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2014 Benefit Options Presentation

Plan Year January 1 through December 31, 2014

This publication is issued by the Office of Management and Enterprise Services as authorized by Title 62, Section 34. Copies have not been printed but are available through the agency website. This work is licensed under a Creative Attribution-NonCommercial-NoDerivs 3.0 Unported License.

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The Employee BenefitOptions Guide

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How to access the Guide:

• View the Guide on the EGID website at www.sib.ok.gov or www.healthchoiceok.com

• Complete the online request to get one by mail

• Contact your Insurance Coordinator• Contact EGID Member Services

• 2014 Plan Changes• Health Plans• Dental Plans• Vision Plans• HealthChoice Life Insurance Plan• Eligibility

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Topics

For More Information

• 2014 Employee Benefit Options Guide• Frequently Asked Questions at

www.sib.ok.gov or www.healthchoiceok.com

• Plan websites and customer service representatives

• Your Insurance Coordinator • EGID Member Services

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Click the links below to access a particular section of this presentation.

• 2014 Plan Changes• HealthChoice Health Plans• HMO Health Plans• Dental Plans• Vision Plans• HealthChoice Life Insurance Plan• Eligibility

Index

2014 PLAN CHANGES

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Eligibility Changes

Enrolling a newborn:• HealthChoice and HMO plan members

must enroll the newborn for the month of birth if dependent coverage is desired

• Premium for month of birth must be paid

HealthChoice High and USA Plans• Calendar year out-of-pocket maximum is

being increased to $3,300 for an individual/Network and $3,800 for an individual/non-Network

HealthChoice High Alternative Plan• Calendar year out-of-pocket maximum is

being increased to $3,550 for an individual/Network and $4,050 for an individual/non-Network

• Calendar year out-of-pocket maximum is being decreased to $8,400 for a family

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HealthChoice Plan Changes

HealthChoice S-Account Plan• Copays for physician office visits for

general practitioners, etc., and VA, Military and Indian Clinics is being reduced to $30

• Copay for specialist office visit will remain $50

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HealthChoice Plan Changes

CommunityCare HMO• Calendar year out-of-pocket is being

increased to $4,000 for an individual and $8,000 for a family

• Copay for hospital inpatient admission increased to $750

• Copay for hospital outpatient visit increased to $500

• Copay for mental health or substance abuse inpatient admission increased to $750

• No referral needed for most specialist visits• Visit state.ccok.com to view benefits, claims,

EOBs, and more 10

HMO Plan Changes

GlobalHealth HMO• Copay for specialty scans will be $750• Copay for outpatient visits in free-standing

facility will be $250 and $750 in a hospital facility

• Copay for emergency health care facility visit increased to $300

• Durable medical equipment – 20% coinsurance

• Occupational or speech therapy and physical therapy/physical medicine limit: 60 combined inpatient and outpatient visits per acute illness or injury 11

HMO Plan Changes

HealthChoice Dental• 12-month waiting period will apply to

all members, including those who had previous group dental coverage

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Dental Plan Changes

CIGNA Dental• Cost for sealant increased to $17 per tooth• Cost for amalgam, one surface increased to

$23• Cost for a root canal, anterior, increased to

$375• Cost for periodontal/scaling/root planing,

1-3 teeth, increased to $75• Out-of-pocket for children through 18

increased to $2,472• Out-of-pocket for adults increased to $3,384

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Dental Plan Changes

Delta Dental• Delta Dental Premier is now Delta Dental

PPO Plus Premier

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Dental Plan Changes

Primary Vision Care Services (PVCS)• Discounts offered through nJoy Vision,

previously TLC, call PVCS for details

Vision Services Plan• $25 copay on contact lenses

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Vision Plan Changes

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HealthChoice Life Insurance Plan Changes

Dependent Life Insurance• Dependent life benefit for birth to 6

months of age is being eliminated• Dependent children eligible for Low,

Standard, or Premier Option from live birth to age 26

HEALTHCHOICEHEALTH PLANS

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Available Plans

• HealthChoice High• HealthChoice High Alternative• HealthChoice Basic • HealthChoice Basic Alternative• HealthChoice S-Account• HealthChoice USAUsing a HealthChoice Network Provider will lower your out-of-pocket costs.

