The
Oklahoma State and Education Employees Group Insurance Board
For
Plan Year January 1, 2009 through December 31, 2009
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
http://www.sib.ok.gov and http://www.healthchoiceok.com
FORMS ARE BEING MAILED SEPARATELY
THE DEADLINE
FOR TURNING IN YOUR OPTION PERIOD FORM IS DETERMINED BY YOUR INSURANCE
COORDINATOR.
Monthly Premiums for Current Employees
2009 Plan Year Changes
Introduction
Health, Dental, and Vision Plan Highlights
HealthChoice Disability Insurance
General Enrollment Information
Comparison of Benefits for Health Plans – All
Plans
HealthChoice High Option Plan Benefits
HealthChoice Basic Plan Benefits
HealthChoice S-Account Plan Benefits
Aetna Alternative HMO Plan Benefits
CommunityCare
Alternative HMO Plan Benefits
GlobalHealth
Alternative HMO Plan Benefits
PacifiCare Alternative HMO Plan Benefits
Comparison of Benefits for Dental Plans – All
Plans
HealthChoice Dental Plan Benefits
Assurant Freedom Preferred Plan Benefits
Assurant Prepaid Plans, Heritage Plus with
SBA and Heritage Secure Plan Benefits
Cigna Dental Care Plan Benefits
Delta Dental PPO ‘Point of Service’ - PPO Network,
Premier Network, and Non-Network Plan Benefits
Delta’s Choice PPO – PPO Network
Comparison of Benefits for Vision Plans – All
Plans
Primary Vision Care Services, Inc. (PVCS)
Audio
CDs of the Benefit Guides have been prepared and are available 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, and TDD 1-405-521-4672. You may also
access a searchable text version of this document on the OSEEGIB website at www.sib.ok.gov
or www.healthchoiceok.com.
The
participating carriers reviewed and approved the information in this material.
There is no guarantee that all providers will remain with the plans or have
open patient slots all year long. Please verify your provider is still
participating in your plan’s network.
For
Plan Year January 1, 2009 through December 31, 2009
Member $409.12
Spouse
$587.92
Child $199.98
Children $343.10
Member $347.96
Spouse $503.74
Child $171.56
Children $293.44
Member $322.68
Spouse $468.90
Child $162.24
Children $276.72
Member $668.30
Spouse $888.76
Child $654.90
Children $654.90
Member $431.16
Spouse $573.40
Child $422.52
Children $422.52
Member $715.76
Spouse $1,023.52
Child $357.88
Children $572.60
Member $484.72
Spouse $693.14
Child $242.36
Children $387.78
Member $333.78
Spouse $495.26
Child $178.98
Children $285.40
Member
$303.44
Spouse $450.28
Child $162.74
Children $259.46
Member $600.46
Spouse $858.64
Child $300.22
Children $480.36
Member $388.70
Spouse $555.68
Child $194.20
Children $310.81
Member $7.62
Member $28.58
Spouse $28.58
Child $23.82
Children $61.84
Member $24.84
Spouse $24.70
Child $18.52
Children $49.80
Member $11.74
Spouse $8.86
Child $7.60
Children $15.20
Member $7.20
Spouse $5.98
Child $5.20
Children $10.38
Member $9.26
Spouse $6.06
Child $7.08
Children $15.32
Member $29.88
Spouse $29.90
Child $26.28
Children $66.88
Member $12.88
Spouse $29.48
Child $29.26
Children $71.56
Member $6.76
Spouse $5.06
Child $3.57
Children $4.46
Member $9.25
Spouse $8.00
Child $8.50
Children $10.75
Member $6.98
Spouse $6.90
Child $6.60
Children $6.60
Member $8.18
Spouse $5.79
Child $4.59
Children $6.98
Member $8.96
Spouse $6.00
Child $5.74
Children $12.92
HealthChoice Basic Life
($20,000) $3.50
First $20,000 of Supplemental Life $3.50
Age-rated Supplemental Life per $20,000
Less than 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 above $52.00
Low Option $2.16
Spouse coverage of $6,000
Children over 6 months
coverage of $3,000
Birth to 6 months $1,000
Standard Option $3.60
Spouse coverage of $10,000
Children over 6 months
coverage of $5,000
Birth to 6 months $1,000
Premier Option $7.20
Spouse coverage of $20,000
Children over 6 months
coverage of $10,000
Birth to 6 months $1,000
For all dependent life
options, dependents age birth to 6 months have a
maximum coverage of $1,000.
The number of visits allowed without prior
authorization for occupational and speech therapy is being increased from 15
visits to 20 visits. There is a limit of 60 visits per year for each type of
therapy. The maximum of three services per visit has been removed.
The number of visits allowed without prior
authorization for physical therapy/physical medicine is being increased from 15
visits to 20 visits. There is a limit of 60 visits per year. The maximum of
three services per visit is being removed.
The number of visits allowed without prior
authorization for chiropractic therapy is being increased from 15 visits to 20
visits. There is a limit of 60 visits per year. The maximum of three services
per visit is being removed.
The health, dental, and life claims
administrator for HealthChoice is changing to EDS Administrative Services, LLC.
A new health/dental identification card is being sent to all HealthChoice
members.
The precertification administrator is
changing to APS.
Most prescription antihistamines,
decongestants, and cough suppressants are no longer covered medications. This
includes all non-sedating antihistamines such as Allegra and Clarinex. Contact HealthChoice for more information; refer
to Help Lines at the end of this guide.
Members obtaining specialty pharmacy
medications through Accredo Health Group will now pay the applicable copay for
every 30-day fill.
The HMO service areas are changing. Refer to the HMO ZIP Code listing.
Several of the copays are changing. Please refer to the Comparison of
Benefits for Health Plans – All Plans or each plan’s benefit listing.
The coinsurance for Network orthodontia services is being changed to
50%.
The $50 orthodontia deductible for Network services and the $150
orthodontia deductible for non-Network services is
being removed.
The $1,800 lifetime maximum for orthodontia benefits is being removed.
CompBenefits VisionCare Plan’s name has
changed to Humana/CompBenefits VisionCare Plan. The new web address is www.compbenefits.com/custom/stateofoklahoma
Spectera Vision’s name has changed to
UnitedHealthcare Vision. The new web address is www.myuhcvision.com
The Oklahoma State and Education Employees Group
Insurance Board (OSEEGIB) produced this Employee Benefit Options Guide to help
you select your benefits. It is only a summary of the plans available. The
insurance benefits explained in this Guide are Health, Dental, Life,
Disability, and Vision.
Section B
of your Option Period Enrollment/Change Form lists the coverage you will have
effective January 1, 2009, if you do not make any changes during Option Period.
Contact your
Insurance Coordinator if you have questions about your current coverage.
Check Plan Changes
for 2009 in this guide.
Check with
your Insurance Coordinator about the need to return your form even if you are
not making any changes.
Use the
following resources to help you decide what coverage you (and your dependents)
wish to carry – this guide, plan websites, customer services telephone numbers,
provider directories, OSEEGIB member services, and your Insurance Coordinator.
Decide on
the coverage you want for you and/or your dependents for 2009.
Complete
your Option Period Enrollment/Change Form and return it to your Insurance
Coordinator by his/her designated deadline.
You will
receive a Confirmation Statement in the mail.
Contact
your Insurance Coordinator if your Confirmation Statement is not correct. If
you do not make any 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.
Use the
following resources to help you decide what coverage you (and your dependents)
wish to carry – this guide, plan websites, customer services telephone numbers,
provider directories, OSEEGIB member services, and your Insurance Coordinator.
Decide on the
coverage you want for you and/or your dependents for 2009.
Complete
your Enrollment Form and return it to your Insurance Coordinator by his/her
designated deadline.
You will
receive a Confirmation Statement in the mail.
Contact
your Insurance Coordinator if your Confirmation Statement is not correct.
There are 12
health plans available – HealthChoice High Option Plan, HealthChoice Basic
Plan, HealthChoice S-Account Plan, HealthChoice USA Plan*, Aetna Standard and Alternative
HMO, CommunityCare Standard and Alternative HMO, GlobalHealth Standard and Alternative
HMO, and PacifiCare Standard and Alternative HMO.
*The HealthChoice USA Plan is a plan designed for
employees who receive an assignment of more than 90 consecutive days outside of
Oklahoma and Arkansas. Call HealthChoice Member Services for more details.
All plans
have toll-free numbers for customer service; refer to Help
Lines at the end of this document.
To enroll
in the HealthChoice S-Account Plan, you must provide OSEEGIB with proof you
have set up a Health Savings Account at a bank or other financial institution.
This proof must be submitted by December 15, 2008.
You must
live or work within the HMO’s ZIP Code service area to be eligible for that
HMO. PO Box addresses cannot be used to determine your eligibility for an HMO.
Refer to the HMO Zip Code listing.
Check with
each health plan if you have benefit questions.
Verify your employer offers dental coverage through
OSEEGIB.
There are
seven 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 – POS, and Delta’s Choice –
PPO
All plans
have toll-free numbers for customer service; refer to Help
Lines at the end of this document.
Check with
each dental plan if you have benefit questions.
There are
five vision plans available – Humana/CompBenefits VisionCare Plan, Primary
Vision Care Services (PVCS), Superior Vision Services, UnitedHealthcare Vision
(formerly Spectera), and Vision Service Plan (VSP).
All plans
have toll-free numbers for customer service; refer to Help
Lines at the end of this document.
All vision
plans have limited coverage for services received from non-participating providers.
Verify your
vision provider is a member of the vision plan’s network by calling the
toll-free numbers provided, or check with each plan’s website for the most
up-to-date list of providers.
Check with
each vision plan if you have benefit questions.
The loss of your provider on any of the health,
dental, or vision plans does not allow a change in plans until the next annual
Option Period. You may change providers within your selected plan as needed.
If you are a current employee thinking about
retiring before January 1, 2009, please contact Member Services so we can send
you the appropriate materials. You will select your benefits from the Former
Pre-Medicare or Medicare Option Period Guide not this guide. To contact Member
Services, refer to the Help Lines at the end of this
document.
Verify your employer offers HealthChoice Life
Insurance.
As a new
employee, you may elect life coverage within 30 days following your initial
entry-on-duty date or the date you become eligible. A limited amount
(Guaranteed Issue) can be obtained without an approved Life Insurance
Application.
As a current employee, if you did not enroll when
first eligible, you may enroll at the next annual Option Period or if you have
proof of loss of other group life coverage within the previous 30 days. An
approved Life Insurance Application will be required for Option Period
enrollment. Contact your Insurance Coordinator for this form.
To enroll
during Option Period, you must provide a Life Insurance Application for review
and approval.
Basic Life
pays a benefit of $20,000 to your beneficiaries in the event of your death.
Included
in the Basic Life Plan is Accidental Death and Dismemberment (AD&D)
coverage. This coverage automatically pays an additional $20,000 in benefits to
your beneficiaries if your death is due to an accident, or it pays you a
reduced amount for the loss of your sight or limb.
You may
purchase additional coverage in units of $20,000 with an approved Life
Insurance Application.
The first
$20,000 unit of Supplemental Life provides you with an additional $20,000 of
AD&D insurance.
At the
time of your initial enrollment only, you can purchase supplemental life
coverage of two times your annual salary (Guaranteed Issue), rounded up to the
next $20,000 unit, without providing a Life Insurance Application.
You may also
purchase supplemental life coverage up to an amount equal to five times your
annual salary, rounded up to the next $20,000 unit, or $300,000, whichever is
less, with an approved Life Insurance Application.
Life
Insurance Applications are available from your Insurance Coordinator.
