The Oklahoma State and Education Employees Group Insurance Board, a Division of the Office of State Finance
EMPLOYEE BENEFIT OPTIONS GUIDE FOR CURRENT EMPLOYEES
For Plan Year January 1, 2012 through December 31, 2012
Before choosing a plan, it is very important that you review the list of network providers available in your area for that plan. Although a plan may be available in your area, the number of network providers may be limited. Refer to the network provider listing on each plan’s website or contact their customer service. Refer to Help Lines for contact information.
This information is only a brief summary of the plans. All benefits and limitations of these plans are governed in all cases by the relevant plan document, insurance contracts, handbooks, and Rules of the Oklahoma State and Education Employees Group Insurance Board, a division of the Office of State Finance. The Rules of the Oklahoma Administrative Code, Title 360, are controlling in all aspects of Plan benefits. No oral statement of any person shall modify or otherwise affect the benefits, limitations, or exclusions of any plan.
www.sib.ok.gov and www.healthchoiceok.com
THE DEADLINE FOR TURNING IN YOUR OPTION PERIOD FORM IS DETERMINED BY YOUR INSURANCE COORDINATOR.
TABLE OF CONTENTS
Monthly Premiums for Current Employees
2011 Plan Changes
Introduction
General Enrollment Information
Health Plans
Dental Plans
Vision Plans
HealthChoice Life Insurance
HealthChoice Disability Insurance
Enrollment Periods
Eligibility
HMO ZIP Code List
Comparison of Benefits for Health Plans – All Plans
HealthChoice High, High Alternative, and USA Plan Benefits
HealthChoice Basic Plan Benefits
HealthChoice Basic Alternative Plan Benefits
HMO Standard Option Benefits
CommunityCare Alternative and Wellness Alternative Plus HMO Benefits
GlobalHealth Alternative and Wellness Alternative Plus HMO Benefits
UnitedHealthcare Alternative and Wellness Alternative Plus HMO Benefits
Comparison of Benefits for Dental Plans – All Plans
HealthChoice Dental Plan Benefits
Assurant Freedom Preferred Benefits
Assurant Prepaid Plans - Heritage Plus with SBA and Heritage Secure Benefits
Cigna Dental Care Plan (Prepaid) Benefits
Delta Dental PPO In-Network and Out-of-Network
Delta Dental Premier In-Network and Out-of-Network
Delta Dental PPO – Choice PPO Network
Comparison of Benefits for Vision Plans – All Plans
Humana/CompBenefits VisionCare Plan
Primary Vision Care Services, Inc.
Superior Vision Plan
UnitedHealthcare Vision
Vision Service Plan (VSP)
Help Lines
If you have any questions concerning anything in this Guide, please refer to Help Lines for contact information.
The participating carriers reviewed and approved the information in this Guide. There is no guarantee that a provider will remain within a plan’s network or have open patient slots throughout the year. Please verify your provider’s participation in your plan’s network.
A text version of this Guide is available on the OSEEGIB website at www.sib.ok.gov or www.healthchoiceok.com. This Guide is also available in CD format at the Oklahoma Library for the Blind and Physically Handicapped (OLBPH). Contact the OLBPH at 1-405-521-3514, toll-free 1-800-523-0288, or TDD 1-405-521-4672.
MONTHLY PREMIUMS FOR CURRENT EMPLOYEES
For Plan Year January 1, 2012 through December 31, 2012
HEALTH PLANS
HealthChoice High
Member $449.48
Spouse $668.10
Child $228.20
Children $352.08
HealthChoice High Alternative
Member $449.48
Spouse $668.10
Child $228.20
Children $352.08
HealthChoice Basic
Member $391.64
Spouse $571.84
Child $201.82
Children $310.80
HealthChoice Basic Alternative
Member $391.64
Spouse $571.84
Child $201.82
Children $310.80
HealthChoice S-Account
Member $382.56
Spouse $542.52
Child $190.18
Children $291.90
HealthChoice USA Plan
Member $688.82
Spouse $688.82
Child $226.22
Children $348.86
CommunityCare Standard HMO
Member $803.22
Spouse $1,148.58
Child $401.60
Children $642.56
CommunityCare Alternative HMO
Member $553.96
Spouse $792.14
Child $276.98
Children $443.16
CommunityCare Wellness Alternative Plus HMO
Member $528.96
Spouse $792.14
Child $276.98
Children $443.16
GlobalHealth Standard HMO
Member $402.84
Spouse $660.72
Child $212.27
Children $338.44
GlobalHealth Alternative HMO
Member $366.24
Spouse $600.68
Child $193.00
Children $307.70
GlobalHealth Wellness Alternative Plus HMO
Member $341.24
Spouse $600.68
Child $193.00
Children $307.70
UnitedHealthcare Standard HMO (formerly PacifiCare)
Member $768.80
Spouse $1,105.36
Child $384.12
Children $614.72
UnitedHealthcare Alternative HMO
Member $530.20
Spouse $762.32
Child $264.90
Children $423.94
UnitedHealthcare Wellness Alternative Plus HMO
Member $505.20
Spouse $762.32
Child $264.90
Children $423.94
DISABILITY (Employee only)
$9.10 (Limited county participation only)
DENTAL PLANS
HealthChoice Dental
Member $30.20
Spouse $30.20
Child $25.18
Children $65.32
Assurant Freedom Preferred
Member $28.83
Spouse $28.67
Child $21.50
Children $57.80
Assurant Heritage Plus with SBA Prepaid
Member $11.74
Spouse $8.86
Child $7.60
Children $15.20
Assurant Heritage Secure Prepaid
Member $7.20
Spouse $5.98
Child $5.20
Children $10.38
CIGNA Dental Care Plan Prepaid
Member $9.26
Spouse $6.06
Child $7.08
Children $15.32
Delta Dental PPO
Member $33.64
Spouse $33.62
Child $29.26
Children $74.04
Delta Dental Premier
Member $38.36
Spouse $38.36
Child $33.38
Children $84.46
Delta Dental PPO - Choice
Member $15.06
Spouse $34.18
Child $34.44
Children $83.60
VISION PLANS
Humana/CompBenefits Vision Care Plan
Member $6.76
Spouse $5.06
Child $3.57
Children $4.46
Primary Vision Care Services
Member $9.25
Spouse $8.00
Child $8.50
Children $10.75
Superior Vision Plan
Member $7.14
Spouse $7.10
Child $6.72
Children $13.80
UnitedHealthcare Vision
Member $8.18
Spouse $5.79
Child $4.59
Children $6.98
Vision Service Plan (VSP)
Member $8.76
Spouse $5.87
Child $5.62
Children $12.64
LIFE
Member
HealthChoice Basic Life ($20,000) - $4.00
First $20,000 of Supplemental Life - $4.00
Age-Rated Supplemental Life - Cost Per $20,000
Under 30 $0.60
30 – 34 $0.60
35 – 39 $0.80
40 – 44 $1.20
45 – 49 $2.00
50 – 54 $3.40
55 – 59 $5.40
60 – 64 $6.20
65 – 69 $10.20
70 – 74 $17.40
75 and older $27.00
Dependent Life
Low Option $2.60
Spouse coverage of $6,000
Children over 6 months, coverage of $3,000
Birth to 6 months $1,000
Standard Option $4.32
Spouse coverage of $10,000
Children over 6 months, coverage of $5,000
Birth to 6 months $1,000
Premier Option $8.64
Spouse coverage of $20,000
Children over 6 months, coverage of $10,000
Birth to 6 months $1,000
Return to Table of Contents
2012 PLAN CHANGES
Health Plan Changes
HealthChoice Health Plans
Each year, tobacco use costs the HealthChoice health plans and their members approximately $52 million. Because these costs affect the premiums of all health plan members, HealthChoice is encouraging our members to stay or become tobacco-free by freezing the deductibles and out-of-pocket limits of the HealthChoice High and Basic Plans at 2011 amounts for non-tobacco users. The HealthChoice High Alternative and HealthChoice Basic Alternative Plans are being introduced for tobacco users. The individual deductibles and out-of-pocket limits for these two plans are $250 higher than the High and Basic Plans.
