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Home / Member / Handbooks / 2011 Text Version BOG

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

   Health Plans

   Dental Plans

   Vision Plans

   HealthChoice Life Insurance

   HealthChoice Disability Insurance

Enrollment Periods

Eligibility

HMO ZIP Code List

Comparison of Benefits for Health Plans – All Plans

HealthChoice High Option Plan Benefits

HealthChoice Basic Plan Benefits

HealthChoice S-Account Plan Benefits

HMO Standard 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.

Superior Vision Plan

UnitedHealthcare Vision

Vision Service Plan (VSP)

How to Access the Online Provider Networks

Help Lines

 

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

Return to Table of Contents

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.

 

Return to Table of Contents

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.

 

Return to Table of Contents

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.

 

Return to Table of Contents

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.

 

Return to Table of Contents

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.

 

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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.

 

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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

 

Return to Table of Contents

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

 

Return to Table of Contents

 

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

 

Return to Table of Contents

 

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

 

Return to Table of Contents

 

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

 

Return to Table of Contents

 

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

 

Return to Table of Contents

 

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

 

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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

 

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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

 

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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

 

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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

 

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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

 

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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

 

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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

 

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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

 

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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

 

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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

 

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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

 

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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

 

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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

 

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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

 

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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

 

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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

 

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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.

 

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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

 

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Last Modified on 09/23/2010
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