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Click here to view HealthChoice plan changes

Tobacco-free Attestation• To remain enrolled in the HealthChoice

High or Basic Plan, you must attest that you and your covered dependents are tobacco-free

• Due to HealthChoice by Nov. 15, 2013

The Attestation is available:• On the EGID website• Through a mobile app, or• By calling HealthChoice Member Services

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HealthChoice Plan Changes

If you cannot complete the Attestation, you must either:• Enroll in the quit tobacco program AND

complete three coaching calls, or• Provide a letter from your doctor indicating

it is not medically advisable for you or your dependent to quit tobacco.

If you do not complete the Attestation or complete one of the reasonable alternatives as defined previously, you will be enrolled in the HealthChoice High Alternative or Basic Alternative Plan with a higher deductible and out-of-pocket maximum.

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HealthChoice Plan Changes

When using a Network Provider:• $30 copay for primary care office visits• $50 copay for specialist office visits• Annual deductible $500 for an

individual or $1,500 for a family• Plan pays 80% and member pays 20%

of Allowed Charges up to the out-of-pocket maximum of $3,300 for an individual or $8,400 for a family

High

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High AlternativeWhen using a Network Provider:• Benefits the same as High Plan except

deductible and out-of-pocket maximum• Annual deductible $750 for an

individual or $2,250 for a family• Plan pays 80% and member pays 20%

of Allowed Charges up to the out-of-pocket maximum of $3,550 for an individual or $8,400 for a family

When using a Network Provider:• Office visit copays do not apply• Plan pays first $500 then member pays

next $500 as deductible; $1,000 deductible for a family of two or more

• Plan then pays 50% until the out-of-pocket maximum is met; $5,500 for an individual or $11,000 for a family

• Plan then pays 100% of Allowed Charges

Basic

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When using a Network Provider:• Office visit copays do not apply• Plan pays first $250 then member pays

next $750 as deductible; $1,500 deductible for a family of two or more

• Plan then pays 50% until the out-of-pocket maximum is met; $5,750 for an individual or $11,500 for a family

• Plan then pays 100% of Allowed Charges

Basic Alternative

Plan designed for members with a Health Savings Account (HSA)When using a Network Provider:• Combined $1,500 deductible for an

individual and $3,000 for a family*• Entire deductible must be met before

benefits are paid (including prescriptions)• $30/$50 copay for office visits• The calendar year out-of-pocket maximum

is $3,000 for an individual or $6,000 for a family

*Individual deductible does not apply if two or more family members are covered.

S-Account

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• For members who live and work outside of Oklahoma and Arkansas for more than 90 consecutive days

• Benefits are the same as the HealthChoice High Plan

• Members have access to the USA Plan’s nationwide provider network

USA

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Network Pharmacy Benefits

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• Prescriptions can be filled at HealthChoice Network Pharmacies

• Benefits are the same for all plans; S-Account members must meet the Plan deductible before benefits are paid

• You are responsible for the cost difference when choosing a brand-name if a generic is available

Network Pharmacy Benefits

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When purchasing up to a 30-day supply:• Generic – Up to $10• Preferred brand-name – Up to $45• Non-Preferred brand-name – Up to

$75

Network Pharmacy Benefits

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When purchasing up to a 90-day supply:• Generic – Up to $25• Preferred brand-name – Up to $90• Non-Preferred brand-name – Up to

$15090-day fill does not apply to medications with quantity or dosage limits

Network Pharmacy Benefits

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• Certain prescription tobacco cessation medications for a $0 copay

• A calendar year pharmacy out-of-pocket maximum of $2,500/individual, $4,000/ family (does not apply to S-Account Plan)

• Specialty medications must be purchased through Accredo Health, the HealthChoice specialty care, delivery service pharmacy

Return to Index

HMOPLANS

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• You must live or work within the ZIP Code service area of the HMO

• Copay system for services and supplies• Primary Care Physician (PCP) is required• Select your providers from the network

designated by your plan for the State of Oklahoma

You must select another provider within your HMO’s network in the event your provider leaves the network.