If you enroll in Basic Life, you may purchase
Dependent Life insurance for your spouse and/or your children at initial
enrollment, during Option Period, or within 30 days of loss of other group life
insurance.
Dependent
Life does not include AD&D coverage.
You may
choose Low Option, Standard Option, or Premier Option coverage. Regardless of
the number of dependents, the monthly premium is the same.
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 25) $3,000
Child
(live birth to 6 months) $1,000
Amount of Coverage for Standard Option
Spouse
$10,000
Child (age
6 months to 25) $5,000
Child
(live birth to 6 months) $1,000
Amount of Coverage for Premier Option
Spouse
$20,000
Child (age
6 months to 25) $10,000
Child
(live birth to 6 months) $1,000
Benefits are paid to your beneficiaries in a lump sum.
You must name your beneficiaries when you enroll. Your beneficiary designation
may be changed at any time. Death benefits for covered dependents are paid to
the member. For a beneficiary form or more information, contact your Insurance
Coordinator. Beneficiary forms are also available on our website at www.sib.ok.gov
or www.healthchoiceok.com.
Verify your employer offers HealthChoice Disability
(limited county participation only).
The Disability Plan provides partial income
replacement if you are unable to work due to illness or injury. Disability
coverage is not available for dependents.
You are enrolled in the Plan on the first day of the
month following your entry-on-duty date or the date you become eligible. You
become eligible for benefits after 31 consecutive days of employment. During
that time, you must have continuously performed all of the material duties of
your regular occupation. Any claim for disability benefits must be filed within
one year of the beginning of the disability.
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 under your
employer’s Employee Benefit Plan.
The benefits you elect will be in effect from
January 1, 2009, or the effective date of your coverage, through December 31,
2009. Please contact the insurance plan(s) at the phone number(s) or website(s)
listed in the Help Lines section at the end of this document
for more information on any of the plans or if you have any questions.
After enrollment, the plan(s) you have selected will
provide a member handbook or additional material with detailed information on
your benefits.
Once enrolled in any of the plan choices, it is your
responsibility to review the benefits carefully so you know what is covered or
what the plan policies are before you have to use your benefits.
This is the time when eligible employees may enroll
in plans, change plans or drop coverage, increase life insurance, and add or
drop eligible family members to or from coverage.
You may add health, dental, life, and/or vision
coverage for yourself and/or your dependent(s) during Option Period,
as long as you have not dropped that coverage within the past 12 months
(limitations and/or exceptions may apply).
If you want to enroll in or increase your life
insurance coverage, you must complete and submit a Life Insurance Application
for approval. Contact your Insurance Coordinator for this form.
This is the time when new employees become eligible
to enroll in insurance benefits, enroll eligible dependents in benefits, and
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 make your benefit selections. If you
do not enroll within 30 days, you will not be able to elect benefits until the
next annual Option Period unless a qualifying event occurs during the Plan
Year. Your employer’s Section 125 Plan (if applicable) determines any exception
to this rule. Check with your Insurance Coordinator for more information.
If you request life coverage of more than two times
your annual salary (Guaranteed Issue), you must complete a Life Insurance
Application. Contact your Insurance Coordinator for this form.
Keep a copy of your enrollment form for your
records.
You
must be a current Education employee eligible to participate in the Oklahoma
Teachers’ Retirement System and 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 or life
insurance.
You
may exclude your spouse from health and/or dental coverage. Contact your
Insurance Coordinator for details. You and your spouse must both sign the spouse
exclusion section of the Enrollment Form or the Option Period Enrollment/Change
Form
If
one eligible dependent is covered, all eligible dependents must be covered. Dependents
can be excluded from coverage if they have other group coverage of the same
type, or are eligible for Indian or military health benefits. Eligible dependents
are:
Your legal spouse (including common-law)
Your unmarried children up to age 25; or
regardless of age, a dependent who is incapable of self-support and who has a
disability diagnosed prior to age 25, subject to medical review and approval
Children, including your natural or adopted
child, or your stepchild, provided you are primarily responsible for their
support, regardless of residence, if ordered by the court; court documentation is
required
Other dependent children with an approved
Declaration of Dependency form (required if not claimed on your income tax
return)
If your spouse is enrolled separately in one
of the OSEEGIB plans, children may be covered under either parent’s health,
dental, or vision plan (but not both); however, the spouse and children may be
covered for dependent life by each employee
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 a change in address, marital or family status, loss
of other group coverage, or termination of employment occurs. If eligible
dependents are dropped from coverage, you cannot re-enroll those dependents for
a minimum of 12 months. The 12-month requirement does not apply when the
dependents have lost other group health, dental, vision, and/or life insurance
coverage and are seeking reinstatement. Eligible dependents can be excluded
from coverage if they have other group coverage of the same type, or are
eligible for Indian or military health benefits.
Family
members may only be enrolled in the same coverages
you have as the primary member
Newborns
– A change form must be provided to your Insurance Coordinator within 30 days
of the birth to enroll your newborn. 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. Newborns will be covered only for the first 48 hours following a
vaginal birth or the first 96 hours following a cesarean section birth without
enrollment.
A
dependent who loses eligibility may apply for continuation of health, dental,
or vision coverage under COBRA for a maximum of 36 months. Contact your
Insurance Coordinator for more information.
Option
Period elections become effective on January 1, 2009, the beginning of the new
plan year.
New
employee coverage is effective the first day of the month following your
employment date or the date you become eligible through your employer.
Midyear
changes become effective the first of the month following a qualifying event or
the date the change is made.
As
a new employee, you have a 30-day window following the date you became eligible
to make changes to your original benefit selections. These changes are
effective the first day of the month following the date the change in coverage
is made.
Midyear
plan changes are allowed only if a qualifying event occurs. Contact your
Insurance Coordinator for more information.
You
will be provided a Confirmation Statement (CS) when you enroll or make changes
to your coverage. The CS lists the coverage you are enrolled in, the effective
date of the coverage, and the premium amounts for the coverage.
Section
B of your Option Period Enrollment/Change Form lists the coverage you will have
effective January 1, 2009, if you do not make changes to your coverage during
Option Period. In this event, you will not receive a CS from OSEEGIB. Keep a
copy of your Option Period Enrollment/Change Form as proof of your coverage.
Review
your CS to ensure the coverage shown is correct. Any corrections must be
submitted to your Insurance Coordinator within 60 days of the election.
Corrections reported after 60 days will be effective the first of the month
following notification.
When
moving from one participating employer to another, you are eligible for
continuous coverage provided there is no more than a 30-day break in coverage, and
premiums are paid upon reporting for work.
Benefit
options may vary from employer to employer. Changes may be made within the
first 30 days of transfer. Contact your Insurance Coordinator for more
information.
Coverage
will end on the last day of the month in which a termination event occurs.
Examples of termination events are loss of employment,
a dependent becomes ineligible for coverage, non-payment of premiums, and
death.
The
Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) allows you or
your dependents to continue health, dental, or vision insurance coverage after
your employment terminates or after a dependent loses eligibility. Certain time
limits apply to enrollment. An additional two percent administration fee is
added for COBRA insurance premiums. 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. Your Insurance
Coordinator will provide the necessary paperwork and information on COBRA
enrollment and premiums. COBRA is limited to 18 months for eligible employee
events; up to 29 months for certain eligible disabilities; and up to 36 months
for dependents who lose coverage except for specific, qualifying events.
If you do not live or work
in the ZIP Code area for a plan, that plan is not available to you. Post office
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.
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.
73002
GlobalHealth, PacifiCare
73003
Aetna, CommunityCare, GlobalHealth, PacifiCare
73004
Aetna, GlobalHealth, PacifiCare
73007