To enroll or remain enrolled in the HealthChoice High or Basic Plan for Plan Year 2012, you must attest that you and your covered dependents are tobacco-free by completing the HealthChoice High and Basic Plans Tobacco-Free Attestation for Plan Year 2012 by December 7, 2011. The Attestation is available to you
Online at www.sib.ok.gov or www.healthchoiceok.com
Included with your Option Period Enrollment/Change Form
By calling HealthChoice Member Services at 1-405-717-8780 or toll-free 1-800-752-9475. TDD users call 1-405-949-281 or toll-free 1-866-447-0436.
If you cannot complete the tobacco-free Attestation because you and/or your covered dependents are not tobacco-free, you can still qualify for the HealthChoice High or HealthChoice Basic plan if you can show proof of an attempt to quit using tobacco or provide a letter from your doctor. To qualify for the tobacco-free plans, you must provide one of the following
A letter from Alere Wellbeing indicating you and/or your covered dependents have enrolled in the quit tobacco program available through the Oklahoma Tobacco Settlement Endowment Trust (TSET) and Alere Wellbeing within the previous 90 days.
A letter from Alere Wellbeing indicating you and/or your covered dependents have completed the quit tobacco program available through the Oklahoma Tobacco Settlement Endowment Trust (TSET) and Alere Wellbeing within the previous 90 days.
A letter from your doctor indicating it is not medically advisable for you or your covered dependents to quit tobacco.
The letter from Alere Wellbeing or your doctor must be provided to HealthChoice, 3545 NW 58 St., Ste. 110, Oklahoma City, OK 73112 by December 7, 2011. Be sure to write your member ID number located in Section A of your pre-printed Option Period Enrollment/Change Form on your letter. If you do not or cannot complete the tobacco-free Attestation or provide one of the letters described previously, you and your covered dependents will be enrolled in the new HealthChoice High Alternative Plan or Basic Alternative Plan.
HealthChoice High, High Alternative, Basic, Basic Alternative, S-Account, and USA Plans
No limit on visits and treatment days for mental health and substance abuse.
Non-Network emergency room visits will be covered at the Network benefit level; however, you are still responsible for non-covered services and amounts over Allowed Charges.
As an enhanced benefit for HealthChoice members, preventive procedures and many other services will be covered at 100% of Allowed Charges with no out-of-pocket costs when using a Network Provider. This means no-cost access to
Blood pressure, diabetes, and cholesterol tests
Breast, cervical, prostate, and colorectal cancer screenings
Osteoporosis screening
Counseling from your health care provider on topics including quitting tobacco, losing weight, eating healthy, treating depression, and reducing alcohol use
Prescription tobacco cessation products
Vaccines for children and adults
Flu and Pneumonia shots
Screening for obesity and counseling from your doctor and other health professionals to promote sustained weight loss, including dietary counseling from your doctor
Screening for conditions that can harm pregnant women or their babies, including iron deficiency, hepatitis B, a pregnancy related immune condition called Rh incompatibility, and a bacterial infection called bacteriuria
Special, pregnancy-tailored counseling from a doctor to help pregnant women quit smoking and avoid alcohol use
Counseling to support breast-feeding and help nursing mothers
Visit the HealthChoice website at www.sib.ok.gov or www.healthchoiceok.com for more details.
HealthChoice High, High Alternative, and USA Plans
HealthChoice is implementing a family out-of-pocket limit for the HealthChoice High, High Alternative, and USA Plans. The family out-of-pocket limit for the High and USA Plans will be $8,400 when using a Network Provider and $9,900 when using a non-Network provider. The family out-of-pocket limit for the High Alternative Plan will be $9,150 when using a Network Provider and $10,650 when using a non-Network provider.
HealthChoice S-Account Plan
The out-of-pocket limits are being lowered to $3,000 for an individual and $6,000 for a family.
Proof of a Health Savings Account (HSA) is not required to enroll.
HealthChoice has contracted with American Fidelity Health Services Administrator to make establishing and keeping a Health Savings Account easier and more convenient for S-Account members. HSA deposits are invested in a money market account and all interest is applied to your account. The monthly maintenance fee is waived as long as you continue to be an employee of the state of Oklahoma. Refer to Health Savings Accounts for more information.
HealthChoice Pharmacy Benefit
Two 90-day courses of certain prescription tobacco cessation products will be covered at 100% with no cost to members.
HealthChoice is introducing a mail order pharmacy benefit and changing the quantity of medication you can get per copay. A 30-day supply of medication will be covered, when purchased at a retail pharmacy, for one copay. A 90-day supply of a maintenance medication will be covered for one copay when purchased through Medco’s mail order service or one of the Network Retail Maintenance Pharmacies. Refer to the Comparison of Benefits for Health Plans for copay amounts.
HMOs
CommunityCare Wellness Alternative Plus, GlobalHealth Wellness Alternative Plus, and UnitedHealthcare Wellness Alternative Plus HMO Plans
To be eligible for one of the Wellness Alternative Plus plans, you must complete the Health Risk Assessment (HRA) available at www.sib.ok.gov or www.healthchoiceok.com. If you completed the HRA as a HealthChoice member after July 1, 2011, you do not have to complete it again.
HMO service areas have changed. Refer to the HMO ZIP Code List to check your eligibility.
Life Plan Changes
HealthChoice Life Insurance
You must submit a Life Insurance Application to enroll in or increase the amount of your life insurance.
The maximum amount of Supplemental Life insurance you can carry is being increased to $500,000 regardless of your salary.
Vision Plan Changes
Superior Vision Plan
For in-network services, there is a $25 fitting fee copay for standard and specialty fitting of contact lenses. The plan then pays 100% for standard fitting and up to $50 for specialty fitting. The fitting fee is not a covered benefit when out-of-network.
UnitedHealthcare Vision
UV coating and tinting will be covered in full when using in-network providers.
Vision Service Plan (VSP)
After a copay of up to $60, a contact lens exam is covered in full when using in-network providers.
There are no dental plan changes for 2012
INTRODUCTION
The Oklahoma State and Education Employees Group Insurance Board (OSEEGIB), a division of the Office of State Finance, produced this Employee Benefit Options Guide to help you select your benefits. It is a summary of the available plans. The insurance benefits explained in this Guide are Health, Dental, Vision, Life, and Disability.
Refer to the Monthly Premiums for Current Employees and Comparison of Benefits for each plan to determine your costs.
Helpful Hints For Option Period
Review Section B of your pre-printed Option Period Enrollment/Change Form. This is the coverage you will have effective January 1, 2012, if you do not make changes during Option Period.
Contact your Insurance Coordinator if you have questions about your current coverage.
Review the 2012 Plan Changes.
Ask your Insurance Coordinator about returning your form even if you are not making changes.
Use the following resources to help you decide on coverage for you and your dependents for 2012 – this guide, plan websites, customer service telephone numbers, provider directories, OSEEGIB Member Services, and your Insurance Coordinator.
Complete your Option Period Enrollment/Change Form and return it to your Insurance Coordinator by the deadline set by your coordinator.
Review your Confirmation Statement when you receive it in the mail to verify your coverage is correct.
