximum plus a dispensing fee
NON-PREFERRED MEDICATION:
You pay the cost of medication up to $125 maximum plus a dispensing fee
HMO Standard Option
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
CommunityCare Alternative HMO
Tier 1: $10
Tier 2: $40
Tier 3: $65
$0 copay for selected generics
Up to $65 non-formulary
30-day supply
Certain medications have restricted quantities
GlobalHealth Alternative HMO
Tier 1: $10
Tier 2: $50
Tier 3: $75
30-day supply
Certain medications may have restricted quantities
These copays do not apply to the maximum out-of-pocket
PacifiCare Alternative HMO
$5 copay for formulary generic drugs
$30 copay for formulary brand-name drugs
$60 copay for non-formulary generic and non-formulary brand drugs
Lesser of 30-day supply or 100 units
Certain medications have restricted quantities
HEALTHCHOICE HIGH OPTION PLAN BENEFITS
This is only a sample of the services covered by each plan. For services that are not listed in this comparison chart, contact each plan. Refer to the Help Lines at the end of this document for contact information.
HealthChoice members do not need to designate a primary care physician and can change physicians at any time.
This chart reflects your cost for the listed Network services.
Calendar Year Deductibles
$500 individual and $1,500 family
Calendar Year Out-of-Pocket Maximum
$2,800 Network, individual and $3,300 non-Network individual, plus amounts over Allowed Charges
Office Visit (Professional Services)
$30 copay/primary care physician office visit and $50 copay/specialist office visit
Diagnostic X-ray and Lab
20% of Allowed Charges after deductible
Hospital Inpatient Admission
20% of Allowed Charges after deductible; additional $300 deductible per non-Network admission
Hospital Outpatient Visit
20% of Allowed Charges after deductible
Well Child Care Visit
$0 copay; no deductible applies; according to the following schedule
Age 0 to 12 months – 8 visits
Age 1 through 2 years – 4 visits
Age 3 through 5 years – 2 visits
Age 6 through 19 years – 1 visits
Immunizations
No charge for well child and adult immunizations; $30/$50 office visit copay and/or administration fee may apply
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
Allergy Treatment and Testing
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
After Hours Urgent Care
20% of Allowed Charges after deductible
Mental Health or Substance Abuse Inpatient Admission
*Mental Health Parity provides that certain biological conditions for severe mental illness are not limited as other mental health conditions. This does not apply to substance abuse.
20% of Allowed Charges after deductible; Limit: 30 days per year*
Mental Health or Substance Abuse Outpatient Visit
*Mental Health Parity provides that certain biological conditions for severe mental illness are not limited as other mental health conditions. This does not apply to substance abuse.
20% of Allowed Charges after deductible; Limit: 26 visits per year*
Durable Medical Equipment (DME)
20% of Allowed Charges after deductible for purchase, rental, repair, or replacement
Occupational or Speech Therapy Visits
20% of Allowed Charges after deductible; For each service – Limit: 20 visits per year without certification; 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
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 - Refer to 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
Hearing Screening and Hearing Aids
$30 copay/primary care physician; $50 copay/specialist basic hearing screening; Limit: one per year; Hearing aids are covered as durable medical equipment for children up to age 18
Pharmacy Benefits
$5 copay per fill for certain prescription tobacco cessation products
NETWORK:
Generic Mandate
PREFERRED MEDICATION:
If the cost of medication is $100 or less – you pay up to $30 or actual cost if less
If the cost of medication is more than $100 – you pay 25% up to a $60 maximum
Out-of-pocket maximum - $2,500 per person using Preferred products at Network pharmacies, then you pay $0
NON-PREFERRED MEDICATION:
If the cost of medication is $100 or less – you pay up to $60 or actual cost if less
If the cost of medication is more than $100 – you pay 50% up to a $120 maximum
Out-of-pocket maximums do not apply to non-Preferred medications
NOTE:
Pharmacy benefits may cover up to a 34-day supply or 100 units, whichever is greater
Some medications may have a limit on quantity and/or duration of therapy
Some medications require prior authorization
Specialty medications are covered when ordered through Accredo Health Group
If you choose a brand-name medication when a generic is available, you will be responsible for the difference in cost, plus the copay
NON-NETWORK:
PREFERRED MEDICATION:
You pay the cost of medication up to $75 maximum plus a dispensing fee
NON-PREFERRED MEDICATION:
You pay the cost of medication up to $125 maximum plus a dispensing fee
HEALTHCHOICE BASIC PLAN BENEFITS
This is only a sample of the services covered by each plan. For services that are not listed in this comparison chart, contact each plan. Refer to Help Lines at the end of this document for contact information.
HealthChoice members do not need to designate a primary care physician and can change physicians at any time.
This chart reflects your cost for the listed Network services.
Calendar Year Deductibles
$500 individual and $1,000 family; deductible applied after Plan pays first $500 of Allowed Charges
Calendar Year Out-of-Pocket Maximum
$5,500 individual and $11,000 family
HealthChoice Basic Plan Description
*Mental Health Parity provides that certain biological conditions for severe mental illness are not limited as other mental health conditions. This does not apply to substance abuse.
Copays do not apply
All services, benefits, exceptions, limitations, and conditions are identical to the HealthChoice High Option Plan
For Network Services, you pay:
$0 the first $500 of Allowed Charges
100% of the next $500 of Allowed Charges (deductible); only Allowed Charges apply to the deductible
50% of the next $10,000 of Allowed Charges
$0 of Allowed Charges over $5,500/individual or $11,000/family
You may use non-Network providers, but it will be more costly
Pharmacy Benefits
$5 copay per fill for certain prescription tobacco cessation products
NETWORK:
Generic Mandate
PREFERRED MEDICATION:
If the cost of medication is $100 or less – you pay up to $30 or actual cost if less
If the cost of medication is more than $100 – you pay 25% up to a $60 maximum
Out-of-pocket maximum - $2,500 per person using Preferred products at Network pharmacies, then you pay $0
NON-PREFERRED MEDICATION:
If the cost of medication is $100 or less – you pay up to $60 or actual cost if less
If the cost of medication is more than $100 – you pay 50% up to a $120 maximum
Out-of-pocket maximums do not apply to non-Preferred medications
NOTE:
Pharmacy benefits may cover up to a 34-day supply or 100 units, whichever is greater
Some medications may have a limit on quantity and/or duration of therapy
Some medications require prior authorization
Specialty medications are covered when ordered through Accredo Health Group
If you choose a brand-name medication when a generic is available, you will be responsible for the difference in cost, plus the copay
NON-NETWORK:
PREFERRED MEDICATION:
You pay the cost of medication up to $75 maximum plus a dispensing fee
NON-PREFERRED MEDICATION:
You pay the cost of medication up to $125 maximum plus a dispensing fee
HEALTHCHOICE S-ACCOUNT PLAN BENEFITS
This is only a sample of the services covered by each plan. For services that are not listed in this comparison chart, contact each plan. Refer to Help Lines at the end of this document for contact information.