Aetna, CommunityCare, GlobalHealth, PacifiCare
73008
Aetna, CommunityCare, GlobalHealth, PacifiCare
73010
Aetna, GlobalHealth, PacifiCare
73011
GlobalHealth, PacifiCare
73012
Aetna, CommunityCare, PacifiCare
73013
Aetna, CommunityCare, GlobalHealth, PacifiCare
73014
CommunityCare, GlobalHealth, PacifiCare
73016
PacifiCare
73018
GlobalHealth, PacifiCare
73019
Aetna, CommunityCare, GlobalHealth, PacifiCare
73020
Aetna, CommunityCare, GlobalHealth, PacifiCare
73022
Aetna, CommunityCare, GlobalHealth, PacifiCare
73023
GlobalHealth
73025
Aetna, CommunityCare, PacifiCare
73026
Aetna, CommunityCare, GlobalHealth, PacifiCare
73027
Aetna, CommunityCare, GlobalHealth, PacifiCare
73028
Aetna, CommunityCare, GlobalHealth, PacifiCare
73031
Aetna, GlobalHealth, PacifiCare
73034
Aetna, CommunityCare, GlobalHealth, PacifiCare
73036
Aetna, CommunityCare, GlobalHealth, PacifiCare
73037
CommunityCare, PacifiCare
73040
GlobalHealth
73043
GlobalHealth
73044
Aetna, CommunityCare, GlobalHealth, PacifiCare
73045
Aetna, CommunityCare, GlobalHealth, PacifiCare
73048
GlobalHealth
73049
Aetna, CommunityCare, GlobalHealth, PacifiCare
73050
Aetna, CommunityCare, GlobalHealth, PacifiCare
73051
Aetna, CommunityCare, GlobalHealth, PacifiCare
73052
GlobalHealth
73054
Aetna, CommunityCare, GlobalHealth, PacifiCare
73056
Aetna, CommunityCare, GlobalHealth, PacifiCare
73057
GlobalHealth, PacifiCare
73058
Aetna, CommunityCare, GlobalHealth, PacifiCare
73059
Aetna, GlobalHealth, PacifiCare
73061
CommunityCare
73063
Aetna, CommunityCare, GlobalHealth, PacifiCare
73064
Aetna, CommunityCare, GlobalHealth, PacifiCare
73065
Aetna, GlobalHealth, PacifiCare
73066
Aetna, CommunityCare, GlobalHealth, PacifiCare
73067
GlobalHealth, PacifiCare
73068
Aetna, CommunityCare, GlobalHealth, PacifiCare
73069
Aetna, CommunityCare, GlobalHealth, PacifiCare
73070
Aetna, CommunityCare, GlobalHealth, PacifiCare
73071
Aetna, CommunityCare, GlobalHealth, PacifiCare
73072
Aetna, CommunityCare, GlobalHealth, PacifiCare
73073
Aetna, CommunityCare, GlobalHealth, PacifiCare
73074
GlobalHealth
73075
GlobalHealth
73077
CommunityCare
73078
Aetna, CommunityCare, GlobalHealth, PacifiCare
73079
GlobalHealth, PacifiCare
73080
Aetna, GlobalHealth, PacifiCare
73082
GlobalHealth
73083
Aetna, CommunityCare, GlobalHealth, PacifiCare
73084
Aetna, CommunityCare, GlobalHealth, PacifiCare
73085
Aetna, CommunityCare, GlobalHealth, PacifiCare
73089
Aetna, GlobalHealth, PacifiCare
73090
Aetna, CommunityCare, GlobalHealth, PacifiCare
73092
GlobalHealth, PacifiCare
73093
Aetna, GlobalHealth, PacifiCare
73095
GlobalHealth, PacifiCare
73096
GlobalHealth
73097
Aetna, CommunityCare, GlobalHealth, PacifiCare
73098
GlobalHealth
73099
Aetna, CommunityCare, GlobalHealth, PacifiCare
73100
CommunityCare
73101
Aetna, CommunityCare, GlobalHealth, PacifiCare
73102
Aetna, CommunityCare, GlobalHealth, PacifiCare
73103
Aetna, CommunityCare, GlobalHealth, PacifiCare
73104
Aetna, CommunityCare, GlobalHealth, PacifiCare
73105
Aetna, CommunityCare, GlobalHealth, PacifiCare
73106
Aetna, CommunityCare, GlobalHealth, PacifiCare
73107
Aetna, CommunityCare, GlobalHealth, PacifiCare
73108
Aetna, CommunityCare, GlobalHealth, PacifiCare
73109
Aetna, CommunityCare, GlobalHealth, PacifiCare
73110
Aetna, CommunityCare, GlobalHealth, PacifiCare
73111
Aetna, CommunityCare, GlobalHealth, PacifiCare
73112
Aetna, CommunityCare, GlobalHealth, PacifiCare
73113
Aetna, CommunityCare, GlobalHealth, PacifiCare
73114
Aetna, CommunityCare, GlobalHealth, PacifiCare
73115
Aetna, CommunityCare, GlobalHealth, PacifiCare
73116
Aetna, CommunityCare, GlobalHealth, PacifiCare
73117
Aetna, CommunityCare, GlobalHealth, PacifiCare
73118
Aetna, CommunityCare, GlobalHealth, PacifiCare
73119
Aetna, CommunityCare, GlobalHealth, PacifiCare
73120
Aetna, CommunityCare, GlobalHealth, PacifiCare
73121
Aetna, CommunityCare, GlobalHealth, PacifiCare
73122
Aetna, CommunityCare, GlobalHealth, PacifiCare
73123
Aetna, CommunityCare, GlobalHealth, PacifiCare
73124
Aetna, CommunityCare, GlobalHealth, PacifiCare
73125
Aetna, CommunityCare, GlobalHealth, PacifiCare
73126
Aetna, CommunityCare, GlobalHealth, PacifiCare
73127
Aetna, CommunityCare, GlobalHealth, PacifiCare
73128
Aetna, CommunityCare, GlobalHealth, PacifiCare
73129
Aetna, CommunityCare, GlobalHealth, PacifiCare
73130
Aetna, CommunityCare, GlobalHealth, PacifiCare
73131
Aetna, CommunityCare, GlobalHealth, PacifiCare
73132
Aetna, CommunityCare, GlobalHealth, PacifiCare
73134
Aetna, CommunityCare, GlobalHealth, PacifiCare
73135
Aetna, CommunityCare, GlobalHealth, PacifiCare
73136
Aetna, CommunityCare, GlobalHealth, PacifiCare
73137
Aetna, CommunityCare, GlobalHealth, PacifiCare
73139
Aetna, CommunityCare, GlobalHealth, PacifiCare
73140
Aetna, CommunityCare, GlobalHealth, PacifiCare
73141
Aetna, CommunityCare, GlobalHealth, PacifiCare
73142
Aetna, CommunityCare, GlobalHealth, PacifiCare
73143
Aetna, CommunityCare, GlobalHealth, PacifiCare
73144
Aetna, CommunityCare, GlobalHealth, PacifiCare
73145
Aetna, CommunityCare, GlobalHealth, PacifiCare
73146
Aetna, CommunityCare, GlobalHealth, PacifiCare
73147
Aetna, CommunityCare, GlobalHealth, PacifiCare
73148
Aetna, CommunityCare, GlobalHealth, PacifiCare
73149
Aetna, CommunityCare, GlobalHealth, PacifiCare
73150
Aetna, CommunityCare, GlobalHealth, PacifiCare
73151
Aetna, CommunityCare, GlobalHealth, PacifiCare
73152
Aetna, CommunityCare, GlobalHealth, PacifiCare
73153
Aetna, CommunityCare, GlobalHealth, PacifiCare
73154
Aetna, CommunityCare, GlobalHealth, PacifiCare
73155
Aetna, CommunityCare, GlobalHealth, PacifiCare
73156
Aetna, CommunityCare, GlobalHealth, PacifiCare
73157
Aetna, CommunityCare, GlobalHealth, PacifiCare
73159
Aetna, CommunityCare, GlobalHealth, PacifiCare
73160
Aetna, CommunityCare, GlobalHealth, PacifiCare
73162
Aetna, CommunityCare, GlobalHealth, PacifiCare
73163
Aetna, CommunityCare, GlobalHealth, PacifiCare
73164
CommunityCare, GlobalHealth, PacifiCare
73165
Aetna, CommunityCare, GlobalHealth, PacifiCare
73167
Aetna, CommunityCare, GlobalHealth, PacifiCare
73169
Aetna, CommunityCare, GlobalHealth, PacifiCare
73170
Aetna, CommunityCare, GlobalHealth, PacifiCare
73172
Aetna, CommunityCare, GlobalHealth, PacifiCare
73173
Aetna, CommunityCare, GlobalHealth, PacifiCare
73177
CommunityCare, PacifiCare
73178
Aetna, CommunityCare, GlobalHealth, PacifiCare
73179
Aetna, CommunityCare, GlobalHealth, PacifiCare
73180
CommunityCare, PacifiCare
73184
Aetna, CommunityCare, GlobalHealth, PacifiCare
73185
Aetna, CommunityCare, GlobalHealth, PacifiCare
73189
Aetna, CommunityCare, GlobalHealth, PacifiCare
73190
Aetna, CommunityCare, GlobalHealth, PacifiCare
73193
CommunityCare, GlobalHealth, PacifiCare
73194
Aetna, CommunityCare, GlobalHealth, PacifiCare
73195
Aetna, CommunityCare, GlobalHealth, PacifiCare
73196
Aetna, CommunityCare, GlobalHealth, PacifiCare
73197
Aetna, CommunityCare, GlobalHealth, PacifiCare
73198
Aetna, CommunityCare, GlobalHealth, PacifiCare
73199
Aetna, CommunityCare, GlobalHealth, PacifiCare
73432
GlobalHealth
73433
GlobalHealth
73446
GlobalHealth
73447
GlobalHealth
73450
GlobalHealth
73455
GlobalHealth
73460
GlobalHealth
73461
GlobalHealth
73532
GlobalHealth
73537
GlobalHealth
73544
GlobalHealth
73550
GlobalHealth
73554
GlobalHealth
73571
GlobalHealth
73646
GlobalHealth
73658
GlobalHealth
73669
GlobalHealth
73718
GlobalHealth
73724
GlobalHealth
73729
GlobalHealth
73737
GlobalHealth
73744
GlobalHealth
73747
GlobalHealth
73755
GlobalHealth
73757
CommunityCare
73760
GlobalHealth
73762
PacifiCare
73763
GlobalHealth
73764
GlobalHealth
73768
GlobalHealth
73770
GlobalHealth
73772
GlobalHealth
73838
GlobalHealth
74100
CommunityCare
74001
CommunityCare, GlobalHealth
74002
CommunityCare, GlobalHealth, PacifiCare
74003
CommunityCare
74004
CommunityCare
74005
CommunityCare
74006
CommunityCare
74008
Aetna, CommunityCare, GlobalHealth, PacifiCare
74009
CommunityCare
74010
CommunityCare, GlobalHealth, PacifiCare
74011
Aetna, CommunityCare, GlobalHealth, PacifiCare
74012
Aetna, CommunityCare, GlobalHealth, PacifiCare
74013
Aetna, CommunityCare, GlobalHealth, PacifiCare
74014
Aetna, CommunityCare, GlobalHealth, PacifiCare
74015
Aetna, CommunityCare, GlobalHealth, PacifiCare
74016
Aetna, CommunityCare, GlobalHealth, PacifiCare
74017
Aetna, CommunityCare, GlobalHealth, PacifiCare
74018
Aetna, CommunityCare, GlobalHealth, PacifiCare
74019
Aetna, CommunityCare, GlobalHealth, PacifiCare
74020
CommunityCare, PacifiCare
74021
Aetna, CommunityCare, GlobalHealth, PacifiCare
74022
CommunityCare
74023
CommunityCare, PacifiCare
74026
GlobalHealth, PacifiCare
74027
CommunityCare
74028
CommunityCare, GlobalHealth, PacifiCare
74029
CommunityCare
74030
CommunityCare, GlobalHealth, PacifiCare
74031
Aetna, CommunityCare, GlobalHealth, PacifiCare
74032
CommunityCare, PacifiCare
74033
Aetna, CommunityCare, GlobalHealth, PacifiCare
74034
CommunityCare
74035
CommunityCare, GlobalHealth, PacifiCare
74036
Aetna, CommunityCare, GlobalHealth, PacifiCare
74037
Aetna, CommunityCare, GlobalHealth, PacifiCare
74038
CommunityCare, PacifiCare
74039
Aetna, CommunityCare, GlobalHealth, PacifiCare
74041
CommunityCare, GlobalHealth, PacifiCare
74042
CommunityCare
74043
Aetna, CommunityCare, GlobalHealth, PacifiCare
74044
CommunityCare, GlobalHealth, PacifiCare
74045
CommunityCare
74046
CommunityCare, GlobalHealth, PacifiCare
74047
Aetna, CommunityCare, GlobalHealth, PacifiCare
74048
CommunityCare
74050
Aetna, CommunityCare, GlobalHealth, PacifiCare
74051
CommunityCare
74052
CommunityCare, GlobalHealth, PacifiCare
74053
Aetna, CommunityCare, GlobalHealth, PacifiCare
74054
Aetna, CommunityCare, GlobalHealth, PacifiCare
74055
Aetna, CommunityCare, GlobalHealth, PacifiCare
74056
CommunityCare, GlobalHealth
74058
CommunityCare
74059
CommunityCare, PacifiCare
74060
Aetna, CommunityCare, GlobalHealth, PacifiCare
74061
CommunityCare, PacifiCare
74062
CommunityCare, PacifiCare
74063
Aetna, CommunityCare, GlobalHealth, PacifiCare