Contact your Insurance Coordinator right away if your Confirmation Statement is not correct. If you do not make changes to your coverage and you are not automatically enrolled in one of the HealthChoice alternative plans, you will not receive a Confirmation Statement from OSEEGIB. Keep a copy of your Option Period Enrollment/Change Form as verification of insurance coverage.
Helpful Hints For New Employees
Use the following resources to help you decide on coverage for you and your dependents – this guide, plan websites, customer service telephone numbers, provider directories, OSEEGIB Member Services, and your Insurance Coordinator.
Complete your Insurance Enrollment Form and return it to your Insurance Coordinator by the deadline set by your coordinator.
Review your Confirmation Statement when you receive it in the mail to verify your coverage is correct.
Contact your Insurance Coordinator right away if your Confirmation Statement is not correct.
GENERAL ENROLLMENT INFORMATION
Your employer determines which benefits are available to you and may not participate in all the benefits explained in this Guide. Ask your Insurance Coordinator which benefits are available to you.
The benefits you select will be in effect from January 1, 2012, or for new employees, the effective date of your coverage, through December 31, 2012.
After enrollment, the plans you have selected will provide more information about your benefits.
Once enrolled in any of the plans, it is your responsibility to review your benefits carefully so you know what is covered, as well as the plan’s policies and procedures, before you use your benefits.
Health Plans
There are 15 health plans available – HealthChoice High and High Alternative Plans, HealthChoice Basic and Basic Alternative Plans, HealthChoice S-Account Plan, HealthChoice USA Plan*, CommunityCare Standard, Alternative, and Wellness Alternative Plus HMO, GlobalHealth Standard, Alternative, and Wellness Alternative Plus HMO, and PacifiCare Standard, Alternative, and Alternative Plus HMO. Refer to the Comparison of Benefits for Health Plans for specific benefit information.
*The HealthChoice USA Plan is designed for employees who receive a work assignment of more than 90 consecutive days outside of Oklahoma and Arkansas. Call HealthChoice Member Services for more details. Refer to Help Lines for contact information.
There are no preexisting condition exclusions or limitations applied to any of the health plans.
To be eligible for the HealthChoice High or Basic Plan, you must complete the tobacco-free Attestation located on the OSEEGIB website or complete and return the Attestation included with your Option Period form.
You must live or work within the HMO’s ZIP Code service area to be eligible. Post Office Box addresses cannot be used to determine your HMO eligibility. Refer to the HMO ZIP Code List to verify your eligibility.
If you select an HMO, you must use the provider network designated by your plan for Oklahoma.
You must complete the HRA through the OSEEGIB website to enroll in an HMO Wellness Alternative Plus plan.
All health plans coordinate benefits with other group insurance plans you have in force. For more information, check with each health plan.
All plans have toll-free numbers for customer service. Refer to Help Lines for contact information.
Check with the individual health plan if you have benefit questions.
Dental Plans
Verify your employer offers dental coverage through OSEEGIB.
There are eight dental plans available – HealthChoice Dental, Assurant Freedom Preferred, Assurant Heritage Plus with SBA Prepaid, Assurant Heritage Secure Prepaid, CIGNA Dental Care Plan Prepaid, Delta Dental PPO, Delta Dental Premier, and Delta Dental PPO – Choice.
All dental plans have toll-free numbers for customer service. Refer to Help Lines for contact information.
Check with the individual dental plan if you have benefit questions.
Vision Plans
Verify your employer offers vision coverage through OSEEGIB.
There are five vision plans available – Humana/CompBenefits VisionCare Plan, Primary Vision Care Services, Superior Vision Plan, UnitedHealthcare Vision, and Vision Service Plan (VSP).
Verify your vision provider participates in a vision plan’s network by contacting the plan, visiting the plan’s website, or calling your provider.
All vision plans have limited coverage for services provided by out-of-network providers.
All vision plans have toll-free numbers for customer service. Refer to Help Lines for contact information.
Check with the individual vision plan if you have benefit questions.
If your provider leaves your health, dental, or vision plan, you cannot change plans until the next annual Option Period; however, you may change providers within your plan’s network as needed.
Thinking About Retirement?
If you are a current employee who will be retiring before January 1, 2012, please contact OSEEGIB Member Services and request the appropriate materials. You will select your benefits from either the Former Pre-Medicare Option Period Guide or the Medicare Option Period Guide. To contact Member Services, refer to Help Lines for contact information.
HEALTHCHOICE LIFE INSURANCE PLAN
Verify your employer offers HealthChoice Life Insurance through OSEEGIB.
As a new employee, you can elect life coverage within 30 days of your employment date or the date you become eligible. You can enroll in a limited amount of coverage, known as Guaranteed Issue, without an approved Life Insurance Application. All requests for coverage above Guaranteed Issue require an approved Life Insurance Application.
As a current employee, if you did not enroll when first eligible, you can enroll:
During the annual Option Period. An approved Life Insurance Application is required to enroll in or increase life insurance coverage.
Within 30 days of a midyear qualifying event. An approved Life Insurance Application is required.
Within 30 days of the loss of other group life coverage. You can enroll in the amount of coverage you lost, rounded up to the next $20,000 unit, without a Life Insurance Application. Proof of loss is required.
Basic Life…For You
Basic Life pays a benefit of $20,000 to your beneficiary in the event of your death.
Basic Life includes Accidental Death and Dismemberment (AD&D) coverage. This coverage pays an additional $20,000 to your beneficiary if your death is due to an accident. It also pays benefits if you lose your sight or a limb due to an accident.
Supplemental Life Insurance…For You
At the time of initial enrollment, you can purchase Supplemental Life coverage in an amount equal to two times your annual salary, rounded up to the next $20,000. This amount, known as Guaranteed Issue, is available without an approved Life Insurance Application.
You may purchase Supplemental Life in units of $20,000. The maximum amount of Supplemental Life coverage available in $500,000, regardless of your salary. You must complete a Life Insurance Application to apply for coverage.
The first $20,000 unit of Supplemental Life provides an additional $20,000 of AD&D coverage.
A Life Insurance Application is available from your Insurance Coordinator.
Dependent Life Insurance…For Your Family
If you enroll in Basic Life insurance, you can purchase Dependent Life insurance for your spouse and eligible dependents during your initial enrollment, during the annual Option Period, or within 30 days of loss of other group life insurance or other midyear qualifying event.
Dependent Life does not include AD&D coverage.
There are three options for Dependent Life coverage - Low, Standard, or Premier Option. Regardless of the number of dependents, the monthly premium is the same. Each eligible dependent must be enrolled in Dependent Life.
A Life Insurance Application is not required for Dependent Life coverage.
Amount of Coverage for Low Option
Spouse $6,000
Child (age 6 months to 26) $3,000
Child (live birth to 6 months) $1,000
Amount of Coverage for Standard Option
Spouse $10,000
Child (age 6 months to 26) $5,000
Child (live birth to 6 months) $1,000
Amount of Coverage for Premier Option
Spouse $20,000
Child (age 6 months to 26) $10,000
Child (live birth to 6 months) $1,000
Beneficiary Designation
Benefits are paid to your beneficiary in a lump sum. You must name your beneficiary or beneficiaries when you enroll. Your beneficiary designation can be changed at any time. For a Beneficiary Designation Form or more information, contact your Insurance Coordinator. This form is also available on the HealthChoice website at www.sib.ok.gov or www.healthchoiceok.com. Be aware that life insurance benefits for covered dependents are always paid to the member.
HEALTHCHOICE DISABILITY INSURANCE
Verify your employer offers HealthChoice Disability Insurance through OSEEGIB (limited county participation only).
The HealthChoice Disability Insurance Plan provides partial replacement income if you are unable to work due to an illness or injury. Disability coverage is not available to dependents.