Click here to view HMO Plan Changes

HMO Plans

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• $35 office visit copay for PCP• $50 office visit copay for specialist• $750 copay for hospital and mental

health or substance use disorder admission

• $200 copay each emergency room visit• $50 copay for after-hours urgent care• Out-of-pocket maximum of $4,000 for

an individual or $8,000 for a family

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• 30-day supply per copay• $0 copay for select generics• Up to a $10 copay for formulary generic

medications • Up to a $40 copay for formulary brand-

name medications• Up to a $65 copay for all other

medications • Some medications have quantity limits

PharmacyBenefits

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• $25/$50 office visit copay for PCP/specialist• $300 copay each emergency room visit• $25 copay for after-hours urgent care PCP;

$50 copay for all others• $250 copay for free-standing outpatient

facility or $750 for a hospital facility• No copay for x-ray and lab services• MRI, PET, CAT, or nuclear scan – copay of

$250 for free-standing facility or $750 for hospital facility

• Out-of-pocket maximum of $3,000 for an individual or $5,000 for a family

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• 30-day supply per copay• $4 copay for select generics• Up to a $10 copay for formulary generic

medications • Up to a $50 copay for formulary brand-

name medications• Up to a $75 copay for all other

medications • Some medications have quantity limits

Pharmacy Benefits

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DENTALPLANS

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• Assurant Freedom Preferred• Assurant Heritage Plus with SBA

(Prepaid)• Assurant Heritage Secure (Prepaid)• CIGNA Dental Care Plan (Prepaid)• Delta Dental PPO• Delta Dental PPO Plus Premier• Delta Dental PPO – Choice• HealthChoice Dental

Dental Plans Available

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All the dental plans have the same core benefits which are divided into four different classes:

• Preventive Care includes cleanings, bitewing x-rays, and routine oral exams

• Basic Care includes fillings, extractions, root canals, endodontics, and periodontics

Dental Benefits

*Assurant Freedom Preferred has a 12-month waiting period for orthodontic care; waived if proof of continuous dental insurance is provided.HealthChoice has a 12-month waiting period for orthodontic care.

• Major Care includes dentures, bridgework, crowns, and implants

• Orthodontic Care* is covered for members under age 19 and members age 19 or older with temporomandibular joint dysfunction (unless otherwise noted)

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Dental Benefits

• Preventive Care is covered at 100%• A $25 deductible applies to Basic and

Major Care After the deductible:• Basic Care is covered at 85%• Major Care is covered at 60%• Orthodontic Care under age 19 is covered

at 60%; lifetime maximum benefit $2,000 • All other services have a combined

$2,000 maximum annual benefit

Freedom Preferred Dental Plan

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• No deductible or annual maximum for general dentist

• You must select a Primary Care Dentist for each covered person

• Preventive Care is covered at 100%• Copay schedule applies to other services• Orthodontic Care for children and adults• The Special Benefit Amendment provides

an additional discount for network specialists

Heritage Plus with SBA Dental Plan

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• No deductible or annual maximum with general dentist

• You must select a Primary Care Dentist for each covered person

• Preventive Care is covered at 100%• Copay schedule applies to other

services• Orthodontic Care for children and adults

Heritage Secure Dental Plan

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• No deductible or maximum annual benefit

• You must select a Primary Care Dentist for each covered person

• After a $5 copay, routine cleanings, x-rays, and evaluations are covered at 100%

• A copay schedule applies to other services, including specialist care

• Orthodontic Care for children and adults

Dental Care Plan

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• Preventive Care is covered at 100% • $25 annual deductible for Basic and