This chart reflects your cost for the listed Network services.
Calendar Year Deductibles
$1,500 individual and $3,000 family; the combined medical and pharmacy deductible must be met before benefits are paid
Calendar Year Out-of-Pocket Maximum
$4,000 individual and $8,000 family; non-Network charges do not apply
Office Visit (Professional Services)
Member pays 100% of Allowed Charges until deductible is met; $50 copay applies after deductible
Diagnostic X-ray and Lab
20% of Allowed Charges after deductible
Hospital Inpatient Admission
20% of Allowed Charges after deductible; additional $300 deductible per non-Network admission
Hospital Outpatient Visit
20% of Allowed Charges after deductible
Well Child Care Visit
$50 copay; no deductible applies
Immunizations
No charge for well child and adult immunizations; $50 office visit copay and/or administration fee may apply
Periodic Health Exams
$50 copay per exam, 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
Emergency Health Care Facility Visit
20% of Allowed Charges after deductible; Additional $100 ER deductible, waived if admitted
After Hours Urgent Care
20% of Allowed Charges after deductible
Mental Health or Substance Abuse Inpatient Admission
*Mental Health Parity provides that certain biological conditions for severe mental illness are not limited as other mental health conditions. This does not apply to substance abuse.
20% of Allowed Charges after deductible; Limit: 30 days per year*
Mental Health or Substance Abuse Outpatient Visit
*Mental Health Parity provides that certain biological conditions for severe mental illness are not limited as other mental health conditions. This does not apply to substance abuse.
20% of Allowed Charges after deductible; Limit: 26 visits per year*
Durable Medical Equipment (DME)
20% of Allowed Charges after deductible for purchase, rental, repair, or replacement
Occupational or Speech Therapy Visits
20% of Allowed Charges after deductible; For each service – Limit: 20 visits per year without certification; 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
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 - Refer to 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
Hearing Screening and Hearing Aids
$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
Pharmacy Benefits
After the combined medical and pharmacy deductible - $1,500 individual or $3,000 family - has been met, the pharmacy benefits are:
NETWORK:
Generic Mandate
PREFERRED MEDICATION:
If the cost of medication is $100 or less – you pay up to $30 or actual cost if less
If the cost of medication is more than $100 – you pay 25% up to a $60 maximum
NON-PREFERRED MEDICATION:
If the cost of medication is $100 or less – you pay up to $60 or actual cost if less
If the cost of medication is more than $100 – you pay 50% up to a $120 maximum
NOTE:
Pharmacy benefits may cover up to a 34-day supply or 100 units, whichever is greater
Some medications may have a limit on quantity and/or duration of therapy
Some medications require prior authorization
Specialty medications are covered when ordered through Accredo Health Group
If you choose a brand-name medication when a generic is available, you will be responsible for the difference in cost, plus the copay
NON-NETWORK:
PREFERRED MEDICATION:
You pay the cost of medication up to $75 maximum plus a dispensing fee
NON-PREFERRED MEDICATION:
You pay the cost of medication up to $125 maximum plus a dispensing fee
HMO STANDARD PLAN BENEFITS
This is only a sample of the services covered by each plan. For services that are not listed in this comparison chart, contact each plan. Refer to Help Lines at the end of this document for contact information.
This chart reflects your cost for the listed Network services.
Calendar Year Deductibles
No deductible
Calendar Year Out-of-Pocket Maximum
$2,500 individual and $5,000 family
Office Visit (Professional Services)
$30 copay/PCP and $40 copay/specialist
Diagnostic X-ray and Lab
No copay for laboratory services or outpatient radiology; $150 copay per MRI, CAT, MRA, or PET scan
Hospital Inpatient Admission
$350 copay; preauthorization required
Hospital Outpatient Visit
$250 copay; preauthorization required
Well Child Care Visit
$0 copay
Immunizations
$0 copay ages birth through age 18; $0 copay ages 19 and over
Periodic Health Exams
$0 copay per visit for routine physicals
Allergy Treatment and Testing
$30 copay/PCP; $40 copay/specialist; $30 serum and shots including a 6-week supply of antigen
Emergency Health Care Facility Visit
$150 copay; waived if admitted
After Hours Urgent Care
$40 copay per visit
Mental Health or Substance Abuse Inpatient Admission
$350 copay
Mental Health or Substance Abuse Outpatient Visit
$30 copay/PCP; $40 copay/specialist
Durable Medical Equipment (DME)
20% coinsurance initial device; 20% coinsurance repair and replacement
Occupational or Speech Therapy Visits
No copay inpatient; $30 copay/PCP; $40 copay/specialist; Limit: 60 treatment days per illness
Physical Therapy/Physical Medicine Visit
No copay inpatient; $30 copay/PCP; $40 copay/specialist; Limit: 60 treatment days per illness
Chiropractic and Manipulative Therapy Visit
$40 copay; Limit: 15 visits per year; PCP referral required
Maternity Pre and Post Natal Care
$30 copay for initial visit; $350 copay per hospital admission
Hearing Screening and Hearing Aids
$0 copay children birth through age 21; $30 copay age 22 and over; Limit: one per year; Hearing aids – 20% coinsurance for children up to age 18
Pharmacy Benefits
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
COMMUNITYCARE ALTERNATIVE HMO BENEFITS
This is only a sample of the services covered by each plan. For services that are not listed in this comparison chart, contact each plan. Refer to the Help Lines at the end of this document for contact information.
This chart reflects your cost for the listed Network services.