Eligibility
Enrollment in the disability plan begins the first day of the month following your employment date or the date you become eligible. You become eligible for disability benefits after 31 consecutive days of employment. During that time, you must continuously perform all the material duties of your regular occupation. Any claim for disability benefits must be filed within one year of the date your disability began.
HEALTH SAVINGS ACCOUNTS
Information provided by American Fidelity Health Services Administration.
A Health Savings Account (HSA) is an individually owned savings account that allows you to set aside money for health care tax-free whenever you select an HSA qualified High Deductible Health Plan (HDHP). Money left in the account can accumulate interest tax-free and money used to pay for qualified medical expenses can be paid tax-free. Through your employer’s Section 125 plan, you can make HSA contributions on a pre-tax basis up to the yearly maximum allowed.
Some Highlights of HSAs
HSA contributions are tax-free.
Interest accrues tax-free.
Interest earned is applied to your account starting with the first dollar contribution.
Withdrawals are not taxed when funds are used for qualified medical expenses.
You decide when and how to use your money.
No “use it or lose it” requirement meaning whatever deposits you make each year can be left in the HSA to earn interest and to be available to pay for future medical expenses.
You can pay for qualified medical expenses on yourself, your spouse, or your tax dependents regardless of whether or not they are covered by your health plan.
No matter where you go, your account follows you. Even if you change jobs, change medical coverage, become unemployed, move to another state, or change your marital status, your HSA goes with you. You own it!
If you do not remain a qualified individual, you can continue to earn interest and pay for qualified medical expenses as long as there are funds in your account.
Contributions
You can contribute up to the annual maximum amount allowed by law in any given tax-year. The IRS establishes the maximum amounts on an annual basis. The 2011 maximum allowable is $3,050 for an individual or $6,150 for a family. Effective January 1, 2012, the maximum allowable will increase to $3,100 for an individual or $6,250 for a family. If your HDHP is effective on a date other than January 1 and you wish to make the maximum contribution, you must meet certain requirements. Visit www.afhsa.com for more information.
If you are age 55 or older, you are eligible to make an additional catch-up contribution of $1,000 per year. An HSA is owned by one individual, so if you and your spouse are covered under the family HDHP and both of you are age 55 or older, only you as the owner of the account can make the catch-up contribution. Your spouse would be required to establish his or her own HSA to make catch-up contributions.
Qualified Medical Expenses
There are many expenses that qualify for tax-free distributions. For a listing, you can refer to the HSA Eligible Expenses listed on www.afhsa.com. If you use funds for any expenses that are not eligible, then the funds withdrawn are subject to income taxes and a 20% additional tax penalty. The non-qualified distributions must be reported on your annual income tax return.
Additional information on eligible expenses can be found in IRS Publication 502 at www.irs.gov. Even though Publication 502 is a valuable resource on what qualifies as a medical expense, it addresses only what expenses are deductible.
Making Withdrawals from Your HSA
You can withdraw funds from your account in three ways:
1. HSA Debit Card
2. Online Distribution Request
3. Distribution Form
You can use the money from your HSA as follows:
1. You can only use the funds that have been deposited.
2. You can withdraw funds for qualified medical expenses incurred after the date your account is established.
3. You may elect to make withdrawals from your HSA when expenses are incurred, or you may make withdrawals for those expenses anytime in the future. There is no time limit.
In order to receive the tax benefit, the IRS requires that you keep records to prove that your HSA funds were used to pay for qualified medical expenses and that the qualified expense was not reimbursed from another source. Although you are not required to send your receipts with your tax returns, keeping your receipts with your tax information is an excellent way to ensure proper documentation. You will receive two forms each year as a result of having an HSA:
1. A 1099-SA which shows the total distributions from your account will be mailed by January 31, and
2. A 5498-SA which shows total contributions to your account will be mailed by May 31.
Each of these forms will also be sent to the IRS.
Eligibility Requirements
To be eligible to establish and contribute to an HSA, you must meet the following requirements:
1. You must be covered by an HSA-qualified HDHP.
2. You cannot be claimed as a dependent on anyone else’s tax return.
3. You cannot be covered under a non-HDHP coverage other than “permitted coverage” or “permitted insurance” and/or preventative care. Products such as Cancer, Accident, Long Term Care, and Disability Income are usually considered permitted coverage/insurance. Check with your employer or visit www.irs.gov to be sure.
4. You cannot have a general purpose Health FSA-Medical Reimbursement Account. However, you can have a Limited Purpose Health FSA which allows for dental and vision reimbursement only should your employer offer this benefit. Note: If you are covered under your spouse’s general purpose Health FSA, then you are not eligible to establish and contribute to an HSA.
5. You cannot be enrolled in Medicare.
Interest and Account Fees
HSA deposits are invested in a money market account and all interest is applied to your account. The monthly maintenance fee is waived as long as you continue to be employed by the State of Oklahoma. This fee covers unlimited account withdrawals, the debit card, and other investment funds for balances above the minimum $2,500 required in the money market account. A $15 fee will also apply for an additional or replacement debit card.
Summary
HSAs give you the savings potential, flexibility, portability, and tax savings unlike any other savings account. By enrolling in a qualified HDHP, you save on premiums. By investing those savings into an HSA, you can save for medical expenses in the future.
Individuals who elect an HSA with us will receive a welcome packet outlining all the information associated with the account. This flyer is meant to provide you high level information on HSAs. For more information on HSAs visit our website at www.afhsa.com. There you will find an overview specific to employees/individuals along with other helpful information. You can also find additional information about HSAs in the IRS Publication 969 at www.irs.gov.
Contact Information
American Fidelity Health Services Administration
2000 N Classen Blvd, Ste G16
Oklahoma City, OK 73125
1-405-523-5699 or toll-free 1-866-326-3600
Fax 1-405-523-5072
Website www.afhsa.com
Email HSA-Support@af-group.com
American Fidelity Health Services and its affiliates do not provide legal or tax advice. The information provided here is general in nature and should not be considered legal or tax advice. We recommend you consult with your tax or legal counsel about your personal situation.
ENROLLMENT PERIODS
Option Period Enrollment – Coverage effective January 1, 2012
This is the time when eligible employees can:
Enroll in plans
Change plans or drop coverage
Increase or decrease life insurance coverage
Add or drop eligible family members from coverage
You can enroll in health, dental, life, and/or vision coverage for yourself and/or your dependents during the annual Option Period, as long as you have not dropped that coverage within the past 12 months. If you have dropped coverage within the past 12 months, limitations and/or exceptions may apply.
Initial Enrollment – Coverage effective the first of the month following your employment date or the date set by your employer
This is the time when new employees are eligible to:
Enroll in plans
Enroll eligible dependents
Apply for life insurance coverage above Guaranteed Issue
As a new employee, you have 30 days from your employment date, or the date you become eligible, to enroll in coverage. If you do not enroll within 30 days, you cannot enroll until the next annual Option Period unless you experience a qualifying event. Check with your Insurance Coordinator for more information.
You have 30 days following your eligibility date to make changes to your original enrollment.
You have 30 days following your eligibility date to complete the HRA if you want to enroll in one of the HMO Wellness Alternative Plus plans.
If you request life insurance coverage in an amount greater than two times your annual salary, known as Guaranteed Issue, you must complete and submit a Life Insurance Application for approval. Contact your Insurance Coordinator for an application.
Keep a copy of your Insurance Enrollment Form for your records.
Midyear Changes – Coverage generally effective the first of the month following a qualifying event
Midyear plan changes are allowed only when a qualifying event such as birth, marriage, or loss of other group coverage occurs. You must complete an Insurance Change Form within 30 days of the event. Contact your Insurance Coordinator for more information.