Major Care• Basic Care is covered at 85%• Major Care is covered at 60%• Orthodontic Care for children and adults

is covered at 60% with a $2,000 lifetime maximum benefit

• $2,500 maximum annual benefit for other services

Delta Dental PPO

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• A $50 combined deductible applies to Diagnostic, Preventive, Basic, and Major Care

• Preventive Care is covered at 100%• Basic Care is covered at 70%• Major Care is covered at 50%• Orthodontic Care for children and adults

is covered at 60% with a lifetime maximum of $2,000

• $3,000 maximum annual benefit

DeltaDental PPO

Plus Premier

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• You must select a Primary Care Dentist for each covered person

• No deductible for Preventive or Basic Care

• $100 deductible for Major Care• Copay schedule for all other services • Orthodontic Care for children and adults

has a maximum lifetime benefit of $1,800• $2,000 maximum annual benefit for

Preventive, Basic, and Major Care

Delta Dental PPO – Choice

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When using a Network Provider:

• Preventive Care is covered at 100%• A $25 deductible applies to Basic and

Major Care• Basic Care is covered at 85%• Major Care is covered at 60%• Orthodontic Care is covered at 50% —no

lifetime maximum, 12-month waiting period applies

• A $2,500 calendar year maximum applies to all other services

Dental

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VISIONPLANS

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• Humana CompBenefits VisionCare Plan• Primary Vision Care Services (PVCS)• Superior Vision Plan• UnitedHealthcare Vision• Vision Service Plan (VSP)

Vision Plans Available

• Each vision plan has its own provider network

• A copay schedule for services and materials

• The toll-free number and website address of each plan is listed in the Employee Benefit Options Guide

• Contact each vision plan for specific benefit questions

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Vision Plans Overview

When using an in-network provider:• $10 copay for an annual eye exam• $25 copay for lenses and frames; one

pair per year• Discounts are available for other vision

services and lens options• Contact lenses are available instead of

glasses; $130 allowance• Discount through TLC for laser surgery

Humana/CompBenefits

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When using an in-network provider:• There is no copay or limit on the

number of eye exams• Lenses and frames are sold at wholesale

cost• There is no limit on the number of pairs

of glasses • Benefits available for contact lenses• Discount through nJoy for laser surgery

Primary Vision Care Services

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When using an in-network provider:• $10 copay for eye exams; one per year• $25 copay for lenses and frames; one pair

per year• Contact lenses – available instead of

glasses; $25 copay/standard fitting then plan pays 100% or $50 copay/specialty fitting then plan pays up to $50

• Discounts available for other vision services and lens options, including laser vision correction

Superior Vision

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When using an in-network provider:• $10 copay for eye exams; one per year• $25 copay for lenses and frames; one pair

per year• Lens UV coating and tints are covered in

full• Contact lenses are available instead of

glasses• Discounts available for other vision

services and lens options including laser vision correction

UnitedHealthcare Vision

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When using an in-network provider:• $10 copay for eye exams; one per year• $25 copay for lenses and frames; one

pair per year• No copay for contact lens exam with

network provider• Contact lenses are available instead of

glasses• Discounts are available for glasses and

other vision benefits, including laser vision correction

VSP

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LIFE INSURANCE PLAN

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Basic and Supplemental Life for You• First $20,000 of life coverage (Basic Life)• All additional coverage is known as

Supplemental Life• $500,000 of Supplemental Life coverage

is available with an approved Life Insurance Application

• Basic Life and the first $20,000 of Supplemental Life include Accidental Death and Dismemberment (AD&D) benefits

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Employee Life

During initial enrollment:• You can enroll in Guaranteed Issue

(two times your annual salary rounded up to the next $20,000) without a Life Insurance Application

• You can apply for amounts above Guaranteed Issue; a Life Insurance Application is required