Calendar Year Deductibles
No deductible
Calendar Year Out-of-Pocket Maximum
$3,000 individual and $6,000 family
Office Visit (Professional Services)
$35 copay/PCP and $50 copay/specialist
Diagnostic X-ray and Lab
No additional copay for laboratory services or outpatient radiology; $200 copay per MRI, CAT, MRA, or PET scan
Hospital Inpatient Admission
$500 copay; preauthorization required
Hospital Outpatient Visit
$300 copay
Well Child Care Visit
$0 copay
Immunizations
$0 copay ages birth through age 18 years; $0 copay ages 19 and over; when medically necessary
Periodic Health Exams
$0 copay
Allergy Treatment and Testing
$35 copay/PCP; $50 copay/specialist; $30 serum and shots including a 6-week supply of antigen
Emergency Health Care Facility Visit
$200 copay; waived if admitted
After Hours Urgent Care
$50 copay per visit; preauthorization required
Mental Health or Substance Abuse Inpatient Admission
$500 copay; must be preauthorized and approved through CCOK Behavioral Health Services
Mental Health or Substance Abuse Outpatient Visit
$35 copay/PCP; $50 copay/specialist; must be preauthorized and approved through CCOK Behavioral Health Services
Durable Medical Equipment (DME)
20% coinsurance initial device; 20% coinsurance repair and replacement
Occupational or Speech Therapy Visits
No copay inpatient; $50 copay outpatient therapy; Limit: 60 days per illness
Physical Therapy/Physical Medicine Visit
No copay inpatient; $50 copay outpatient therapy; Limit: 60 days per illness
Chiropractic and Manipulative Therapy Visit
$50 copay; Limit: 15 visits per year; PCP referral required
Maternity Pre and Post Natal Care
$35 copay for initial visit; $500 copay per hospital admission
Hearing Screening and Hearing Aids
$0 copay; Limit: one per year; Hearing aids – 20% coinsurance for children up to age 18
Pharmacy Benefits
Tier 1: $10
Tier 2: $40
Tier 3: $65
$0 copay for selected generics
Up to $65 non-formulary
30-day supply
Certain medications have restricted quantities
GLOBALHEALTH ALTERNATIVE HMO BENEFITS
This is only a sample of the services covered by each plan. For services that are not listed in this comparison chart, contact each plan. Refer to Help Lines at the end of this document for contact information.
This chart reflects your cost for the listed Network services.
Calendar Year Deductibles
No deductible
Calendar Year Out-of-Pocket Maximum
$3,000 individual and $5,000 family
Office Visit (Professional Services)
$25 copay/PCP and $50 copay/specialist
Diagnostic X-ray and Lab
$0 copay; $250 copay per MRI, MRA, PET, CAT, or nuclear scan
Hospital Inpatient Admission
$250 copay per day; $750 maximum per admission; preauthorization required
Hospital Outpatient Visit
$250 copay; preauthorization required
Well Child Care Visit
$0 copay ages 0-21
Immunizations
$0 copay; office visit copay may apply
Periodic Health Exams
$0 copay/PCP; Limit: one per year
Allergy Treatment and Testing
$25 copay/PCP; $50 copay/specialist; $30 serum and shots including a 6-week supply of antigen
Emergency Health Care Facility Visit
$150 copay; waived if admitted
After Hours Urgent Care
$25 copay/PCP; $50 copay/all others; must use Network facilities
Mental Health or Substance Abuse Inpatient Admission
$250 per day; $750 maximum per admission; must be preauthorized
Mental Health or Substance Abuse Outpatient Visit
$25 copay; must be preauthorized
Durable Medical Equipment (DME)
20% coinsurance
Occupational or Speech Therapy Visits
No copay inpatient; $50 copay per outpatient therapy; Limit: 60 consecutive days per illness
Physical Therapy/Physical Medicine Visit
No copay inpatient; $50 copay per outpatient visit; Limit: 60 consecutive days per illness
Chiropractic and Manipulative Therapy Visit
$50 copay; must be preauthorized
Maternity Pre and Post Natal Care
$25 copay for initial visit only; $250 copay per hospital admission per day; $750 maximum per admission
Hearing Screening and Hearing Aids
$0 copay children birth through age 21; $25 copay age 22 and over; Limit: one visit per year; Hearing aids – 20% coinsurance; Covered for children up to age 18
Pharmacy Benefits
Tier 1: $10
Tier 2: $50
Tier 3: $75
30-day supply
Certain medications may have restricted quantities
These copays do not apply to the maximum out-of-pocket
PACIFICARE ALTERNATIVE HMO BENEFITS
This is only a sample of the services covered by each plan. For services that are not listed in this comparison chart, contact each plan. Refer to the Help Lines at the end of this document for contact information.
This chart reflects your cost for the listed Network services.
Calendar Year Deductibles
No deductible
Calendar Year Out-of-Pocket Maximum
$2,500 individual and $5,000 family
Office Visit (Professional Services)
$35 copay/PCP and $50 copay/specialist
Diagnostic X-ray and Lab
$0 copay for standard lab and radiology; $200 copay per MRI, MRA, PET, or CAT scan
Hospital Inpatient Admission
$1,000 copay/admission
Hospital Outpatient Visit
$500 copay
Well Child Care Visit
$0 copay
Immunizations
$0 copay ages birth through age 18 (if no other service is rendered); $0 copay ages 19 and over
Periodic Health Exams
$0 copay/PCP; $50 copay/specialist
Allergy Treatment and Testing
$35 copay/PCP; $50 copay/specialist; $35 serum and shots including a 6-week supply of antigen
Emergency Health Care Facility Visit
$200 copay; waived if admitted
After Hours Urgent Care
$50 copay per visit
Mental Health or Substance Abuse Inpatient Admission
$1,000 copay per admission
Mental Health or Substance Abuse Outpatient Visit
$35 copay/PCP; $50 copay/specialist
Durable Medical Equipment (DME)
20% coinsurance
Occupational or Speech Therapy Visits
$0 copay inpatient; $35 copay/PCP; $50 copay/specialist; Limit: 60 days per illness
Physical Therapy/Physical Medicine Visit
$0 copay inpatient; $35 copay/PCP; $50 copay/specialist; Limit: 60 days per illness
Chiropractic and Manipulative Therapy Visit
$50 copay; Limit: 15 visits per year – referral required; Limited to treatment of neurological and orthopedic conditions
Maternity Pre and Post Natal Care
$35 copay/PCP; $50 copay/specialist for initial visit once diagnosis of pregnancy is confirmed; $1,000 copay per hospital admission
Hearing Screening and Hearing Aids
$0 copay/PCP; Hearing aids – covered for children up to age 18
Pharmacy Benefits
$5 copay for formulary generic drugs
$30 copay for formulary brand-name drugs
$60 copay for non-formulary generic and non-formulary brand drugs
Lesser of 30-day supply or 100 units
Certain medications have restricted quantities
COMPARISON OF BENEFITS FOR DENTAL PLANS – ALL PLANS
For services that are not listed in this comparison chart, contact each plan. Refer to the Help Lines at the end of this document for contact information.