ELIGIBILITY
Members
Your employer must participate in the plans offered through OSEEGIB.
You must be a current Education employee eligible to participate in the Oklahoma Teachers’ Retirement System working a minimum of four hours per day or 20 hours per week, or a current State of Oklahoma or Local Government employee regularly scheduled to work at least 1,000 hours a year and not classified as a temporary or seasonal employee.
You must be enrolled in a group health plan to enroll in dental and/or life insurance.
Dependents
If one eligible dependent is covered, all eligible dependents must be covered. You can choose not to cover dependents who do not reside with you, are married, are not financially dependent on you for support, or have other group coverage. Eligible dependents include:
Your legal spouse (including common-law).
Your daughter, son, stepdaughter, stepson, eligible foster child, adopted child, or child legally placed with you for adoption up to age 26, whether married or unmarried.
A dependent, regardless of age, who is incapable of self-support due to a disability that was diagnosed prior to age 26. Subject to medical review and approval.
Other unmarried dependent children up to age 26, upon completion of an Application for Coverage for Other Dependent Children. Guardianship papers or a tax return showing dependency may be provided in lieu of the application.
If your spouse is enrolled separately in one of the OSEEGIB plans, your dependents can be covered under only one parent’s health, dental, and/or vision plan (but not both); however, both parents can cover dependents under Dependent Life insurance.
Dependents who are not enrolled within 30 days of your eligibility date cannot be enrolled until the next annual Option Period, unless a qualifying event such as birth, marriage, or loss of other group coverage occurs. If eligible dependents are dropped from coverage, you cannot re-enroll them for a minimum of 12 months. The 12-month requirement does not apply when dependents lose other group health, dental, vision, and/or life insurance coverage and are seeking reinstatement of coverage through OSEEGIB.
Dependents can only be enrolled in the same types of coverage and in the same plans you enroll in.
To enroll your newborn, an Insurance Change Form must be provided to your Insurance Coordinator within 30 days of the birth. If you do not enroll your newborn during this 30-day period, you cannot do so until the next annual Option Period. Direct notification to a plan will not enroll your newborn or any other dependents. The newborn’s Social Security number is not required at the time of initial enrollment, but must be provided once it is received from the Social Security Administration. Insurance premiums for the month the child was born must be paid. Under the HealthChoice plans, a separate deductible and coinsurance may apply.
Without enrollment, newborns are covered only for the first 48 hours following a vaginal birth or the first 96 hours following a cesarean section birth. Deductible and coinsurance may apply.
Excluding Dependents from Coverage
You can exclude your spouse from health and/or dental coverage while covering other dependents on these benefits. Your spouse must sign the Spouse Exclusion Certification section of the enrollment or change form.
You can exclude your spouse or other dependents who do not reside with you, are married, are not financially dependent on you for support, have other group coverage, or are eligible for Indian or military health benefits.
Note: Your spouse cannot be excluded from vision coverage if your other dependents are covered unless your spouse has proof of other group vision coverage.
Confirmation Statement
You are mailed a Confirmation Statement (CS) when you enroll or make changes to your coverage. Your CS lists the coverage you are enrolled in, the effective date of your coverage, and the premium amounts.
Always review your CS to verify your coverage is correct. Corrections to your coverage must be submitted to your Insurance Coordinator within 60 days of your election. Corrections reported after 60 days are effective the first of the month following notification.
Section B of your Option Period Enrollment/Change Form lists the coverage you will have effective January 1, 2012, if you don’t make changes to your coverage during Option Period and you are not automatically enrolled in one of the HealthChoice alternative plans. If you don’t make changes and you are not automatically enrolled in one of the HealthChoice Alternative plans, you will not receive a CS from OSEEGIB. Keep a copy of your Option Period Enrollment/Change Form as verification of your coverage.
Transfer Employee
You can keep your coverage continuous when you move from one participating employer to another as long as there is no break in coverage that lasts longer than 30 days. Premiums must be paid upon reporting to work.
Benefit options vary from employer to employer. Changes to your coverage must be made within the first 30 days of your transfer. Contact your Insurance Coordinator for more information.
Termination of Coverage
Coverage will end the last day of the month in which a termination event occurs. Examples of termination events include loss of employment, loss of dependent eligibility, non-payment of premiums, and death.
COBRA – Temporary Continuation of Coverage
The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) allows you and/or your dependents to continue health, dental, and/or vision insurance coverage after your employment terminates or after a dependent loses eligibility. Certain time limits apply to enrollment. Contact your Insurance Coordinator immediately upon termination of your employment, or when changes to your family status occur, to find out more about your COBRA rights. Be aware, dropping dependent coverage during Option Period is not a COBRA qualifying event.
HMO ZIP CODE LIST
If you do not live or work in the ZIP Code area for a plan, that plan is not available to you. PO Box addresses cannot be used to determine HMO enrollment eligibility. There is no guarantee that all providers remain with the plans or that they have open patient slots all year long. Please verify availability and physician status prior to scheduling an appointment.