74066
Aetna, CommunityCare, GlobalHealth, PacifiCare
74067
Aetna, CommunityCare, GlobalHealth, PacifiCare
74068
CommunityCare, GlobalHealth, PacifiCare
74070
Aetna, CommunityCare, GlobalHealth, PacifiCare
74071
CommunityCare, GlobalHealth, PacifiCare
74072
CommunityCare
74073
Aetna, CommunityCare, GlobalHealth, PacifiCare
74074
CommunityCare, PacifiCare
74075
CommunityCare, PacifiCare
74076
CommunityCare, PacifiCare
74077
CommunityCare
74078
CommunityCare
74079
GlobalHealth, PacifiCare
74080
Aetna, CommunityCare, GlobalHealth, PacifiCare
74081
CommunityCare, PacifiCare
74082
CommunityCare, PacifiCare
74083
CommunityCare
74084
CommunityCare, GlobalHealth
74085
CommunityCare, PacifiCare
74101
Aetna, CommunityCare, GlobalHealth, PacifiCare
74102
Aetna, CommunityCare, GlobalHealth, PacifiCare
74103
Aetna, CommunityCare, GlobalHealth, PacifiCare
74104
Aetna, CommunityCare, GlobalHealth, PacifiCare
74105
Aetna, CommunityCare, GlobalHealth, PacifiCare
74106
Aetna, CommunityCare, GlobalHealth, PacifiCare
74107
Aetna, CommunityCare, GlobalHealth, PacifiCare
74108
Aetna, CommunityCare, GlobalHealth, PacifiCare
74110
Aetna, CommunityCare, GlobalHealth, PacifiCare
74112
Aetna, CommunityCare, GlobalHealth, PacifiCare
74114
Aetna, CommunityCare, GlobalHealth, PacifiCare
74115
Aetna, CommunityCare, GlobalHealth, PacifiCare
74116
Aetna, CommunityCare, GlobalHealth, PacifiCare
74117
Aetna, CommunityCare, GlobalHealth, PacifiCare
74119
Aetna, CommunityCare, GlobalHealth, PacifiCare
74120
Aetna, CommunityCare, GlobalHealth, PacifiCare
74121
Aetna, CommunityCare, GlobalHealth, PacifiCare
74126
Aetna, CommunityCare, GlobalHealth, PacifiCare
74127
Aetna, CommunityCare, GlobalHealth, PacifiCare
74128
Aetna, CommunityCare, GlobalHealth, PacifiCare
74129
Aetna, CommunityCare, GlobalHealth, PacifiCare
74130
Aetna, CommunityCare, GlobalHealth, PacifiCare
74131
Aetna, CommunityCare, GlobalHealth, PacifiCare
74132
Aetna, CommunityCare, GlobalHealth, PacifiCare
74133
Aetna, CommunityCare, GlobalHealth, PacifiCare
74134
Aetna, CommunityCare, GlobalHealth, PacifiCare
74135
Aetna, CommunityCare, GlobalHealth, PacifiCare
74136
Aetna, CommunityCare, GlobalHealth, PacifiCare
74137
Aetna, CommunityCare, GlobalHealth, PacifiCare
74141
Aetna, CommunityCare, GlobalHealth, PacifiCare
74145
Aetna, CommunityCare, GlobalHealth, PacifiCare
74146
Aetna, CommunityCare, GlobalHealth, PacifiCare
74147
Aetna, CommunityCare, GlobalHealth, PacifiCare
74148
Aetna, CommunityCare, GlobalHealth, PacifiCare
74149
Aetna, CommunityCare, GlobalHealth, PacifiCare
74150
Aetna, CommunityCare, GlobalHealth, PacifiCare
74152
Aetna, CommunityCare, GlobalHealth, PacifiCare
74153
Aetna, CommunityCare, GlobalHealth, PacifiCare
74155
Aetna, CommunityCare, GlobalHealth, PacifiCare
74156
Aetna, CommunityCare, GlobalHealth, PacifiCare
74157
Aetna, CommunityCare, GlobalHealth, PacifiCare
74158
Aetna, CommunityCare, GlobalHealth, PacifiCare
74159
Aetna, CommunityCare, GlobalHealth, PacifiCare
74169
Aetna, CommunityCare, GlobalHealth, PacifiCare
74170
Aetna, CommunityCare, GlobalHealth, PacifiCare
74171
Aetna, CommunityCare, GlobalHealth, PacifiCare
74172
Aetna, CommunityCare, GlobalHealth, PacifiCare
74182
Aetna, CommunityCare, GlobalHealth, PacifiCare
74183
Aetna, CommunityCare, GlobalHealth, PacifiCare
74184
Aetna, CommunityCare, GlobalHealth
74186
Aetna, CommunityCare, GlobalHealth, PacifiCare
74187
Aetna, CommunityCare, GlobalHealth, PacifiCare
74189
Aetna, CommunityCare, GlobalHealth, PacifiCare
74192
Aetna, CommunityCare, GlobalHealth, PacifiCare
74193
Aetna, CommunityCare, GlobalHealth, PacifiCare
74194
Aetna, CommunityCare, GlobalHealth, PacifiCare
74301
CommunityCare, PacifiCare
74330
Aetna, CommunityCare, GlobalHealth, PacifiCare
74331
CommunityCare
74332
CommunityCare
74333
CommunityCare
74335
CommunityCare
74337
Aetna, CommunityCare, GlobalHealth, PacifiCare
74338
CommunityCare
74339
CommunityCare
74340
Aetna, CommunityCare, GlobalHealth, PacifiCare
74342
CommunityCare
74343
CommunityCare
74344
CommunityCare
74345
CommunityCare
74346
CommunityCare
74347
CommunityCare
74349
Aetna, CommunityCare, GlobalHealth, PacifiCare
74350
Aetna, CommunityCare, GlobalHealth, PacifiCare
74352
Aetna, CommunityCare, GlobalHealth, PacifiCare
74353
CommunityCare, PacifiCare
74354
CommunityCare
74355
CommunityCare
74358
CommunityCare
74359
CommunityCare
74360
CommunityCare
74361
Aetna, CommunityCare, GlobalHealth, PacifiCare
74362
Aetna, CommunityCare, GlobalHealth, PacifiCare
74363
CommunityCare
74364
Aetna, CommunityCare, GlobalHealth, PacifiCare
74365
Aetna, CommunityCare, GlobalHealth, PacifiCare
74366
Aetna, CommunityCare, GlobalHealth, PacifiCare
74367
Aetna, CommunityCare, GlobalHealth, PacifiCare
74368
CommunityCare
74369
CommunityCare
74370
CommunityCare
74401
CommunityCare
74402
CommunityCare
74403
CommunityCare
74421
CommunityCare, GlobalHealth, PacifiCare
74422
CommunityCare, GlobalHealth, PacifiCare
74423
CommunityCare
74425
CommunityCare
74426
CommunityCare
74427
CommunityCare
74428
CommunityCare
74429
Aetna, CommunityCare, GlobalHealth, PacifiCare
74430
CommunityCare
74431
CommunityCare, GlobalHealth, PacifiCare
74432
CommunityCare
74434
CommunityCare
74435
CommunityCare
74436
CommunityCare, GlobalHealth, PacifiCare
74437
CommunityCare, GlobalHealth, PacifiCare
74438
CommunityCare
74439
CommunityCare
74440
CommunityCare
74441
CommunityCare
74442
CommunityCare
74444
CommunityCare
74445
CommunityCare, GlobalHealth, PacifiCare
74446
CommunityCare, GlobalHealth, PacifiCare
74447
CommunityCare, GlobalHealth, PacifiCare
74450
CommunityCare
74451
CommunityCare
74452
CommunityCare
74454
CommunityCare, GlobalHealth, PacifiCare
74455
CommunityCare
74456
CommunityCare, GlobalHealth, PacifiCare
74457
CommunityCare
74458
CommunityCare, GlobalHealth, PacifiCare
74459
CommunityCare
74460
CommunityCare, GlobalHealth, PacifiCare
74461
CommunityCare
74462
CommunityCare
74463
CommunityCare
74464
CommunityCare
74465
CommunityCare
74466
CommunityCare, PacifiCare
74467
CommunityCare, GlobalHealth, PacifiCare
74468
CommunityCare
74469
CommunityCare
74470
CommunityCare
74471
CommunityCare
74472
CommunityCare
74477
CommunityCare, GlobalHealth, PacifiCare
74501
CommunityCare
74502
CommunityCare
74521
CommunityCare
74522
CommunityCare
74523
CommunityCare
74526
CommunityCare
74528
CommunityCare
74529
CommunityCare
74530
GlobalHealth
74531
GlobalHealth
74536
CommunityCare
74543
CommunityCare
74545
CommunityCare
74546
CommunityCare
74547
CommunityCare
74548
CommunityCare
74549
CommunityCare
74552
CommunityCare
74553
CommunityCare
74554
CommunityCare
74557
CommunityCare
74558
CommunityCare
74559
CommunityCare
74560
CommunityCare
74561
CommunityCare
74562
CommunityCare
74563
CommunityCare
74565
CommunityCare
74567
CommunityCare
74570
CommunityCare, GlobalHealth
74571
CommunityCare
74574
CommunityCare
74577
CommunityCare
74578
CommunityCare
74630
CommunityCare
74633
CommunityCare, GlobalHealth
74637
CommunityCare, GlobalHealth
74644
CommunityCare
74650
CommunityCare
74651
CommunityCare
74652
CommunityCare, GlobalHealth
74653
CommunityCare
74727
CommunityCare
74735
CommunityCare
74738
CommunityCare
74743
CommunityCare
73748
GlobalHealth
74756
CommunityCare
74759
CommunityCare
74760
CommunityCare
74761
CommunityCare
74801
Aetna, CommunityCare, GlobalHealth, PacifiCare
74802
Aetna, CommunityCare, GlobalHealth, PacifiCare
74804
Aetna, CommunityCare, GlobalHealth, PacifiCare
74818
CommunityCare, GlobalHealth, PacifiCare
74820
GlobalHealth
74821
GlobalHealth
74824
GlobalHealth, PacifiCare
74825
GlobalHealth
74826
Aetna, CommunityCare, GlobalHealth, PacifiCare
74827
GlobalHealth, PacifiCare
74829
GlobalHealth, PacifiCare
74830
CommunityCare, GlobalHealth, PacifiCare
74831
Aetna, PacifiCare
74832
GlobalHealth, PacifiCare
74833
PacifiCare
74834
GlobalHealth, PacifiCare
74835
PacifiCare
74836
GlobalHealth
74837
CommunityCare, GlobalHealth, PacifiCare
74838
PacifiCare
74839
GlobalHealth
74840
Aetna, CommunityCare, GlobalHealth, PacifiCare
74842
GlobalHealth
74843
GlobalHealth
74844
GlobalHealth
74845
CommunityCare
74848
GlobalHealth
74849
CommunityCare, GlobalHealth, PacifiCare
74850
GlobalHealth
74851
Aetna, CommunityCare, GlobalHealth, PacifiCare
74852
Aetna, CommunityCare, GlobalHealth, PacifiCare
74854
Aetna, CommunityCare, GlobalHealth, PacifiCare
74855
Aetna, GlobalHealth, PacifiCare
74856
GlobalHealth
74857
Aetna, CommunityCare, GlobalHealth, PacifiCare
74859
GlobalHealth, PacifiCare
74860
PacifiCare
74862
PacifiCare
74864
GlobalHealth, PacifiCare
74865
GlobalHealth
74866
Aetna, CommunityCare, GlobalHealth, PacifiCare
74867
CommunityCare, GlobalHealth, PacifiCare
74868
CommunityCare, GlobalHealth, PacifiCare
74869
Aetna, GlobalHealth, PacifiCare
74871
GlobalHealth
74872
GlobalHealth
74873
Aetna, CommunityCare, GlobalHealth, PacifiCare
74875
GlobalHealth, PacifiCare
74878
Aetna, CommunityCare, GlobalHealth, PacifiCare
74880
GlobalHealth, PacifiCare
74881
Aetna, GlobalHealth, PacifiCare
74882
PacifiCare
74883
GlobalHealth
74884
CommunityCare, GlobalHealth, PacifiCare
74901
CommunityCare
74902
CommunityCare
74930
CommunityCare
74931
CommunityCare
74932
CommunityCare
74935
CommunityCare
74936
CommunityCare
74937
CommunityCare
74939
CommunityCare
74940
CommunityCare
74941
CommunityCare
74942
CommunityCare
74943
CommunityCare
74944
CommunityCare
74945
CommunityCare
74946
CommunityCare
74947
CommunityCare
74948
CommunityCare
74949
CommunityCare
74951
CommunityCare
74953
CommunityCare
74954
CommunityCare
74955
CommunityCare
74956
CommunityCare
74959
CommunityCare
74960
CommunityCare
74962
CommunityCare
74964
CommunityCare
74965
CommunityCare
74966
CommunityCare
This
is only a sample of the services covered by each plan. 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.
This
chart reflects your cost for the listed Network services.
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.