This chart reflects your cost for the listed services.
Annual Deductible
HealthChoice Dental
Network: $25 Basic and Major; Non-Network: $25 Preventive, Basic, and Major services combined
Assurant Freedom Preferred
$25 per person, per year; waived for preventive services in-network
Assurant Prepaid Plans - Heritage Plus with SBA and Heritage Secure
No deductible
CIGNA Dental Care Plan Prepaid
No deductible or plan maximum; $5 office copay applies
Delta Dental PPO – In-Network and Out-of-Network
$25 per person, per year, applies to Basic and Major Care only
Delta Dental Premier – In-Network and Out-of-Network
$50 per person, per year, applies to Diagnostic, Preventive, Basic, and Major Care
Delta Dental PPO – Choice PPO Network
$100 per person, per year, applies to Major Care only (Level 4)
Preventive Care
Allowed Charges apply
HealthChoice Dental
Network: $0; Non-Network: $0 of Allowed Charges after deductible
Assurant Freedom Preferred
$0 with no deductible when in-network
Assurant Prepaid Plans - Heritage Plus with SBA and Heritage Secure
No charge for routine cleaning (once every six months); No charge for topical fluoride application (up to age 18); No charge for periodic oral evaluations
CIGNA Dental Care Plan Prepaid
Sealant: $15 per tooth; No charge for routine cleaning once every six months; No charge for topical fluoride application (through age 18); No charge for periodic oral evaluations
Delta Dental PPO – In-Network and Out-of-Network
$0 of allowable amounts; No deductible applies; Includes diagnostic
Delta Dental Premier – In-Network and Out-of-Network
$0 of allowable amounts; Includes diagnostic
Delta Dental PPO – Choice PPO Network
Schedule of covered services and copays. Copay examples: Routine cleaning $5; Periodic oral evaluations $5; Topical fluoride application (up to age 19) $5; Includes diagnostic
Basic Care; e.g., Extractions, Oral Surgery
Allowed Charges apply
HealthChoice Dental
Network: 15%; Non-Network: 30%; Deductible applies
Assurant Freedom Preferred
Network: 15%; Non-Network 30%; Plan pays 85% of usual and customary when in-network; Deductible applies
Assurant Prepaid Plans - Heritage Plus with SBA and Heritage Secure
Fillings; Minor oral surgery; Refer to the copay schedule for each plan
CIGNA Dental Care Plan Prepaid
Amalgam: One surface, permanent teeth $21
Delta Dental PPO – In-Network and Out-of-Network
15% of allowable amounts after deductible
Delta Dental Premier – In-Network and Out-of-Network
30% of allowable amounts after deductible
Delta Dental PPO – Choice PPO Network
Schedule of covered services and copays. Copay example: Amalgam, one surface, primary or permanent tooth $12
Major Care; e.g., Dentures, Bridge work
Allowed Charges apply
HealthChoice Dental
Network: 40%; Non-Network: 50%; Deductible applies
Assurant Freedom Preferred
Network: 40%; Non-Network: 50%; Plan pays 60% of usual and customary when in-network; Deductible applies
Assurant Prepaid Plans - Heritage Plus with SBA and Heritage Secure
Root canal; Periodontal; Crowns; Refer to the copay schedule for each plan
CIGNA Dental Care Plan Prepaid
Root canal, anterior: $355; Periodontal/scaling/root planing one to three teeth (per quadrant): $65
Delta Dental PPO – In-Network and Out-of-Network
40% of allowable amounts after deductible
Delta Dental Premier – In-Network and Out-of-Network
50% of allowable amounts after deductible
Delta Dental PPO – Choice PPO Network
Schedule of covered services and copays. Copay examples: Crown, porcelain/ceramic substrate $241; Complete denture, maxillary $320
Orthodontic Care
Allowed Charges apply
HealthChoice Dental
Network: 50%; Non-Network: 50%; 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
Assurant Freedom Preferred
Network: 40%; Non-Network: 50%; Up to $2,000 lifetime maximum for members under age 19*; 12-month waiting period may apply
*Increase in orthodontic lifetime maximum will apply to treatment beginning on or after January 1, 2011
Assurant Prepaid Plans - Heritage Plus with SBA and Heritage Secure
25% discount; Adults and children
CIGNA Dental Care Plan Prepaid
$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
Delta Dental PPO – In-Network and Out-of-Network
40% of allowable amounts, up to lifetime maximum of $2,000; No deductible; No waiting period
Orthodontic benefits are available to the employee and his/her lawful spouse and eligible dependent children
Delta Dental Premier – In-Network and Out-of-Network
40% of allowable amounts, up to lifetime maximum of $2,000; No deductible; No waiting period
Orthodontic benefits are available to the employee and his/her lawful spouse and eligible dependent children
Delta Dental PPO – Choice PPO Network
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 his/her lawful spouse and eligible dependent children
Plan Year Maximum
HealthChoice Dental
Network and non-Network: $2,000 per person, per year
Assurant Freedom Preferred
$2,000
Assurant Prepaid Plans - Heritage Plus with SBA and Heritage Secure
No annual maximum for general dentist
CIGNA Dental Care Plan Prepaid
No maximum
Delta Dental PPO – In-Network and Out-of-Network
$2,500 per person, per year
Delta Dental Premier – In-Network and Out-of-Network
$3,000 per person, per year
Delta Dental PPO – Choice PPO Network
$2,000 per person, per year
Filing Claims
HealthChoice Dental
Network: No claims to file; Non-Network: You file claims
Assurant Freedom Preferred
Member/provider must file claims
Assurant Prepaid Plans - Heritage Plus with SBA and Heritage Secure
No claims to file
CIGNA Dental Care Plan Prepaid
No claims to file
Delta Dental PPO – In-Network and Out-of-Network
Claims are filed by participating dentists
Delta Dental Premier – In-Network and Out-of-Network
Claims are filed by participating dentists
Delta Dental PPO – Choice PPO Network
Claims are filed by participating dentists
HEALTHCHOICE DENTAL PLAN
For services that are not listed in this comparison chart, contact each plan. Refer to Help Lines at the end of this document for contact information.