GlobalHealth may not be available in all the ZIP Codes indicated. Please check the Employee Benefit Options Guide posted on OSEEGIB’s website or contact GlobalHealth. Refer to Help Lines for contact information.
Use your screen readers find command to search for a specific ZIP Code. Press the letter H to move to the heading that begins the next section.
72761 CommunityCare, GlobalHealth
73001 GlobalHealth, UnitedHealthcare
73002 GlobalHealth, UnitedHealthcare
73003 CommunityCare, GlobalHealth, UnitedHealthcare
73004 GlobalHealth, UnitedHealthcare
73005 GlobalHealth, UnitedHealthcare
73006 GlobalHealth, UnitedHealthcare
73007 CommunityCare, GlobalHealth, UnitedHealthcare
73008 CommunityCare, GlobalHealth, UnitedHealthcare
73009 GlobalHealth, UnitedHealthcare
73010 GlobalHealth, UnitedHealthcare
73011 GlobalHealth, UnitedHealthcare
73012 GlobalHealth, UnitedHealthcare
73013 CommunityCare, GlobalHealth, UnitedHealthcare
73014 CommunityCare, GlobalHealth, UnitedHealthcare
73015 GlobalHealth, UnitedHealthcare
73016 GlobalHealth, UnitedHealthcare
73017 GlobalHealth, UnitedHealthcare
73018 GlobalHealth, UnitedHealthcare
73019 CommunityCare, GlobalHealth, UnitedHealthcare
73020 CommunityCare, GlobalHealth, UnitedHealthcare
73021 GlobalHealth, UnitedHealthcare
73022 CommunityCare, GlobalHealth, UnitedHealthcare
73023 GlobalHealth, UnitedHealthcare
73024 GlobalHealth, UnitedHealthcare
73025 GlobalHealth, UnitedHealthcare
73026 CommunityCare, GlobalHealth, UnitedHealthcare
73027 CommunityCare, GlobalHealth, UnitedHealthcare
73028 CommunityCare, GlobalHealth, UnitedHealthcare
73029 GlobalHealth, UnitedHealthcare
73030 GlobalHealth, UnitedHealthcare
73031 GlobalHealth, UnitedHealthcare
73032 GlobalHealth, UnitedHealthcare
73033 GlobalHealth, UnitedHealthcare
73034 CommunityCare, GlobalHealth, UnitedHealthcare
73035 GlobalHealth, UnitedHealthcare
73036 CommunityCare, GlobalHealth, UnitedHealthcare
73037 CommunityCare, GlobalHealth
73038 GlobalHealth, UnitedHealthcare
73039 GlobalHealth, UnitedHealthcare
73040 GlobalHealth, UnitedHealthcare
73041 GlobalHealth, UnitedHealthcare
73042 GlobalHealth, UnitedHealthcare
73043 GlobalHealth, UnitedHealthcare
73044 CommunityCare, GlobalHealth, UnitedHealthcare
73045 CommunityCare, GlobalHealth, UnitedHealthcare
73046 GlobalHealth, UnitedHealthcare
73047 GlobalHealth, UnitedHealthcare
73048 GlobalHealth, UnitedHealthcare
73049 CommunityCare, GlobalHealth, UnitedHealthcare
73050 CommunityCare, GlobalHealth, UnitedHealthcare
73051 CommunityCare, GlobalHealth, UnitedHealthcare
73052 GlobalHealth, UnitedHealthcare
73053 GlobalHealth, UnitedHealthcare
73054 CommunityCare, GlobalHealth, UnitedHealthcare
73055 GlobalHealth, UnitedHealthcare
73056 CommunityCare, GlobalHealth, UnitedHealthcare
73057 GlobalHealth, UnitedHealthcare
73058 CommunityCare, GlobalHealth, UnitedHealthcare
73059 GlobalHealth, UnitedHealthcare
73061 CommunityCare, GlobalHealth, UnitedHealthcare
73062 GlobalHealth, UnitedHealthcare
73063 CommunityCare, GlobalHealth, UnitedHealthcare
73064 CommunityCare, GlobalHealth, UnitedHealthcare
73065 GlobalHealth, UnitedHealthcare
73066 CommunityCare, GlobalHealth, UnitedHealthcare
73067 GlobalHealth, UnitedHealthcare
73068 CommunityCare, GlobalHealth, UnitedHealthcare
73069 CommunityCare, GlobalHealth, UnitedHealthcare
73070 CommunityCare, GlobalHealth, UnitedHealthcare
73071 CommunityCare, GlobalHealth, UnitedHealthcare
73072 CommunityCare, GlobalHealth, UnitedHealthcare
73073 CommunityCare, GlobalHealth, UnitedHealthcare
73074 GlobalHealth, UnitedHealthcare
73075 GlobalHealth, UnitedHealthcare
73076 GlobalHealth, UnitedHealthcare
73077 CommunityCare, GlobalHealth, UnitedHealthcare
73078 CommunityCare, GlobalHealth, UnitedHealthcare
73079 GlobalHealth, UnitedHealthcare
73080 GlobalHealth, UnitedHealthcare
73081 GlobalHealth, UnitedHealthcare
73082 GlobalHealth, UnitedHealthcare
73083 CommunityCare, GlobalHealth, UnitedHealthcare
73084 CommunityCare, GlobalHealth, UnitedHealthcare
73085 CommunityCare, GlobalHealth, UnitedHealthcare
73086 GlobalHealth, UnitedHealthcare
73087 GlobalHealth, UnitedHealthcare
73088 GlobalHealth, UnitedHealthcare
73089 GlobalHealth, UnitedHealthcare
73090 CommunityCare, GlobalHealth, UnitedHealthcare
73091 GlobalHealth, UnitedHealthcare
73092 GlobalHealth, UnitedHealthcare
73093 GlobalHealth, UnitedHealthcare
73094 GlobalHealth, UnitedHealthcare
73095 GlobalHealth, UnitedHealthcare
73096 GlobalHealth, UnitedHealthcare
73097 CommunityCare, GlobalHealth, UnitedHealthcare
73098 GlobalHealth, UnitedHealthcare
73099 CommunityCare, GlobalHealth, UnitedHealthcare
73100 GlobalHealth, UnitedHealthcare
73101 CommunityCare, GlobalHealth, UnitedHealthcare
73102 CommunityCare, GlobalHealth, UnitedHealthcare
73103 CommunityCare, GlobalHealth, UnitedHealthcare
73104 CommunityCare, GlobalHealth, UnitedHealthcare
73105 CommunityCare, GlobalHealth, UnitedHealthcare
73106 CommunityCare, GlobalHealth, UnitedHealthcare
73107 CommunityCare, GlobalHealth, UnitedHealthcare
73108 CommunityCare, GlobalHealth, UnitedHealthcare
73109 CommunityCare, GlobalHealth, UnitedHealthcare
73110 CommunityCare, GlobalHealth, UnitedHealthcare
73111 CommunityCare, GlobalHealth, UnitedHealthcare
73112 CommunityCare, GlobalHealth, UnitedHealthcare
73113 CommunityCare, GlobalHealth, UnitedHealthcare
73114 CommunityCare, GlobalHealth, UnitedHealthcare
73115 CommunityCare, GlobalHealth, UnitedHealthcare
73116 CommunityCare, GlobalHealth, UnitedHealthcare
73117 CommunityCare, GlobalHealth, UnitedHealthcare
73118 CommunityCare, GlobalHealth, UnitedHealthcare
73119 CommunityCare, GlobalHealth, UnitedHealthcare
73120 CommunityCare, GlobalHealth, UnitedHealthcare
73121 CommunityCare, GlobalHealth, UnitedHealthcare
73122 CommunityCare, GlobalHealth, UnitedHealthcare
73123 CommunityCare, GlobalHealth, UnitedHealthcare
73124 CommunityCare, GlobalHealth, UnitedHealthcare
73125 CommunityCare, GlobalHealth, UnitedHealthcare
73126 CommunityCare, GlobalHealth, UnitedHealthcare
73127 CommunityCare, GlobalHealth, UnitedHealthcare
73128 CommunityCare, GlobalHealth, UnitedHealthcare
73129 CommunityCare, GlobalHealth, UnitedHealthcare
73130 CommunityCare, GlobalHealth, UnitedHealthcare