$500 individual and
$1,500 family
$500 individual and
$1,000 family; deductible applied after Plan pays first $500 of Allowed Charges
The combined medical and
pharmacy deductible must be met before benefits are paid. $1,500 individual and
$3,000 family
No deductible
No deductible
No deductible
No deductible
No deductible
$2,800 Network,
individual and $3,300 plus amounts over Allowed Charges non-Network, individual
$5,500 individual and
$11,000 family
$4,000 individual and
$8,000 family; non-Network charges do not apply
$2,000 individual and
$4,000 family
$3,000 individual and
$6,000 family
$2,500 individual and
$5,000 family
$3,000 individual and
$5,000 family
$2,000 individual and
$4,000 family
$25 copay
Copays do not apply;
refer to the HealthChoice Basic Plan Benefits section for more specific plan
information
Member pays 100% of
Allowed Charges until deductible is met; $25 copay applies after deductible
$25 copay/PCP and $35
copay/specialist
$30 copay/PCP and $45
copay/specialist
$30 copay/PCP and $45
copay/specialist
$25 copay/PCP and $50
copay/specialist
$30 copay/PCP and $50
copay/specialist
20% of Allowed Charges
after deductible
Refer to the
HealthChoice Basic Plan Benefits section for more specific plan information
20% of Allowed Charges
after deductible
No copay/laboratory
services or outpatient radiology; $100 copay per MRI, CAT, MRA, or PET scan
$45 copay
No additional
copay/laboratory services or outpatient radiology; $100 copay per MRI, CAT,
MRA, or PET scan
$0 copay; Specialty
scans (MRI, CAT, PET, etc.) $250 copay per scan
$0 copay/standard lab
and radiology; $300 copay per MRI, MRA, PET, or CAT
20% of Allowed Charges
after deductible; additional $300 non-Network deductible per admission
Refer to the HealthChoice
Basic Plan Benefits section for more specific plan information
20% of Allowed Charges
after deductible; additional $300 non-Network deductible per admission
$250 copay;
preauthorization required
$500 copay;
preauthorization required
$350 copay
$250 copay with $750
maximum per admission
$1,000 copay/admission
20% of Allowed Charges
after deductible
Refer to the
HealthChoice Basic Plan Benefits section for more specific plan information
20% of Allowed Charges
after deductible
$175 copay; preauthorization
required
$300 copay
$200 copay
$250 copay
$500 copay
$25 copay; no deductible
applies
Refer to the HealthChoice
Basic Plan Benefits section for more specific plan information
$25 copay; no deductible
applies
$0 copay up to age 2
$0 copay
$0 copay up to age 2
$25 copay/PCP; $0 copay
up to age 2
$0 copay
No charge for well-baby
and adult immunizations; $25 office visit copay and/or administration fee may
apply
Refer to the
HealthChoice Basic Plan Benefits section for more specific plan information
No charge for well-baby
and adult immunizations; $25 office visit copay and/or administration fee may
apply
$0 copay/birth through
age 18; $10 copay/ages 19 and over
$0 copay/birth through
age 18; $10 copay/ages 19 and over
$0 copay/ages birth
through 18 years; $25 copay/ages 19 and over
$0 copay/birth to age
18; $25 copay/PCP office visit for adults; standard copays may apply in
conjunction with office visit
$0 copay/birth through
age 18 (if no other service is rendered); $30 copay/PCP; $50 copay/specialist ages
19 and over
$25 copay per exam, 1
mammogram at no charge for women age 40 and over
One mammogram at no charge for women age 40 and over, women under 40 pay $25
copay; refer to the HealthChoice Basic Plan Benefits section for more specific
plan information
20% of Allowed Charges
after deductible; 1 mammogram at no charge for women age 40 and over
$10 copay per visit for
routine physicals
$10 copay for adults
$25 copay
$25 copay/PCP; Limit: 1
per year
$30 copay/PCP; $50
copay/specialist
20% of Allowed Charges
after deductible; Limit: 60 tests every 24 months
Refer to the
HealthChoice Basic Plan Benefits section for more specific plan information
20% of Allowed Charges
after deductible; Limit of 60 tests every 24 months
$25 copay/PCP; $35
copay/specialist; $25 for 6 week supply of antigen (including shots)
$20 copay per visit; $20
copay for 6 week supply of antigen (includes shots)
$30 copay/PCP visit; $45
copay/specialist visit; $30 copay for 6 week supply of serum (including shots)
$25 copay/PCP; $50
copay/specialist; $30 for 6 week supply of antigen (including shots)
$30 copay/PCP; $50
copay/specialist
20% of Allowed Charges
after deductible; Additional $100 ER deductible, waived if admitted
Refer to the
HealthChoice Basic Plan Benefits section for more specific plan information
20% of Allowed Charges
after deductible; Additional $100 ER deductible, waived if admitted
$125 copay; waived if
admitted
$150 copay
$150 copay; waived if
admitted
$150 copay; waived if
admitted
$200 copay; waived if
admitted
20% of Allowed Charges
after deductible
Refer to the
HealthChoice Basic Plan Benefits section for more specific plan information
20% of Allowed Charges
after deductible
$35 copay
$75 copay
$35 copay per visit
$25 copay/PCP; $50
copay/all others
$30 copay/PCP; $50
copay/specialist
20% of Allowed Charges
after deductible; Limit: 30 days per year
Refer to the
HealthChoice Basic Plan Benefits section for more specific plan information
20% of Allowed Charges
after deductible; Limit: 30 days per year
$250 copay; Limit: 30
days per year
$500 copay; Limit: 30
days per calendar year
$400 copay; Limit: 30
days per year
$250 copay; $750 maximum
per admission; Limit: 30 days per year
$1,000 copay; Limit: 30
consecutive days per year
20% of Allowed Charges
after deductible; Limit: 26 visits per year
Refer to the
HealthChoice Basic Plan Benefits section for more specific plan information
20% of Allowed Charges
after deductible; Limit: 26 visits per year
$25 copay/PCP; $35
copay/specialist; Limit: 26 visits per year
$45 copay; Limit: 26
visits per calendar year
$30 copay/PCP; $45
copay/specialist; Limit: 26 visits per year
$50 copay; Limit: 26
visits per year
$30 copay/PCP; $50
copay/specialist; Limit: 26 days per year
20% of Allowed Charges
after deductible – for purchase, rental, repair, or replacement
Refer to the
HealthChoice Basic Plan Benefits section for more specific plan information
20% of Allowed Charges
after deductible – for purchase, rental, repair, or replacement
20% coinsurance initial
device; 20% coinsurance repair and replacement
20% of contracted rate
20% coinsurance
20% coinsurance; $5,000
annual maximum
20% coinsurance; Limit:
$10,000 per year
20% of Allowed Charges
after deductible; Each service limited to 20 visits
per year without prior authorization; Each service limited to 60 visits per
year
Refer to the
HealthChoice Basic Plan Benefits section for more specific plan information
20% of Allowed Charges
after deductible; Each service limited to 20 visits
per year without prior authorization; Each service limited to 60 visits per
year
No copay inpatient; $25
copay/PCP; $35 copay/specialist; Limit: 60 days per course of therapy
No copay inpatient; $45
copay/outpatient therapy; Limit: 60 consecutive days per course of therapy
No copay/inpatient; $45
copay outpatient therapy; Limit: 60 days per disability
No copay/inpatient; $50
copay per outpatient visit; Limit: 60 consecutive days per illness or injury
$1,000 copay inpatient;
Outpatient - $30 copay/PCP; $50 copay/specialist; Limit: 60 days per episode
20% of Allowed Charges
after deductible; Limit: 20 visits per year without prior authorization;
Limited to 60 visits per year
Refer to the
HealthChoice Basic Plan Benefits section for more specific plan information
20% of Allowed Charges
after deductible; Limit: 20 visits per year without prior authorization;
Limited to 60 visits per year
No copay inpatient; $25
copay/PCP; $35 copay/specialist; Limit: 60 treatment days per course of therapy
$45 copay/outpatient
therapy; Limit: 60 consecutive days per course of therapy
No copay/inpatient; $45
copay outpatient therapy; Limit: 60 days per disability
No copay/inpatient; $50
copay per outpatient visit; Limit: 60 consecutive days per illness or injury
$1,000 copay inpatient;
Outpatient - $30 copay/PCP; $50 copay/specialist; Limit: 60 days per episode
Chiropractic services
only - 20% of Allowed Charges after deductible; Limit: 20 visits per year
without prior authorization; for manipulative therapy, refer to Physical
Therapy/Physical Medicine; Limited to 60 visits per year
Refer to the
HealthChoice Basic Plan Benefits section for more specific plan information
Chiropractic services
only - 20% of Allowed Charges after deductible; Limit: 20 visits per year
without prior authorization; for manipulative therapy, refer to Physical
Therapy/Physical Medicine; Limited to 60 visits per year
$35 copay; Limit: 15
visits per year; PCP referral required
$45 per visit; Limit: 15
visits per calendar year
$45 copay; Limit: 15
visits per year
$50 copay; Limit: 15
visits per year – referral required
$20 copay; Limit: 15
visits per year – referral required; Limited to treatment of neurological and
orthopedic conditions
20% of Allowed Charges
after deductible; Includes one postpartum home visit – criteria must be met
Refer to the
HealthChoice Basic Plan Benefits section for more specific plan information
20% of Allowed Charges
after deductible; Includes one postpartum home visit – criteria must be met
$25 copay for initial
visit; $250 copay per hospital admission
$45 copay for initial
visit; thereafter covered at 100%; $500 per hospital admission
$30 copay for initial
visit; $350 copay per hospital admission
$25 copay initial visit
only; $250 copay/hospital admission per day; $750 maximum per admission
$30 copay/PCP; $50
copay/specialist for initial visit once diagnosis of pregnancy is confirmed; $1,000
copay hospital admission
$25 copay/basic hearing
screening; Limit: one per year; Hearing aids covered for children up to age 18
as durable medical equipment
Refer to the
HealthChoice Basic Plan Benefits section for more specific plan information
$25 copay after
deductible/basic hearing screening; Limit: one per year; Hearing aids covered
for children up to age 18 as durable medical equipment
$25 copay; Limit: one
per year; Hearing aids – 20% coinsurance for children up to age 18
$10 copay; Hearing aids
covered for children up to age 18; Limit: one per ear every 48 months
$30 copay; Limit: one
per year; Hearing aids – 20% coinsurance for children up to age 18
$25 copay per visit;
Limit: one visit per year; Hearing aids – 20% coinsurance; Limit: $5,000
combined DME, orthotics, and prosthetics; Covered for children up to age 18
$30 copay/PCP; $50
copay/specialist; Hearing aids – covered for children up to age 18
NETWORK:
Generic Mandate
PREFERRED MEDICATION:
The cost of medication is $100 or less – you
pay up to $25 or actual cost if less
The cost of medication is more than $100 –
you pay 25% up to a $50 maximum
Out-of-pocket maximum - $2,500 per person
using Preferred products at Network pharmacies, then you pay $0
NON-PREFERRED
MEDICATION:
The cost of medication is $100 or less – you
pay up to $50 or actual cost if less
The cost of medication is more than $100 –
you pay 50% up to a $100 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
HealthChoice Health
Plans offer each covered individual a lifetime pharmacy benefit of $2 million
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
After the combined
medical and pharmacy $1,500 individual and/or $3,000 family deductible has been
met, the pharmacy benefits are:
NETWORK:
Generic Mandate
PREFERRED MEDICATION:
The cost of medication is $100 or less – you
pay up to $25 or actual cost if less
The cost of medication is more than $100 –
you pay 25% up to a $50 maximum
NON-PREFERRED
MEDICATION:
The
cost of medication is $100 or less – you pay up to $50 or actual cost if less
The cost of medication is more than $100 –
you pay 50% up to a $100 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
HealthChoice Health
Plans offer each covered individual a lifetime pharmacy benefit of $2 million
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
Up to $10 generic
formulary
Up to $30 brand
formulary (when no generic is available)
Up to $50 brand formulary
(when generic is available)
Greater of 30-day supply
or 100 units
Certain medications have
restricted quantities
Mail order may be
available, refer to each Plan for details
Please note: Tier
categories will be determined by each HMO based on their own formulary design
Tier 1: $20
Tier 2: $40
Tier 3: $70
MAIL ORDER 90-DAY SUPPLY
$40 copay for formulary
generic drugs
$80 copay for formulary
drugs
$140 copay for
non-formulary brand-name and non-formulary generic drugs
Greater of a 30-day
supply or 100 units
Certain medications have
restricted quantities
Tier 1: $10
Tier 2: $40
Tier 3: $65
Greater of 30-day supply
or 100 units
Certain medications may
have restricted quantities
These copays do not
apply to the maximum out-of-pocket
Tier 1: $10
Tier 2: $50
Tier 3: $75
Greater of 30-day supply
or 100 units
Certain medications may
have restricted quantities
These copays do not
apply to the maximum out-of-pocket
$10 copay for formulary
generic drugs
$30 copay for formulary
brand-name drugs
$50 copay for
non-formulary generic and non-formulary brand drugs
30-day supply or 100
units
Certain medications have
restricted quantities
This
is only a sample of the services covered. For services that are not listed,
contact HealthChoice. Refer to the Help Lines at the
end of this document for contact information.