This chart reflects your cost for the listed services.
Annual Deductible
Network: $25 Basic and Major; Non-Network: $25 Preventive, Basic, and Major services combined
Preventive Care
Allowed Charges apply
Network: $0; Non-Network: $0 of Allowed Charges after deductible
Basic Care; e.g., Extractions, Oral Surgery
Allowed Charges apply
Network: 15%; Non-Network: 30%; Deductible applies
Major Care; e.g., Dentures, Bridge work
Allowed Charges apply
Network: 40%; Non-Network: 50%; Deductible applies
Orthodontic Care
Allowed Charges apply
Network: 50%; Non-Network: 50%; 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
Plan Year Maximum
Network and non-Network: $2,000 per person, per year
Filing Claims
Network: No claims to file; Non-Network: You file claims
ASSURANT FREEDOM PREFERRED DENTAL PLAN
For services that are not listed in this comparison chart, contact each plan. Refer to Help Lines at the end of this document for contact information.
This chart reflects your cost for the listed services.
Annual Deductible
$25 per person, per year; waived for preventive services in-network
Preventive Care
Allowed Charges apply
$0 with no deductible when in-network
Basic Care; e.g., Extractions, Oral Surgery
Allowed Charges apply
Network: 15%; Non-Network 30%; Plan pays 85% of usual and customary when in-network; Deductible applies
Major Care; e.g., Dentures, Bridge work
Allowed Charges apply
Network: 40%; Non-Network: 50%; Plan pays 60% of usual and customary when in-network; Deductible applies
Orthodontic Care
Allowed Charges apply
Network: 40%; Non-Network: 50%; Up to $2,000 lifetime maximum for members under age 19*; 12-month waiting period may apply
*Increase in orthodontic lifetime maximum will apply to treatment beginning on or after January 1, 2011
Plan Year Maximum
$2,000
Filing Claims
Member/provider must file claims
ASSURANT PREPAID DENTAL PLANS – HERITAGE PLUS WITH SBA AND HERITAGE SECURE
For services that are not listed in this comparison chart, contact each plan. Refer to Help Lines at the end of this document for contact information.
This chart reflects your cost for the listed services.
Annual Deductible
No deductible
Preventive Care
Allowed Charges apply
No charge for routine cleaning (once every six months); No charge for topical fluoride application (up to age 18); No charge for periodic oral evaluations
Basic Care; e.g., Extractions, Oral Surgery
Allowed Charges apply
Fillings; Minor oral surgery; Refer to the copay schedule for each plan
Major Care; e.g., Dentures, Bridge work
Allowed Charges apply
Root canal; Periodontal; Crowns; Refer to the copay schedule for each plan
Orthodontic Care
Allowed Charges apply
25% discount; Adults and children
Plan Year Maximum
No annual maximum for general dentist
Filing Claims
No claims to file
CIGNA DENTAL CARE PLAN PREPAID
For services that are not listed in this comparison chart, contact each plan. Refer to Help Lines at the end of this document for contact information.
This chart reflects your cost for the listed services.
Annual Deductible
No deductible or plan maximum; $5 office copay applies
Preventive Care
Allowed Charges apply
Sealant: $15 per tooth; No charge for routine cleaning once every six months; No charge for topical fluoride application (through age 18); No charge for periodic oral evaluations
Basic Care; e.g., Extractions, Oral Surgery
Allowed Charges apply
Amalgam: One surface, permanent teeth $21
Major Care; e.g., Dentures, Bridge work
Allowed Charges apply
Root canal, anterior: $355; Periodontal/scaling/root planing one to three teeth (per quadrant): $65
Orthodontic Care
Allowed Charges apply
$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
Plan Year Maximum
No maximum
Filing Claims
No claims to file
DELTA DENTAL PPO DENTAL PLAN – IN-NETWORK AND OUT-OF-NETWORK
For services that are not listed in this comparison chart, contact each plan. Refer to Help Lines at the end of this document for contact information.
This chart reflects your cost for the listed services.
Annual Deductible
$25 per person, per year, applies to Basic and Major Care only
Preventive Care
Allowed Charges apply
$0 of allowable amounts; No deductible applies; Includes diagnostic
Basic Care; e.g., Extractions, Oral Surgery
Allowed Charges apply
15% of allowable amounts after deductible
Major Care; e.g., Dentures, Bridge work
Allowed Charges apply
40% of allowable amounts after deductible
Orthodontic Care
Allowed Charges apply
40% of allowable amounts, up to lifetime maximum of $2,000; No deductible; No waiting period
Orthodontic benefits are available to the employee and his/her lawful spouse and eligible dependent children
Plan Year Maximum
$2,500 per person, per year
Filing Claims
Claims are filed by participating dentists
DELTA DENTAL PREMIER DENTAL PLAN – IN-NETWORK AND OUT-OF-NETWORK
For services that are not listed in this comparison chart, contact each plan. Refer to Help Lines at the end of this document for contact information.
This chart reflects your cost for the listed services.
Annual Deductible
$50 per person, per year, applies to Diagnostic, Preventive, Basic, and Major Care
Preventive Care
Allowed Charges apply
$0 of allowable amounts; Includes diagnostic
Basic Care; e.g., Extractions, Oral Surgery
Allowed Charges apply
30% of allowable amounts after deductible
Major Care; e.g., Dentures, Bridge work
Allowed Charges apply
50% of allowable amounts after deductible
Orthodontic Care
Allowed Charges apply
40% of allowable amounts, up to lifetime maximum of $2,000; No deductible; No waiting period
Orthodontic benefits are available to the employee and his/her lawful spouse and eligible dependent children
Plan Year Maximum
$3,000 per person, per year
Filing Claims
Claims are filed by participating dentists
DELTA DENTAL PPO DENTAL PLAN - CHOICE PPO NETWORK
For services that are not listed in this comparison chart, contact each plan. Refer to Help Lines at the end of this document for contact information.