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Employee Life

During Option Period: • You can enroll in Basic Life• You can enroll in Supplemental Life• You can enroll in up to $500,000 of

Supplemental Life insurance coverage• An approved Life Insurance Application

is required

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Employee Life

• Keep your beneficiary designation up-to-date

• Beneficiaries can be changed at any time• Review your beneficiaries if you have a

change, such as a marriage, divorce, death of a family member, or birth of a child

• Beneficiary Designation Forms are available online, from your Insurance Coordinator, or by calling EGID Member Services

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Beneficiary Designation

Premier OptionSpouse $20,000Child $10,000

Standard OptionSpouse $10,000Child $5,000

Low OptionSpouse $6,000Child $3,000

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You must be enrolled in Basic Life coverage to enroll your eligible dependents in Dependent Life.

Dependent Life

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No coverage for a stillbirth.

ELIGIBILITY

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An education employee must be:• Currently employed, eligible for TRS,

and working at least four hours a day or 20 hours a week

A local government employee must be:• Currently employed, regularly

scheduled to work 1,000 hours or more per year, and cannot be listed as a temporary or seasonal employee

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Eligible Employees

Eligible dependents include:• Your legal spouse (including common-

law)• Your daughter, son, stepdaughter,

stepson, eligible foster child, adopted child, or child legally placed with you for adoption up to age 26, whether married or unmarried

• Disabled dependents over age 26 with approved documentation

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Eligible Dependents

• If you insure one dependent, all eligible dependents must be insured

• You can exclude dependents who do not reside with you, are married, are not financially dependent on you for support, have other group insurance, or are eligible for Indian or military benefits

• A spouse can be excluded by signing the Spouse Exclusion Certification statement on the back of the form

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Eligible Dependents

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• Other unmarried dependent children up to age 26, upon completion of an Application for Coverage for Other Dependent Children

• Guardianship papers or a tax return showing dependency can be provided in lieu of the application

• Dependents cannot include your parents or grandparents

Other Dependent Children

Certain qualifying events allow you to make a midyear change, examples include:

• Marriage• Divorce• Adoption• Death• Childbirth*• Gain or loss of other group insurance

*Must be added the first of the month of birth.

Notify your Insurance Coordinator within 30 days

of the event or wait until the next annual Option Period.

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Midyear Qualifying Events

Option Period Enrollment/Change Form:• Your Insurance Coordinator will

provide the deadlineInsurance Enrollment Form:• Return your form to your Insurance

Coordinator within 30 daysInsurance Change Form:• Return your form to your Insurance

Coordinator within 30 days of a qualifying event

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Deadlines for Forms

Tobacco-free Attestation:• Must be completed as part of the

Option Period enrollment process • The Attestation can be completed

online or returned to your Insurance Coordinator

• Deadline is November 15, 2013

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Deadlines for Forms

• EGID mails you a Confirmation Statement when you enroll or make changes to coverage

• If your Confirmation Statement is incorrect, contact your Insurance Coordinator immediately

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Confirmation Statements

If you do not make changes during the annual Option Period and are not automatically enrolled in a HealthChoice alternative plan, no Confirmation Statement will be sent; keep your enrollment form as verification of coverage

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Confirmation Statements

• Option Period is the only time you can make changes to coverage with a qualifying event

• HealthChoice High and Basic require a completed tobacco-free Attestation

• To enroll in dental or life coverage, you must have group health insurance

• If excluding your spouse, your spouse must sign the Spouse Exclusion Certification

• Return signed and dated forms to your Insurance Coordinator by the set deadline

• Notify your Insurance Coordinator if you have a change of address 73

Reminders

• The 2014 Employee Benefit Options Guide

• Plan websites and toll-free numbers available in your Option Period packet

• The FAQ section of the EGID website• EGID Member Services at 1-405-717-

8780 or toll-free 1-800-752-9475; TDD users call 1-405-949-2281 or toll-free 1-866-447-0436

• Your Insurance Coordinator

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Questions

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