This
chart reflects your cost for the listed Network services.
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.
$500 individual and
$1,500 family
$2,800 Network,
individual and $3,300 plus amounts over Allowed Charges non-Network, individual
$25 copay
20% of Allowed Charges
after deductible
20% of Allowed Charges
after deductible; additional $300 non-Network deductible per admission
20% of Allowed Charges
after deductible
$25 copay; no deductible
applies
No charge for well-baby
and adult immunizations; $25 office visit copay and/or administration fee may
apply
$25 copay per exam, 1
mammogram at no charge for women age 40 and over
20% of Allowed Charges
after deductible; Limit: 60 tests every 24 months
20% of Allowed Charges
after deductible; Additional $100 ER deductible, waived if admitted
20% of Allowed Charges
after deductible
20% of Allowed Charges
after deductible; Limit: 30 days per year
20% of Allowed Charges
after deductible; Limit: 26 visits per year
20% of Allowed Charges
after deductible – for purchase, rental, repair, or replacement
20% of Allowed Charges
after deductible; Each service limited to 20 visits
per year without prior authorization; Each service limited to 60 visits per
year
20% of Allowed Charges
after deductible; Limit: 20 visits per year without prior authorization;
Limited to 60 visits per year
Chiropractic services
only - 20% of Allowed Charges after deductible; Limit: 20 visits per year
without prior authorization; for manipulative therapy, refer to Physical
Therapy/Physical Medicine; Limited to 60 visits per year
20% of Allowed Charges
after deductible; Includes one postpartum home visit – criteria must be met
$25 copay/basic hearing
screening; Limit: one per year; Hearing aids covered for children up to age 18
as durable medical equipment
NETWORK:
Generic Mandate
PREFERRED MEDICATION:
The cost of medication is $100 or less – you
pay up to $25 or actual cost if less
The cost of medication is more than $100 –
you pay 25% up to a $50 maximum
Out-of-pocket maximum - $2,500 per person
using Preferred products at Network pharmacies, then you pay $0
NON-PREFERRED
MEDICATION:
The cost of medication is $100 or less – you
pay up to $50 or actual cost if less
The cost of medication is more than $100 –
you pay 50% up to a $100 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
HealthChoice Health
Plans offer each covered individual a lifetime pharmacy benefit of $2 million
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
This
is only a sample of the services covered by this plan. For services that are
not listed, contact HealthChoice. Refer to the Help
Lines at the end of this document for contact information.
This
chart reflects your cost for the listed Network services.
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.
$500 individual and
$1,000 family; deductible applied after Plan pays first $500 of Allowed Charges
$5,500 individual and
$11,000 family
Copays do not apply
All services, benefits, exceptions,
limitations, and conditions are identical between the HealthChoice High Option
Plan and the HealthChoice Basic Plan
For Network Services, you pay:
$0 of Allowed Charges
through the first $500
100% through the next
$500 of deductible (only Allowed Charges apply to the deductible)
50% of the next $10,000
of Allowed Charges
$0 of Allowed Charges
over $11,000
You may use non-Network
providers, but it will be more costly
NETWORK:
Generic Mandate
PREFERRED MEDICATION:
The cost of medication is $100 or less – you
pay up to $25 or actual cost if less
The cost of medication is more than $100 –
you pay 25% up to a $50 maximum
Out-of-pocket maximum - $2,500 per person
using Preferred products at Network pharmacies, then you pay $0
NON-PREFERRED
MEDICATION:
The cost of medication is $100 or less – you
pay up to $50 or actual cost if less
The cost of medication is more than $100 –
you pay 50% up to a $100 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
HealthChoice Health
Plans offer each covered individual a lifetime pharmacy benefit of $2 million
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
This is
only a sample of the services covered. For services that are not listed in this
comparison chart, contact HealthChoice. Refer to the Help
Lines at the end of this document for contact information.
This
chart reflects your cost for the listed Network services.
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.
The combined medical and
pharmacy deductible must be met before benefits are paid. $1,500 individual and
$3,000 family
$4,000 individual and
$8,000 family; non-Network charges do not apply
Member pays 100% of
Allowed Charges until deductible is met; $25 copay applies after deductible
20% of Allowed Charges
after deductible
20% of Allowed Charges
after deductible; additional $300 non-Network deductible per admission
20% of Allowed Charges
after deductible
$25 copay; no deductible
applies
No charge for well-baby
and adult immunizations; $25 office visit copay and/or administration fee may
apply
20% of Allowed Charges
after deductible; 1 mammogram at no charge for women age 40 and over
20% of Allowed Charges
after deductible; Limit of 60 tests every 24 months
20% of Allowed Charges
after deductible; Additional $100 ER deductible, waived if admitted
20% of Allowed Charges
after deductible
20% of Allowed Charges
after deductible; Limit: 30 days per year
20% of Allowed Charges
after deductible; Limit: 26 visits per year
20% of Allowed Charges
after deductible – for purchase, rental, repair, or replacement
20% of Allowed Charges
after deductible; Each service limited to 20 visits
per year without prior authorization; Each service limited to 60 visits per
year
20% of Allowed Charges
after deductible; Limit: 20 visits per year without prior authorization;
Limited to 60 visits per year
Chiropractic services
only - 20% of Allowed Charges after deductible; Limit: 20 visits per year
without prior authorization; for manipulative therapy, refer to Physical
Therapy/Physical Medicine; Limited to 60 visits per year
20% of Allowed Charges
after deductible; Includes one postpartum home visit – criteria must be met
$25 copay after
deductible/basic hearing screening; Limit: one per year; Hearing aids covered
for children up to age 18 as durable medical equipment
After the combined
medical and pharmacy $1,500 individual and/or $3,000 family deductible has been
met, the pharmacy benefits are:
NETWORK:
Generic Mandate
PREFERRED MEDICATION:
The cost of medication is $100 or less – you
pay up to $25 or actual cost if less
The cost of medication is more than $100 –
you pay 25% up to a $50 maximum
NON-PREFERRED MEDICATION:
The cost of medication is $100 or less – you
pay up to $50 or actual cost if less
The cost of medication is more than $100 –
you pay 50% up to a $100 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
HealthChoice Health
Plans offer each covered individual a lifetime pharmacy benefit of $2 million
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
This
is only a sample of the services covered by each HMO Standard Plan. For
services that are not listed, contact the 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.
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.
No deductible
$2,000 individual and
$4,000 family
$25 copay/PCP and $35
copay/specialist
No copay/laboratory
services or outpatient radiology; $100 copay per MRI, CAT, MRA, or PET scan
$250 copay;
preauthorization required
$175 copay;
preauthorization required
$0 copay up to age 2
$0 copay/birth through
age 18; $10 copay/ages 19 and over
$10 copay per visit for
routine physicals
$25 copay/PCP; $35
copay/specialist; $25 for 6 week supply of antigen (including shots)
$125 copay; waived if
admitted
$35 copay
$250 copay; Limit: 30
days per year
$25 copay/PCP; $35
copay/specialist; Limit: 26 visits per year
20% coinsurance initial
device; 20% coinsurance repair and replacement
No copay inpatient; $25
copay/PCP; $35 copay/specialist; Limit: 60 days per course of therapy
No copay inpatient; $25
copay/PCP; $35 copay/specialist; Limit: 60 treatment days per course of therapy
$35 copay; Limit: 15
visits per year; PCP referral required
$25 copay for initial
visit; $250 copay per hospital admission
$25 copay; Limit: one
per year; Hearing aids – 20% coinsurance for children up to age 18
Up to $10 generic
formulary
Up to $30 brand
formulary (when no generic is available)
Up to $50 brand formulary
(when generic is available)
Greater of 30-day supply
or 100 units
Certain medications have
restricted quantities
Mail order may be
available, refer to each Plan for details
Please note: Tier
categories will be determined by each HMO based on their own formulary design
This
is only a sample of the services covered. For services that are not listed,
contact Aetna. Refer to the Help Lines at the end of
this document for contact information.
This
chart reflects your cost for the listed Network services.
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.
No deductible
$3,000 individual and
$6,000 family
$30 copay/PCP and $45
copay/specialist
$45 copay
$500 copay;
preauthorization required
$300 copay
$0 copay
$0 copay/birth through
age 18; $10 copay/ages 19 and over
$10 copay for adults
$20 copay per visit; $20
copay for 6 week supply of antigen (includes shots)
$150 copay
$75 copay
$500 copay; Limit: 30
days per calendar year
$45 copay; Limit: 26
visits per calendar year
20% of contracted rate
No copay inpatient; $45
copay/outpatient therapy; Limit: 60 consecutive days per course of therapy
$45 copay/outpatient
therapy; Limit: 60 consecutive days per course of therapy
$45 per visit; Limit: 15
visits per calendar year
$45 copay for initial
visit; thereafter covered at 100%; $500 per hospital admission
$10 copay; Hearing aids
covered for children up to age 18; Limit: one per ear every 48 months
Tier 1: $20
Tier 2: $40
Tier 3: $70
MAIL ORDER 90-DAY SUPPLY
$40 copay for formulary
generic drugs
$80 copay for formulary
drugs
$140 copay for
non-formulary brand-name and non-formulary generic drugs
Greater of a 30-day
supply or 100 units
Certain medications have
restricted quantities
This
is only a sample of the services covered. For services that are not listed,
contact CommunityCare. Refer to the Help Lines at
the end of this document for contact information.
This
chart reflects your cost for the listed Network services.
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.
No deductible
$2,500 individual and
$5,000 family
$30 copay/PCP and $45
copay/specialist
No additional
copay/laboratory services or outpatient radiology; $100 copay per MRI, CAT,
MRA, or PET scan
$350 copay
$200 copay
$0 copay up to age 2
$0 copay/ages birth
through 18 years; $25 copay/ages 19 and over
$25 copay
$30 copay/PCP visit; $45
copay/specialist visit; $30 copay for 6 week supply of serum (including shots)
$150 copay; waived if
admitted
$35 copay per visit
$400 copay; Limit: 30
days per year
$30 copay/PCP; $45 copay/specialist;
Limit: 26 visits per year
20% coinsurance
No copay/inpatient; $45
copay outpatient therapy; Limit: 60 days per disability
No copay/inpatient; $45
copay outpatient therapy; Limit: 60 days per disability
$45 copay; Limit: 15
visits per year
$30 copay for initial
visit; $350 copay per hospital admission
$30 copay; Limit: one
per year; Hearing aids – 20% coinsurance for children up to age 18
Tier 1: $10
Tier 2: $40
Tier 3: $65
Greater of 30-day supply
or 100 units
Certain medications may
have restricted quantities
These copays do not
apply to the maximum out-of-pocket
This
is only a sample of the services covered. For services that are not listed,
contact GlobalHealth. Refer to the Help Lines at the
end of this document for contact information.