This chart reflects your cost for the listed services.
Annual Deductible
$100 per person, per year, applies to Major Care only (Level 4)
Preventive Care
Allowed Charges apply
Schedule of covered services and copays. Copay examples: Routine cleaning $5; Periodic oral evaluations $5; Topical fluoride application (up to age 19) $5; Includes diagnostic
Basic Care; e.g., Extractions, Oral Surgery
Allowed Charges apply
Schedule of covered services and copays. Copay example: Amalgam, one surface, primary or permanent tooth $12
Major Care; e.g., Dentures, Bridge work
Allowed Charges apply
Schedule of covered services and copays. Copay examples: Crown, porcelain/ceramic substrate $241; Complete denture, maxillary $320
Orthodontic Care
Allowed Charges apply
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 his/her lawful spouse and eligible dependent children
Plan Year Maximum
$2,000 per person, per year
Filing Claims
Claims are filed by participating dentists
COMPARISON OF BENEFITS FOR VISION PLANS – ALL PLANS
Vision benefits apply from January 1 through December 31, 2011.
For services that are not listed in this comparison chart, contact your plan. Refer to Help Lines at the end of this document for contact information.
Eye Exams
Humana/CompBenefits VisionCare Plan
In-Network: $10 copay; One exam for eyeglasses or contacts per year
Out-of-Network: Copays do not apply; Plan pays up to $35; One exam per year
Primary Vision Care Services, Inc.
In-Network: $0 copay; No limit on exams per year
Out-of-Network*: Plan pays up to $40; One exam per year
*Out-of-Network limited to one eye exam and one set of eyeglasses or contact lenses annually. Cannot be used with In-Network services
Superior Vision Plan
In-Network: $10 copay; One exam per year
Out-of-Network: OD - $26 max; MD - $34 max
UnitedHealthcare Vision
In-Network: $10 copay; One exam per year
Out-of-Network: Plan pays up to $40
Vision Service Plan (VSP)
In-Network: $10 copay; One exam per year
Out-of-Network: $10 copay; Plan pays up to $35
Lenses Each Pair
Humana/CompBenefits VisionCare Plan
In-Network: $25 material copay applies to lenses and/or frames (single, lined bifocal, trifocal, lenticular are covered at 100%); A discount applies to progressive lenses; One pair of lenses per year
Out-of-Network: Plan pays up to $25 single, $40 bifocals, $60 trifocals, $100 lenticular; One pair of lenses per year
Primary Vision Care Services
In-Network: You pay wholesale cost with no limit on number of pairs
Out-of-Network*: You pay normal doctor’s fee, reimbursed up to $60 for one set of lenses and frames per year
*Out-of-Network limited to one eye exam and one set of eyeglasses or contact lenses annually. Cannot be used with In-Network services
Superior Vision Plan
In-Network: $25 copay; One pair of lenses per year
Out-of-Network: Plan pays up to $26 single, $39 bifocals, $49 trifocals, $78 lenticular
UnitedHealthcare Vision
In-Network: $25 copay; One pair of lenses per year
Out-of-Network: Plan pays up to $40 single, $60 bifocals, $80 trifocals, $80 lenticular
Vision Service Plan (VSP)
In-Network: $25 copay*; One set of lenses per year; Polycarbonate lenses covered in full for dependent children; Average 35-40% savings on all non-covered lens options
Out-of-Network: $25 copay*; Plan pays up to $25 single, $40 bifocals, $55 trifocals, $80 lenticular
*Benefit includes an annual $25 materials copay for lenses or frames, but not both. Contact VSP for additional information regarding in-network added value discounts.
Frames
Humana/CompBenefits VisionCare Plan
In-Network: $25 material copay applies to lenses and/or frames; $45 wholesale frame allowance; One pair of frames per year
Out-of-Network: $25 copay; Plan pays up to $45; One pair of frames per year
Primary Vision Care Services
In-Network: You pay wholesale cost; no limit on number of frames
Out-of-Network*: You pay normal doctor’s fee, reimbursed up to $60 for one set of lenses and frames per year
*Out-of-Network limited to one eye exam and one set of eyeglasses or contact lenses annually. Cannot be used with In-Network services
Superior Vision Plan
In-Network: $25 copay; Plan pays up to $125; One pair of frames per year
Out-of-Network: Plan pays up to $68
UnitedHealthcare Vision
In-Network: $25 copay; $130 allowance; One set of frames per year
Out-of-Network: Plan pays up to $45
Vision Service Plan (VSP)
In-Network: $25 copay*; $120 allowance; 20% off any out-of-pocket costs above the allowance; One pair of frames per year
Out-of-Network: $25 copay*; Plan pays up to $45
*Benefit includes an annual $25 materials copay for lenses or frames, but not both. Contact VSP for additional information regarding in-network added value discounts.
Contact Lenses
Humana/CompBenefits VisionCare Plan
In-Network: $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
Out-of-Network: $130 allowance for exam, contacts, and fitting fee; In lieu of all other benefits; Medically necessary, plan pays $210; One set of contacts per year
Primary Vision Care Services
In-Network: 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
Out-of-Network*: Limit of one set annually in lieu of glasses; You pay normal doctor fees, reimbursed up to $60
*Out-of-Network limited to one eye exam and one set of eyeglasses or contact lenses annually. Cannot be used with In-Network services
Superior Vision Plan
In-Network: $0 copay; Plan pays up to $120; Medically necessary contacts are covered in full (in lieu of glasses)
Out-of-Network: $0 copay; Plan pays up to $100; Medically necessary contacts, plan pays up to $210 (in lieu of glasses)
UnitedHealthcare Vision
In-Network: $25 copay covers fitting/evaluation fees, contacts (including disposables), and up to two follow-up visits (in lieu of glasses)
Out-of-Network: Plan pays up to $150; For medically necessary contacts, plan pays up to $210 (in lieu of glasses)
Vision Service Plan (VSP)
In-Network: $0 copay; $120 allowance applied to the cost of your contact lens exam and the contact lenses; 15% discount on contact lens exam (in lieu of glasses)
Out-of-Network: $0 copay; Plan pays up to $105 for disposable or conventional contact lenses (in lieu of glasses)
Laser Vision Correction
Humana/CompBenefits VisionCare Plan
In-Network: $895 copay conventional; $1,295 copay custom; $1,895 copay custom plus bladeless when services are rendered by a TLC Network Provider
Out-of-Network: No benefit
Primary Vision Care Services
In-Network: Discount nationwide at The Laser Center (TLC)
Out-of-Network: No benefit
Superior Vision Plan
In-Network: 20% off retail price
Out-of-Network: No benefit
UnitedHealthcare Vision
In-Network: Members have access to discounted refractive eye surgery from numerous provider locations throughout the U.S.