73131 CommunityCare, GlobalHealth, UnitedHealthcare
73132 CommunityCare, GlobalHealth, UnitedHealthcare
73134 CommunityCare, GlobalHealth, UnitedHealthcare
73135 CommunityCare, GlobalHealth, UnitedHealthcare
73136 CommunityCare, GlobalHealth, UnitedHealthcare
73137 CommunityCare, GlobalHealth, UnitedHealthcare
73139 CommunityCare, GlobalHealth, UnitedHealthcare
73140 CommunityCare, GlobalHealth, UnitedHealthcare
73141 GlobalHealth, UnitedHealthcare
73142 CommunityCare, GlobalHealth, UnitedHealthcare
73143 CommunityCare, GlobalHealth, UnitedHealthcare
73144 CommunityCare, GlobalHealth, UnitedHealthcare
73145 CommunityCare, GlobalHealth, UnitedHealthcare
73146 CommunityCare, GlobalHealth, UnitedHealthcare
73147 CommunityCare, GlobalHealth, UnitedHealthcare
73148 CommunityCare, GlobalHealth, UnitedHealthcare
73149 CommunityCare, GlobalHealth, UnitedHealthcare
73150 CommunityCare, GlobalHealth, UnitedHealthcare
73151 CommunityCare, GlobalHealth, UnitedHealthcare
73152 CommunityCare, GlobalHealth, UnitedHealthcare
73153 CommunityCare, GlobalHealth, UnitedHealthcare
73154 CommunityCare, GlobalHealth, UnitedHealthcare
73155 CommunityCare, GlobalHealth, UnitedHealthcare
73156 CommunityCare, GlobalHealth, UnitedHealthcare
73157 CommunityCare, GlobalHealth, UnitedHealthcare
73159 CommunityCare, GlobalHealth, UnitedHealthcare
73160 CommunityCare, GlobalHealth, UnitedHealthcare
73162 CommunityCare, GlobalHealth, UnitedHealthcare
73163 CommunityCare, GlobalHealth, UnitedHealthcare
73164 CommunityCare, GlobalHealth, UnitedHealthcare
73165 CommunityCare, GlobalHealth, UnitedHealthcare
73167 CommunityCare, GlobalHealth, UnitedHealthcare
73169 CommunityCare, GlobalHealth, UnitedHealthcare
73170 CommunityCare, GlobalHealth, UnitedHealthcare
73172 CommunityCare, GlobalHealth, UnitedHealthcare
73173 CommunityCare, GlobalHealth, UnitedHealthcare
73175 GlobalHealth
73177 CommunityCare, GlobalHealth, UnitedHealthcare
73178 CommunityCare, GlobalHealth, UnitedHealthcare
73179 CommunityCare, GlobalHealth, UnitedHealthcare
73180 CommunityCare, GlobalHealth, UnitedHealthcare
73184 CommunityCare, GlobalHealth, UnitedHealthcare
73185 CommunityCare, GlobalHealth, UnitedHealthcare
73189 CommunityCare, GlobalHealth, UnitedHealthcare
73190 CommunityCare, GlobalHealth, UnitedHealthcare
73193 CommunityCare, GlobalHealth, UnitedHealthcare
73194 CommunityCare, GlobalHealth, UnitedHealthcare
73195 CommunityCare, GlobalHealth, UnitedHealthcare
73196 CommunityCare, GlobalHealth, UnitedHealthcare
73197 CommunityCare, GlobalHealth, UnitedHealthcare
73198 CommunityCare, GlobalHealth, UnitedHealthcare
73199 CommunityCare, GlobalHealth, UnitedHealthcare
73210 GlobalHealth
73251 GlobalHealth
73401 GlobalHealth, UnitedHealthcare
73402 GlobalHealth, UnitedHealthcare
73403 GlobalHealth, UnitedHealthcare
73422 GlobalHealth
73425 GlobalHealth, UnitedHealthcare
73430 GlobalHealth, UnitedHealthcare
73432 GlobalHealth, UnitedHealthcare
73433 GlobalHealth, UnitedHealthcare
73434 GlobalHealth, UnitedHealthcare
73435 GlobalHealth, UnitedHealthcare
73436 GlobalHealth, UnitedHealthcare
73437 GlobalHealth, UnitedHealthcare
73438 GlobalHealth, UnitedHealthcare
73439 GlobalHealth, UnitedHealthcare
73440 GlobalHealth, UnitedHealthcare
73441 GlobalHealth, UnitedHealthcare
73442 GlobalHealth, UnitedHealthcare
73443 GlobalHealth, UnitedHealthcare
73444 GlobalHealth, UnitedHealthcare
73446 GlobalHealth, UnitedHealthcare
73447 GlobalHealth, UnitedHealthcare
73448 GlobalHealth, UnitedHealthcare
73449 GlobalHealth, UnitedHealthcare
73450 GlobalHealth, UnitedHealthcare
73451 GlobalHealth
73453 GlobalHealth, UnitedHealthcare
73455 GlobalHealth, UnitedHealthcare
73456 GlobalHealth, UnitedHealthcare
73458 GlobalHealth, UnitedHealthcare
73459 GlobalHealth, UnitedHealthcare
73460 GlobalHealth, UnitedHealthcare
73461 GlobalHealth, UnitedHealthcare
73463 GlobalHealth, UnitedHealthcare
73476 GlobalHealth, UnitedHealthcare
73481 GlobalHealth, UnitedHealthcare
73487 GlobalHealth, UnitedHealthcare
73488 GlobalHealth, UnitedHealthcare
73491 GlobalHealth, UnitedHealthcare
73501 GlobalHealth, UnitedHealthcare
73502 GlobalHealth, UnitedHealthcare
73503 GlobalHealth, UnitedHealthcare
73505 GlobalHealth, UnitedHealthcare
73506 GlobalHealth, UnitedHealthcare
73507 GlobalHealth, UnitedHealthcare
73520 GlobalHealth, UnitedHealthcare
73521 GlobalHealth, UnitedHealthcare
73522 GlobalHealth, UnitedHealthcare
73523 GlobalHealth, UnitedHealthcare
73526 GlobalHealth, UnitedHealthcare
73527 GlobalHealth, UnitedHealthcare
73528 GlobalHealth, UnitedHealthcare
73529 GlobalHealth, UnitedHealthcare
73530 GlobalHealth, UnitedHealthcare
73531 GlobalHealth, UnitedHealthcare
73532 GlobalHealth, UnitedHealthcare
73533 GlobalHealth, UnitedHealthcare
73534 GlobalHealth, UnitedHealthcare
73536 GlobalHealth, UnitedHealthcare
73537 GlobalHealth, UnitedHealthcare
73538 GlobalHealth, UnitedHealthcare
73539 GlobalHealth, UnitedHealthcare
73540 GlobalHealth, UnitedHealthcare
73541 GlobalHealth, UnitedHealthcare
73542 GlobalHealth, UnitedHealthcare
73543 GlobalHealth, UnitedHealthcare
73544 GlobalHealth, UnitedHealthcare
73546 GlobalHealth, UnitedHealthcare
73547 GlobalHealth, UnitedHealthcare
73548 GlobalHealth, UnitedHealthcare
73549 GlobalHealth, UnitedHealthcare
73550 GlobalHealth, UnitedHealthcare
73551 GlobalHealth, UnitedHealthcare
73552 GlobalHealth, UnitedHealthcare
73553 GlobalHealth, UnitedHealthcare
73554 GlobalHealth, UnitedHealthcare
73555 GlobalHealth, UnitedHealthcare
73556 GlobalHealth, UnitedHealthcare
73557 GlobalHealth, UnitedHealthcare
73558 GlobalHealth, UnitedHealthcare
73559 GlobalHealth, UnitedHealthcare
73560 GlobalHealth, UnitedHealthcare
73561 GlobalHealth, UnitedHealthcare
73562 GlobalHealth, UnitedHealthcare
73564 GlobalHealth, UnitedHealthcare
73565 GlobalHealth, UnitedHealthcare
73566 GlobalHealth, UnitedHealthcare
73567 GlobalHealth, UnitedHealthcare
73568 GlobalHealth, UnitedHealthcare
73569 GlobalHealth, UnitedHealthcare
73570 GlobalHealth, UnitedHealthcare
73571 GlobalHealth, UnitedHealthcare
73572 GlobalHealth, UnitedHealthcare
73573 GlobalHealth, UnitedHealthcare
73575 GlobalHealth, UnitedHealthcare
73589 GlobalHealth
73601 GlobalHealth, UnitedHealthcare
73597 GlobalHealth
73620 GlobalHealth, UnitedHealthcare
73622 GlobalHealth, UnitedHealthcare