This
chart reflects your cost for the listed Network services.
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.
No deductible
$3,000 individual and
$5,000 family
$25 copay/PCP and $50 copay/specialist
$0 copay; Specialty
scans (MRI, CAT, PET, etc.) $250 copay per scan
$250 copay with $750
maximum per admission
$250 copay
$25 copay/PCP; $0 copay
up to age 2
$0 copay/birth to age
18; $25 copay/PCP office visit for adults; standard copays may apply in
conjunction with office visit
$25 copay/PCP; Limit: 1
per year
$25 copay/PCP; $50
copay/specialist; $30 for 6 week supply of antigen (including shots)
$150 copay; waived if
admitted
$25 copay/PCP; $50
copay/all others
$250 copay; $750 maximum
per admission; Limit: 30 days per year
$50 copay; Limit: 26
visits per year
20% coinsurance; $5,000
annual maximum
No copay/inpatient; $50
copay per outpatient visit; Limit: 60 consecutive days per illness or injury
No copay/inpatient; $50
copay per outpatient visit; Limit: 60 consecutive days per illness or injury
$50 copay; Limit: 15
visits per year – referral required
$25 copay initial visit
only; $250 copay/hospital admission per day; $750 maximum per admission
$25 copay per visit;
Limit: one visit per year; Hearing aids – 20% coinsurance; Limit: $5,000
combined DME, orthotics, and prosthetics; Covered for children up to age 18
Tier 1: $10
Tier 2: $50
Tier 3: $75
Greater of 30-day supply
or 100 units
Certain medications may
have restricted quantities
These copays do not
apply to the maximum out-of-pocket
This
is only a sample of the services covered. For services that are not listed,
contact PacifiCare. Refer to the Help Lines at the
end of this document for contact information.
This
chart reflects your cost for the listed Network services.
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.
No deductible
$2,000 individual and
$4,000 family
$30 copay/PCP and $50
copay/specialist
$0 copay/standard lab
and radiology; $300 copay per MRI, MRA, PET, or CAT
$1,000 copay/admission
$500 copay
$0 copay
$0 copay/birth through
age 18 (if no other service is rendered); $30 copay/PCP; $50 copay/specialist ages
19 and over
$30 copay/PCP; $50
copay/specialist
$30 copay/PCP; $50
copay/specialist
$200 copay; waived if
admitted
$30 copay/PCP; $50
copay/specialist
$1,000 copay; Limit: 30
consecutive days per year
$30 copay/PCP; $50
copay/specialist; Limit: 26 days per year
20% coinsurance; Limit:
$10,000 per year
$1,000 copay inpatient;
Outpatient - $30 copay/PCP; $50 copay/specialist; Limit: 60 days per episode
$1,000 copay inpatient;
Outpatient - $30 copay/PCP; $50 copay/specialist; Limit: 60 days per episode
$20 copay; Limit: 15
visits per year – referral required; Limited to treatment of neurological and
orthopedic conditions
$30 copay/PCP; $50
copay/specialist for initial visit once diagnosis of pregnancy is confirmed; $1,000
copay hospital admission
$30 copay/PCP; $50
copay/specialist; Hearing aids – covered for children up to age 18
$10 copay for formulary
generic drugs
$30 copay for formulary
brand-name drugs
$50 copay for non-formulary
generic and non-formulary brand drugs
30-day supply or 100
units
Certain medications have
restricted quantities
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.
Network: $25 Basic and Major;
Non-Network: $25 Preventive, Basic, and Major
$25 per person, per
calendar year; waived for preventive services in-network
No deductible
No deductibles or plan
maximums; $5 office copay applies
PPO Network: $25 per
person, per calendar year applies to Basic and Major Care only
Premier Network and
Non-Network: $100 per person, per calendar year applies to all care except
Orthodontic Care (Level 4)
PPO Network: $100 per
person, per calendar year applies to Major Care only (Level 4) only
Allowed Charges apply
Network: 100%; Non-Network:
100% of Allowed Charges after deductible; No charge for topical fluoride
application (up to age 16)
100% of usual and
customary with no deductible when in-network
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
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
PPO Network: Plan pays
100% of allowable amounts
Premier Network and
Non-Network: Plan pays 100% of allowable amounts after deductible
PPO Network: Schedule of
covered services and enrollee copays. Copay examples: Routine cleaning $5;
Periodic oral evaluations $5; Topical fluoride application (up to age 19) $5
Allowed Charges apply
Network: 85%; Non-Network:
70%, deductible applies
Network: 85%;
Non-Network 70%; Plan pays 85% of usual and customary when in-network,
deductible applies
Fillings; Minor oral
surgery; Refer to the copay schedule for each plan
Amalgam: One surface,
permanent teeth $20
PPO Network: Plan pays
85% of allowable amounts after deductible
Premier Network and
Non-Network: Plan pays 70% of allowable amounts after deductible
PPO Network: Schedule of
covered services and enrollee copays. Copay examples: Amalgam, one surface,
permanent teeth $12
Allowed Charges apply
Network: 60%; Non-Network:
50%, deductible applies
Network: 60%;
Non-Network: 50%; Plan pays 60% of usual and customary when in-network,
deductible applies
Root canal; Periodontal;
Crowns; Refer to the copay schedule for each plan
Root canal, anterior:
$325; Periodontal/scaling/root planning one to three teeth (per quadrant): $65
PPO Network: Plan pays
60% of allowable amounts after deductible
Premier Network and
Non-Network: Plan pays 50% of allowable amounts after deductible
PPO Network: Schedule of
covered services and enrollee copays. Copay examples: Crown, porcelain/ceramic
substrate $241; Complete denture, maxillary $320
Allowed Charges apply
Network: 50%; Non-Network:
50%; 12 month waiting period; No lifetime maximum for Network or non-Network
Network: 60%;
Non-Network: 50%; Up to $1,800 lifetime maximum for members under age 19
25% discount; Adults and
children
$2,100 out-of-pocket for
child through age 18; $2,900 out-of-pocket for adult; 24 month treatment
excludes orthodontic treatment plan and banding
PPO Network: Plan pays
60% of allowable amounts, up to lifetime maximum of $1,800
Premier Network and
Non-Network: Plan pays 60% of allowable amounts, up to lifetime maximum of
$1,800
PPO Network: You pay
amounts in excess of $50 per month; Lifetime maximum of $1,800
Network and non-Network:
$2,000
$2,000
No annual maximum for
general dentist
No calendar year maximum
PPO Network: $2,000 per
person, per calendar year
Premier Network and
Non-Network: $2,000 per person, per calendar year
PPO Network: $2,000 per
person, per calendar year
Network: No claims to file;
Non-Network: You file claims
Member/provider must
file claims
No claims to file
No claims to file
PPO Network: Claims are
filed by participating dentists
Premier Network and
Non-Network: Claims are filed by participating dentists
PPO Network: Claims are
filed by participating dentists
For
services that are not listed, contact HealthChoice. Refer to the Help Lines at the end of this document for contact
information.
Network: $25 Basic and Major;
Non-Network: $25 Preventive, Basic, and Major
Allowed Charges apply
Network: 100%; Non-Network:
100% of Allowed Charges after deductible; No charge for topical fluoride
application (up to age 16)
Allowed Charges apply
Network: 85%; Non-Network:
70%, deductible applies
Allowed Charges apply
Network: 60%; Non-Network:
50%, deductible applies
Allowed Charges apply
Network: 50%; Non-Network:
50%; 12 month waiting period; No lifetime maximum for Network or non-Network
Network and non-Network:
$2,000
Network: No claims to file;
Non-Network: You file claims
For
services that are not listed, contact Assurant. Refer to the Help Lines at the end of this document for contact
information.
$25 per person, per
calendar year; waived for preventive services in-network
Allowed Charges apply
100% of usual and
customary with no deductible when in-network
Allowed Charges apply
Network: 85%;
Non-Network 70%; Plan pays 85% of usual and customary when in-network,
deductible applies
Allowed Charges apply
Network: 60%;
Non-Network: 50%; Plan pays 60% of usual and customary when in-network,
deductible applies
Allowed Charges apply
Network: 60%;
Non-Network: 50%; Up to $1,800 lifetime maximum for members under age 19
$2,000
Member/provider must
file claims
For
services that are not listed, contact Assurant. Refer to the Help Lines at the end of this document for contact
information.
No deductible
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
Allowed Charges apply
Fillings; Minor oral
surgery; Refer to the copay schedule for each plan
Allowed Charges apply
Root canal; Periodontal;
Crowns; Refer to the copay schedule for each plan
Allowed Charges apply
25% discount; Adults and
children
No annual maximum for
general dentist
No claims to file
For
services that are not listed, contact Assurant. Refer to the Help Lines at the end of this document for contact
information.
No deductible
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
Allowed Charges apply
Fillings; Minor oral
surgery; Refer to the copay schedule for each plan
Allowed Charges apply
Root canal; Periodontal;
Crowns; Refer to the copay schedule for each plan
Allowed Charges apply
25% discount; Adults and
children
No annual maximum for
general dentist
No claims to file
Premier Network and
Non-Network: Claims are filed by participating dentists
For
services that are not listed, contact CIGNA. Refer to the Help
Lines at the end of this document for contact information.
No deductibles or plan
maximums; $5 office copay applies
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
Allowed Charges apply
Amalgam: One surface,
permanent teeth $20
Allowed Charges apply
Root canal, anterior:
$325; Periodontal/scaling/root planning one to three teeth (per quadrant): $65
Allowed Charges apply
$2,100 out-of-pocket for
child through age 18; $2,900 out-of-pocket for adult; 24 month treatment
excludes orthodontic treatment plan and banding
No calendar year maximum
No claims to file
For
services that are not listed, contact Delta. Refer to the Help
Lines at the end of this document for contact information.
PPO Network: $25 per
person, per calendar year applies to Basic and Major Care only
Premier Network and
Non-Network: $100 per person, per calendar year applies to all care except
Orthodontic Care (Level 4)
Allowed Charges apply
PPO Network: Plan pays
100% of allowable amounts
Premier Network and
Non-Network: Plan pays 100% of allowable amounts after deductible
Allowed Charges apply
PPO Network: Plan pays
85% of allowable amounts after deductible
Premier Network and
Non-Network: Plan pays 70% of allowable amounts after deductible
Allowed Charges apply
PPO Network: Plan pays
60% of allowable amounts after deductible
Premier Network and
Non-Network: Plan pays 50% of allowable amounts after deductible
Allowed Charges apply
PPO Network: Plan pays
60% of allowable amounts, up to lifetime maximum of $1,800
Premier Network and
Non-Network: Plan pays 60% of allowable amounts, up to lifetime maximum of
$1,800
PPO Network: $2,000 per
person, per calendar year
Premier Network and
Non-Network: $2,000 per person, per calendar year
PPO Network: Claims are
filed by participating dentists
Premier Network and
Non-Network: Claims are filed by participating dentists
For
services that are not listed, contact Delta. Refer to the Help
Lines at the end of this document for contact information.