Out-of-Network: No benefit
Vision Service Plan (VSP)
In-Network: Laser vision correction services (PRK, LASIK, and Custom LASIK) are provided at a reduced cost through VSP’s contracted laser surgery centers
Out-of-Network: No benefit
HUMANA/COMPBENEFITS VISIONCARE PLAN
Vision benefits apply from January 1 through December 31, 2011.
For services that are not listed in this comparison chart, contact your plan. Refer to Help Lines at the end of this document for contact information.
Eye Exams
In-Network: $10 copay; One exam for eyeglasses or contacts per year
Out-of-Network: Copays do not apply; Plan pays up to $35; One exam per year
Lenses Each Pair
In-Network: $25 material copay applies to lenses and/or frames (single, lined bifocal, trifocal, lenticular are covered at 100%); A discount applies to progressive lenses; One pair of lenses per year
Out-of-Network: Plan pays up to $25 single, $40 bifocals, $60 trifocals, $100 lenticular; One pair of lenses per year
Frames
In-Network: $25 material copay applies to lenses and/or frames; $45 wholesale frame allowance; One pair of frames per year
Out-of-Network: $25 copay; Plan pays up to $45; One pair of frames per year
Contact Lenses
In-Network: $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
Out-of-Network: $130 allowance for exam, contacts, and fitting fee; In lieu of all other benefits; Medically necessary, plan pays $210; One set of contacts per year
Laser Vision Correction
In-Network: $895 copay conventional; $1,295 copay custom; $1,895 copay custom plus bladeless when services are rendered by a TLC Network Provider
Out-of-Network: No benefit
PRIMARY VISION CARE SERVICES, INC.
Vision benefits apply from January 1 through December 31, 2011.
For services that are not listed in this comparison chart, contact your plan. Refer to the Help Lines at the end of this document for contact information.
Eye Exams
In-Network: $0 copay; No limit on exams per year
Out-of-Network*: Plan pays up to $40; One exam per year
*Out-of-Network limited to one eye exam and one set of eyeglasses or contact lenses annually. Cannot be used with In-Network services
Lenses Each Pair
In-Network: You pay wholesale cost with no limit on number of pairs
Out-of-Network*: You pay normal doctor’s fee, reimbursed up to $60 for one set of lenses and frames per year
*Out-of-Network limited to one eye exam and one set of eyeglasses or contact lenses annually. Cannot be used with In-Network services
Frames
In-Network: You pay wholesale cost; no limit on number of frames
Out-of-Network*: You pay normal doctor’s fee, reimbursed up to $60 for one set of lenses and frames per year
*Out-of-Network limited to one eye exam and one set of eyeglasses or contact lenses annually. Cannot be used with In-Network services
Contact Lenses
In-Network: 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
Out-of-Network*: Limit of one set annually in lieu of glasses; You pay normal doctor fees, reimbursed up to $60
*Out-of-Network limited to one eye exam and one set of eyeglasses or contact lenses annually. Cannot be used with In-Network services
Laser Vision Correction
In-Network: Discount nationwide at The Laser Center (TLC)
Out-of-Network: No benefit
SUPERIOR VISION PLAN
Vision benefits apply from January 1 through December 31, 2011.
For services that are not listed in this comparison chart, contact your plan. Refer to Help Lines at the end of this document for contact information.
Eye Exams
In-Network: $10 copay; One exam per year
Out-of-Network: OD - $26 max; MD - $34 max
Lenses Each Pair
In-Network: $25 copay; One pair of lenses per year
Out-of-Network: Plan pays up to $26 single, $39 bifocals, $49 trifocals, $78 lenticular
Frames
In-Network: $25 copay; Plan pays up to $125; One pair of frames per year
Out-of-Network: Plan pays up to $68
Contact Lenses
In-Network: $0 copay; Plan pays up to $120; Medically necessary contacts are covered in full (in lieu of glasses)
Out-of-Network: $0 copay; Plan pays up to $100; Medically necessary contacts, plan pays up to $210 (in lieu of glasses)
Laser Vision Correction
In-Network: 20% off retail price
Out-of-Network: No benefit
UNITEDHEALTHCARE VISION
Vision benefits apply from January 1 through December 31, 2011.
For services that are not listed in this comparison chart, contact your plan. Refer to the Help Lines at the end of this document for contact information.
Eye Exams
In-Network: $10 copay; One exam per year
Out-of-Network: Plan pays up to $40
Lenses Each Pair
In-Network: $25 copay; One pair of lenses per year
Out-of-Network: Plan pays up to $40 single, $60 bifocals, $80 trifocals, $80 lenticular
Frames
In-Network: $25 copay; $130 allowance; One set of frames per year
Out-of-Network: Plan pays up to $45
Contact Lenses
In-Network: $25 copay covers fitting/evaluation fees, contacts (including disposables), and up to two follow-up visits (in lieu of glasses)
Out-of-Network: Plan pays up to $150; For medically necessary contacts, plan pays up to $210 (in lieu of glasses)
Laser Vision Correction
In-Network: Members have access to discounted refractive eye surgery from numerous provider locations throughout the U.S.
Out-of-Network: No benefit
VISION SERVICE PLAN (VSP)
Vision benefits apply from January 1 through December 31, 2011.
For services that are not listed in this comparison chart, contact your plan. Refer to the Help Lines at the end of this document for contact information.
Eye Exams
In-Network: $10 copay; One exam per year
Out-of-Network: $10 copay; Plan pays up to $35
Lenses Each Pair
In-Network: $25 copay*; One set of lenses per year; Polycarbonate lenses covered in full for dependent children; Average 35-40% savings on all non-covered lens options
Out-of-Network: $25 copay*; Plan pays up to $25 single, $40 bifocals, $55 trifocals, $80 lenticular
*Benefit includes an annual $25 materials copay for lenses or frames, but not both. Contact VSP for additional information regarding in-network added value discounts.