PPO Network: $100 per
person, per calendar year applies to Major Care only (Level 4) only
Allowed Charges apply
PPO Network: Schedule of
covered services and enrollee copays. Copay examples: Routine cleaning $5;
Periodic oral evaluations $5; Topical fluoride application (up to age 19) $5
Allowed Charges apply
PPO Network: Schedule of
covered services and enrollee copays. Copay examples: Amalgam, one surface,
permanent teeth $12
Allowed Charges apply
PPO Network: Schedule of
covered services and enrollee copays. Copay examples: Crown, porcelain/ceramic
substrate $241; Complete denture, maxillary $320
Allowed Charges apply
Premier Network and
Non-Network: Plan pays 60% of allowable amounts, up to lifetime maximum of
$1,800
PPO Network: You pay
amounts in excess of $50 per month; Lifetime maximum of $1,800
PPO Network: $2,000 per
person, per calendar year
PPO Network: Claims are
filed by participating dentists
All
vision plan benefits are based on a calendar year instead of a 12-month basis.
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.
In-Network: $10 copay; One exam for eyeglasses or contacts every calendar year
Out-of-Network: Copays do not
apply; Plan pays up to $35; One exam every calendar year
In-Network: $0 copay; No
limit on exams per year
Out-of-Network*: Exam
fee reimbursed up to $40; One exam every calendar 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
In-Network: $10 copay; One exam every calendar year
Out-of-Network: OD - $26 max;
MD - $34 max
In-Network: $10 copay; One exam every calendar year
Out-of-Network: Plan pays up
to $40
In-Network: $10 copay; One exam every calendar year
Out-of-Network: $10 copay;
Plan pays up to $35
In-Network: $25 material
copay applies to lenses and/or frames (single, lined bifocal, trifocal,
lenticular covered at 100%); Progressive at wholesale cost; One pair of lenses
every calendar year
Out-of-Network: Plan pays up
to $25 single, $40 bifocals, $60 trifocals, $100 lenticular; One
pair of lenses every calendar year
In-Network: You pay
wholesale cost with no limit on number of pairs
Out-of-Network*: Fees
reimbursed up to $40-$60 for one set of lenses and frames
*Out-of-Network limited
to one eye exam and one set of eyeglasses or contact lenses annually. Cannot be
used with In-Network services
In-Network: $25 copay; One pair of lenses every calendar year
Out-of-Network: Plan pays up
to $26 single, $39 bifocals, $49 trifocals, $78 lenticular
In-Network: $25 copay; One pair of lenses every calendar year
Out-of-Network: Plan pays up
to $40 single, $60 bifocals, $80 trifocals, $80 lenticular
In-Network: $25 copay*; One
set of lenses every calendar year; Polycarbonate lenses covered in full for
dependent children
Out-of-Network: $25 copay*;
Plan pays up to $25 single, $40 bifocals, $55 trifocals, $80 lenticular
*Benefit includes an annual $25 materials copay on lenses or frames, but not
both. Contact VSP for discounts on the In-Network added value discounts. Refer
to Help Lines at the end of this document.
In-Network: $25 material
copay applies to lenses and/or frames; $45 wholesale frame allowance; One set
of frames every calendar year
Out-of-Network: Copay does
not apply, Plan pays up to $45; One set of frames
every calendar year
In-Network: You pay
wholesale cost with no limit on number of pairs
Out-of-Network*: Fees
reimbursed up to $40-$60 for one set of lenses and frames
*Out-of-Network limited
to one eye exam and one set of eyeglasses or contact lenses annually. Cannot be
used with In-Network services
In-Network: $25 copay; Plan
pays up to $125; One set of frames every calendar year
Out-of-Network: Plan pays up
to $68
In-Network: $25 copay; One set of frames every calendar year
Out-of-Network: Plan pays up
to $45
In-Network: $25 copay*; One
frame per calendar year $125 allowance; 20% off any out-of-pocket costs above
the allowance
Out-of-Network: $25 copay*;
Plan pays up to $45
*Benefit includes an annual $25 materials copay on lenses or frames, but not
both. Contact VSP for details on the In-Network added value discounts. Refer to
Help Lines at the end of this document.
In-Network: $130 allowance
for conventional or disposable lenses and fitting fee in lieu of all other
benefits; Medically necessary, Plan pays 100%; One set
of contacts every calendar 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
every calendar year
In-Network: You pay
wholesale cost for an annual supply of contacts; for first time fittings, $50
copay on soft lens and $75 copay on all rigid gas permeable lenses
Out-of-Network*: Fees
reimbursed up to $60; One set annually (in lieu of
glasses)
*Out-of-Network limited
to one eye exam and one set of eyeglasses or contact lenses annually. Cannot be
used with In-Network services
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)
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; Medically necessary contacts, Plan pays up to
$210 (in lieu of glasses)
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)
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
In-Network: Discounted
laser refractive surgery at multiple state locations
Out-of-Network*: No
benefit
*Out-of-Network limited
to one eye exam and one set of eyeglasses or contact lenses annually. Cannot be
used with In-Network services
In-Network: 20% off retail
price
Out-of-Network: No benefit
In-Network: members have
access to discounted refractive eye surgery from numerous provider locations
throughout the U.S.
Out-of-Network: No benefit
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
All
vision plan benefits are based on a calendar year instead of a 12-month basis.
For
services that are not listed, contact Humana/CompBenefits. Refer to the Help Lines at the end of this document for contact
information.
In-Network: $10 copay; One exam for eyeglasses or contacts every calendar year
Out-of-Network: Copays do not
apply; Plan pays up to $35; One exam every calendar year
In-Network: $25 material
copay applies to lenses and/or frames (single, lined bifocal, trifocal,
lenticular covered at 100%); Progressive at wholesale cost; One pair of lenses
every calendar year
Out-of-Network: Plan pays up
to $25 single, $40 bifocals, $60 trifocals, $100 lenticular; One
pair of lenses every calendar year
In-Network: $25 material
copay applies to lenses and/or frames; $45 wholesale frame allowance; One set
of frames every calendar year
Out-of-Network: Copay does
not apply, Plan pays up to $45; One set of frames
every calendar year
In-Network: $130 allowance
for conventional or disposable lenses and fitting fee in lieu of all other
benefits; Medically necessary, Plan pays 100%; One set
of contacts every calendar 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
every calendar year
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
All
vision plan benefits are based on a calendar year instead of a 12-month basis.
For
services that are not listed, contact Primary Vision Care Services. Refer to
the Help Lines at the end of this document for
contact information.
In-Network: $0 copay; No
limit on exams per year
Out-of-Network*: Exam
fee reimbursed up to $40; One exam every calendar 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
In-Network: You pay
wholesale cost with no limit on number of pairs
Out-of-Network*: Fees
reimbursed up to $40-$60 for one set of lenses and frames
*Out-of-Network limited
to one eye exam and one set of eyeglasses or contact lenses annually. Cannot be
used with In-Network services
In-Network: You pay
wholesale cost with no limit on number of pairs
Out-of-Network*: Fees
reimbursed up to $40-$60 for one set of lenses and frames
*Out-of-Network limited
to one eye exam and one set of eyeglasses or contact lenses annually. Cannot be
used with In-Network services
In-Network: You pay
wholesale cost for an annual supply of contacts; for first time fittings, $50
copay on soft lens and $75 copay on all rigid gas permeable lenses
Out-of-Network*: Fees
reimbursed up to $60; One set annually (in lieu of
glasses)
*Out-of-Network limited
to one eye exam and one set of eyeglasses or contact lenses annually. Cannot be
used with In-Network services
In-Network: Discounted
laser refractive surgery at multiple state locations
Out-of-Network*: No
benefit
*Out-of-Network limited
to one eye exam and one set of eyeglasses or contact lenses annually. Cannot be
used with In-Network services
All
vision plan benefits are based on a calendar year instead of a 12-month basis.
For
services that are not listed, contact Superior Vision Services. Refer to the Help Lines at the end of this document for contact
information.
In-Network: $10 copay; One exam every calendar year
Out-of-Network: OD - $26 max;
MD - $34 max
In-Network: $25 copay; One pair of lenses every calendar year
Out-of-Network: Plan pays up
to $26 single, $39 bifocals, $49 trifocals, $78 lenticular
In-Network: $25 copay; Plan
pays up to $125; One set of frames every calendar year
Out-of-Network: Plan pays up
to $68
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)
In-Network: 20% off retail
price
Out-of-Network: No benefit
All
vision plan benefits are based on a calendar year instead of a 12-month basis.
For
services that are not listed, contact UnitedHealthcare Vision. Refer to the Help Lines at the end of this document for contact
information.
In-Network: $10 copay; One exam every calendar year
Out-of-Network: Plan pays up
to $40
In-Network: $25 copay; One pair of lenses every calendar year
Out-of-Network: Plan pays up
to $40 single, $60 bifocals, $80 trifocals, $80 lenticular
In-Network: $25 copay; One set of frames every calendar year
Out-of-Network: Plan pays up
to $45
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; Medically necessary contacts, Plan pays up to
$210 (in lieu of glasses)
In-Network: members have
access to discounted refractive eye surgery from numerous provider locations
throughout the U.S.
Out-of-Network: No benefit
All
vision plan benefits are based on a calendar year instead of a 12-month basis.
For
services that are not listed, contact Vision Service Plan (VSP). Refer to the Help Lines at the end of this document for contact
information.
In-Network: $10 copay; One exam every calendar year
Out-of-Network: $10 copay;
Plan pays up to $35
In-Network: $25 copay*; One
set of lenses every calendar year; Polycarbonate lenses covered in full for
dependent children
Out-of-Network: $25 copay*;
Plan pays up to $25 single, $40 bifocals, $55 trifocals, $80 lenticular
*Benefit includes an annual $25 materials copay on lenses or frames, but not
both. Contact VSP for details on the In-Network added value discounts. Refer to
Help Lines at the end of this document.
In-Network: $25 copay*; One
frame per calendar year $125 allowance; 20% off any out-of-pocket costs above
the allowance
Out-of-Network: $25 copay*;
Plan pays up to $45
*Benefit includes an annual $25 materials copay on lenses or frames, but not
both. Contact VSP for details on the In-Network added value discounts. Refer to
Help Lines at the end of this document.
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)
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
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
All Areas 1-800-903-8113
TDD All Areas 1-800-825-1230
All Areas 1-800-848-8121
TDD All Areas 1-877-267-6367
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
Oklahoma City Area 1-405-841-9686
All Areas 1-800-722-2567
TDD All Areas 1-800-863-5488
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
All Areas 1-800-949-3104
TDD All Areas
1-800-628-3323
Website
http://www.aetna.com/okstateemployees/
All Areas 1-800-777-4890
TDD All Areas 1-800-722-0353
Website http://www.ccok.com
Oklahoma
City Area 1-405-280-2990
All Other Areas 1-877-280-2990
TDD All Areas 1-800-522-8506
Website http://www.globalhealth.cc
All Areas 1-800-825-9355
TDD All Areas
1-800-557-7595
Website
http://www.pacificare.com
Prepaid
Plan 1-800-443-2995
Indemnity Plan 1-800-442-7742
Website http://www.assurantemployeebenefits.com
All Areas 1-800-367-1037
Hearing
Impaired Relay Service 1-405-948-3303
Website http://www.cigna.com
Oklahoma
City Area 1-405-607-2100
All Other Areas 1-800-522-0188
Website http://www.deltadentalok.org/state_employees/
All Areas 1-800-865-3676
TDD
All Areas 1-877-553-4327
Website http://www.compbenefits.com/custom/stateofoklahoma
All Areas 1-888-357-6912
TDD
All Areas 1-800-722-0353
Website http://www.pvcs-usa.com
All Areas 1-800-507-3800
TDD
All Areas 1-916-852-2382
Website http://www.superiorvision.com
All Areas 1-800-638-3120
TDD
All Areas 1-800-524-3157
Website http://www.myuhcvision.com
All Areas 1-800-877-7195
TDD All Areas 1-800-428-4833
Website http://www.vsp.com