Frames
In-Network: $25 copay*; $120 allowance; 20% off any out-of-pocket costs above the allowance; One pair of frames per year
Out-of-Network: $25 copay*; Plan pays up to $45
*Benefit includes an annual $25 materials copay for lenses or frames, but not both. Contact VSP for additional information regarding in-network added value discounts.
Contact Lenses
In-Network: $0 copay; $120 allowance applied to the cost of your contact lens exam and the contact lenses; 15% discount on contact lens exam (in lieu of glasses)
Out-of-Network: $0 copay; Plan pays up to $105 for disposable or conventional contact lenses (in lieu of glasses)
Laser Vision Correction
In-Network: Laser vision correction services (PRK, LASIK, and Custom LASIK) are provided at a reduced cost through VSP’s contracted laser surgery centers
Out-of-Network: No benefit
HOW TO ACCESS THE ONLINE PROVIDER NETWORKS
HealthChoice Health Plans
HealthChoice High Option, Basic, and S-Account Plans
Visit http://www.healthchoiceok.com
Click on Find a Provider and follow the on-screen instructions
HealthChoice USA Plan
Visit http://www.choicecarenetwork.com
Click on ChoiceCare Physician Finder Plus under Provider Search
Select ChoiceCare Network PPO under Coverage and Network
Follow the on-screen instructions
HMO Plans
CommunityCare Standard and Alternative HMO
Visit http://www.ccok.com
Click on Find a Provider
Select State, Education and Local Government Employees
GlobalHealth Standard and Alternative HMO
Visit http://www.globalhealth.com
Click on STATE and choose State Employees and Educators
Click on PROVIDER LOOKUP
PacifiCare Standard and Alternative HMO
Visit http://www.pacificare.com
Click on Find a Doctor
Select Plan or Service Type choose PacifiCare Signature Value (HMO)
Dental Plans
HealthChoice Dental Plan
Visit http://www.healthchoiceok.com
Click on Find a Provider and follow the on-screen instructions
Assurant Freedom Preferred (Options for PPO)
Visit http://www.assurantemployeebenefits.com
Click on Find a Dentist
Select DHA Network
Assurant Heritage Plus with SBA and Heritage Secure (Options for Prepaid)
Visit http://www.assurantemployeebenefits.com
Click on Find a Dentist
Select The Heritage Series
CIGNA Dental Care Plans
Visit http://www.cigna.com
Click on Provider Directory
Click on Dentist for the type of provider
Select CIGNA Dental Care (HMO)
Delta Dental Plans
Visit http://www.deltadentalok.org
Click on Click here under State of Oklahoma Dental Plans
Click here on the 3 NEW Dental Plans for 2011 and select your dental plan
(Delta Dental PPO, Delta Premier, and Delta Dental PPO – Choice)
Vision Plans
Humana/Comp Benefits Vision Care Plan
Visit http://www.compbenefits.com/custom/stateofoklahoma
Click on Provider Directory
Primary Vision Care Services, Inc.
Visit http://www.pvcs-usa.com
Click on Find a Doctor
Superior Vision Plan
Visit http://www.superiorvision.com
Click on Locate a Provider
UnitedHealthcare Vision
Visit http://www.myuhcvision.com
Click on Provider Locator
Vision Services Plan (VSP)
Visit http://www.vsp.com
Either click on Find the right doctor for you under the Members tab or click on Choose VSP through your employer under Prospective Members tab
Click on Find a VSP Doctor
Select VSP Signature Network
For assistance in locating the correct provider network, contact each plan’s customer service. Refer to Help Lines at the end of this document.
HELP LINES
HealthChoice
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 Area 1-405-416-1525
TDD All Other Areas 1-800-941-2160
Website http://www.sib.ok.gov/ or http://www.healthchoiceok.com
Pharmacy Claims / Pharmacy ID Cards
All Areas 1-800-903-8113
TDD All Areas 1-800-825-1230
Certification
All Areas 1-800-848-8121
TDD All Areas 1-877-267-6367
Member Services / Provider Directory
Oklahoma City Area 1-405-717-8780
All Other Areas 1-800-752-9475
TDD Oklahoma City Area 1-405-949-2281
TDD All Other Areas 1-866-447-0436
Disability Plan
Oklahoma City Area 1-405-316-7492
All Areas 1-800-722-2567
TDD All Areas 1-800-863-5488
HealthChoice USA
Customer Service and Claims 1-800-782-5218
Provider Information 1-877-877-0715 ext. 4059
TDD All Areas 1-800-941-2160
Website http://www.choicecarenetwork.com
HMO Plans
CommunityCare
All Areas 1-800-777-4890
TDD All Areas 1-800-722-0353
Website http://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 http://www.globalhealth.com
PacifiCare
All Areas 1-800-825-9355
TDD All Areas 1-800-557-7595
Website http://www.pacificare.com
Dental Plans
Assurant, Inc. Dental
Prepaid Plan 1-800-443-2995
Indemnity Plan 1-800-442-7742
Website http://www.assurantemployeebenefits.com
CIGNA Prepaid Dental
All Areas 1-800-244-6224
Hearing Impaired Relay Service 1-405-948-3303
Website http://www.cigna.com
Delta Dental
Oklahoma City Area 1-405-607-2100
All Other Areas 1-800-522-0188
Website http://www.DeltaDentalOK.org
Vision Plans
Humana/CompBenefits
All Areas 1-800-865-3676
TDD All Areas 1-877-553-4327
Website http://www.compbenefits.com/custom/stateofoklahoma
Primary Vision Care Services
All Areas 1-888-357-6912
TDD All Areas 1-800-722-0353
Website http://www.pvcs-usa.com
Superior Vision Plan
All Areas 1-800-507-3800
TDD All Areas 1-916-852-2382
Website http://www.superiorvision.com
UnitedHealthcare Vision
All Areas 1-800-638-3120
TDD All Areas 1-800-524-3157
Website http://www.myuhcvision.com
Vision Service Plan (VSP)
All Areas 1-800-877-7195
TDD All Areas 1-800-428-4833
Website http://www.vsp.com
Last Modified on 09/23/2010