73624 GlobalHealth, UnitedHealthcare
73625 GlobalHealth, UnitedHealthcare
73626 GlobalHealth, UnitedHealthcare
73627 GlobalHealth, UnitedHealthcare
73628 GlobalHealth, UnitedHealthcare
73632 GlobalHealth, UnitedHealthcare
73637 GlobalHealth
73638 GlobalHealth, UnitedHealthcare
73639 GlobalHealth, UnitedHealthcare
73641 GlobalHealth, UnitedHealthcare
73642 GlobalHealth, UnitedHealthcare
73644 GlobalHealth, UnitedHealthcare
73645 GlobalHealth, UnitedHealthcare
73646 GlobalHealth, UnitedHealthcare
73647 GlobalHealth, UnitedHealthcare
73648 GlobalHealth, UnitedHealthcare
73650 GlobalHealth, UnitedHealthcare
73651 GlobalHealth, UnitedHealthcare
73654 GlobalHealth, UnitedHealthcare
73655 GlobalHealth, UnitedHealthcare
73656 GlobalHealth, UnitedHealthcare
73657 GlobalHealth
73658 GlobalHealth, UnitedHealthcare
73659 GlobalHealth, UnitedHealthcare
73660 GlobalHealth, UnitedHealthcare
73661 GlobalHealth, UnitedHealthcare
73662 GlobalHealth, UnitedHealthcare
73663 GlobalHealth, UnitedHealthcare
73664 GlobalHealth, UnitedHealthcare
73666 GlobalHealth, UnitedHealthcare
73667 GlobalHealth, UnitedHealthcare
73668 GlobalHealth, UnitedHealthcare
73669 GlobalHealth, UnitedHealthcare
73673 GlobalHealth, UnitedHealthcare
73701 GlobalHealth, UnitedHealthcare
73702 GlobalHealth, UnitedHealthcare
73703 GlobalHealth, UnitedHealthcare
73705 GlobalHealth, UnitedHealthcare
73707 GlobalHealth
73706 GlobalHealth, UnitedHealthcare
73716 GlobalHealth, UnitedHealthcare
73717 GlobalHealth, UnitedHealthcare
73718 GlobalHealth, UnitedHealthcare
73719 GlobalHealth, UnitedHealthcare
73720 GlobalHealth, UnitedHealthcare
73722 GlobalHealth, UnitedHealthcare
73724 GlobalHealth, UnitedHealthcare
73725 GlobalHealth, UnitedHealthcare
73726 GlobalHealth, UnitedHealthcare
73727 GlobalHealth, UnitedHealthcare
73728 GlobalHealth, UnitedHealthcare
73729 GlobalHealth, UnitedHealthcare
73730 GlobalHealth, UnitedHealthcare
73731 GlobalHealth, UnitedHealthcare
73733 GlobalHealth, UnitedHealthcare
73734 GlobalHealth, UnitedHealthcare
73735 GlobalHealth, UnitedHealthcare
73736 GlobalHealth, UnitedHealthcare
73737 GlobalHealth, UnitedHealthcare
73738 GlobalHealth, UnitedHealthcare
73739 GlobalHealth, UnitedHealthcare
73741 GlobalHealth, UnitedHealthcare
73742 GlobalHealth, UnitedHealthcare
73743 GlobalHealth, UnitedHealthcare
73744 GlobalHealth, UnitedHealthcare
73746 GlobalHealth, UnitedHealthcare
73747 GlobalHealth, UnitedHealthcare
73749 GlobalHealth, UnitedHealthcare
73750 GlobalHealth, UnitedHealthcare
73753 GlobalHealth, UnitedHealthcare
73754 GlobalHealth, UnitedHealthcare
73755 GlobalHealth, UnitedHealthcare
73756 GlobalHealth, UnitedHealthcare
73757 CommunityCare, GlobalHealth, UnitedHealthcare
73758 GlobalHealth, UnitedHealthcare
73759 GlobalHealth, UnitedHealthcare
73760 GlobalHealth, UnitedHealthcare
73761 GlobalHealth, UnitedHealthcare
73762 GlobalHealth, UnitedHealthcare
73763 GlobalHealth, UnitedHealthcare
73764 GlobalHealth, UnitedHealthcare
73766 GlobalHealth, UnitedHealthcare
73768 GlobalHealth, UnitedHealthcare
73770 GlobalHealth, UnitedHealthcare
73771 GlobalHealth, UnitedHealthcare
73772 GlobalHealth, UnitedHealthcare
73773 GlobalHealth, UnitedHealthcare
73801 GlobalHealth, UnitedHealthcare
73802 GlobalHealth, UnitedHealthcare
73820 GlobalHealth
73832 GlobalHealth, UnitedHealthcare
73834 GlobalHealth, UnitedHealthcare
73835 GlobalHealth, UnitedHealthcare
73838 GlobalHealth, UnitedHealthcare
73840 GlobalHealth, UnitedHealthcare
73841 GlobalHealth, UnitedHealthcare
73842 GlobalHealth, UnitedHealthcare
73843 GlobalHealth, UnitedHealthcare
73844 GlobalHealth, UnitedHealthcare
73847 GlobalHealth, UnitedHealthcare
73848 GlobalHealth, UnitedHealthcare
73849 GlobalHealth, UnitedHealthcare
73851 GlobalHealth, UnitedHealthcare
73852 GlobalHealth, UnitedHealthcare
73853 GlobalHealth, UnitedHealthcare
73855 GlobalHealth, UnitedHealthcare
73857 GlobalHealth, UnitedHealthcare
73858 GlobalHealth, UnitedHealthcare
73859 GlobalHealth, UnitedHealthcare
73860 GlobalHealth, UnitedHealthcare
73901 GlobalHealth, UnitedHealthcare
73931 GlobalHealth, UnitedHealthcare
73932 GlobalHealth, UnitedHealthcare
73933 GlobalHealth, UnitedHealthcare
73937 GlobalHealth, UnitedHealthcare
73938 GlobalHealth, UnitedHealthcare
73939 GlobalHealth, UnitedHealthcare
73942 GlobalHealth, UnitedHealthcare
73944 GlobalHealth, UnitedHealthcare
73945 GlobalHealth, UnitedHealthcare
73946 GlobalHealth, UnitedHealthcare
73947 GlobalHealth, UnitedHealthcare
73949 GlobalHealth, UnitedHealthcare
73950 GlobalHealth, UnitedHealthcare
73951 GlobalHealth, UnitedHealthcare
74001 CommunityCare, GlobalHealth, UnitedHealthcare
74002 CommunityCare, GlobalHealth, UnitedHealthcare
74003 CommunityCare, GlobalHealth, UnitedHealthcare
74004 CommunityCare, GlobalHealth, UnitedHealthcare
74005 CommunityCare, GlobalHealth, UnitedHealthcare
74006 CommunityCare, GlobalHealth, UnitedHealthcare
74008 CommunityCare, GlobalHealth, UnitedHealthcare
74009 CommunityCare, GlobalHealth, UnitedHealthcare
74010 CommunityCare, GlobalHealth, UnitedHealthcare
74011 CommunityCare, GlobalHealth, UnitedHealthcare
74012 CommunityCare, GlobalHealth, UnitedHealthcare
74013 CommunityCare, GlobalHealth, UnitedHealthcare
74014 CommunityCare, GlobalHealth, UnitedHealthcare
74015 CommunityCare, GlobalHealth, UnitedHealthcare
74016 CommunityCare, GlobalHealth, UnitedHealthcare
74017 CommunityCare, GlobalHealth, UnitedHealthcare
74018 CommunityCare, GlobalHealth, UnitedHealthcare
74019 CommunityCare, GlobalHealth, UnitedHealthcare
74020 CommunityCare, GlobalHealth, UnitedHealthcare
74021 CommunityCare, GlobalHealth, UnitedHealthcare
74022 CommunityCare, GlobalHealth, UnitedHealthcare
74023 CommunityCare, GlobalHealth, UnitedHealthcare
74026 GlobalHealth, UnitedHealthcare
74027 CommunityCare, GlobalHealth, UnitedHealthcare
74028 CommunityCare, GlobalHealth, UnitedHealthcare
74029 CommunityCare, GlobalHealth, UnitedHealthcare
74030 CommunityCare, GlobalHealth, UnitedHealthcare
74031 CommunityCare, GlobalHealth, UnitedHealthcare
74032 CommunityCare, GlobalHealth, UnitedHealthcare
74033 CommunityCare, GlobalHealth, UnitedHealthcare
74034 CommunityCare, GlobalHealth, UnitedHealthcare
74035 CommunityCare, GlobalHealth, UnitedHealthcare
74036 CommunityCare, GlobalHealth, UnitedHealthcare
74037 CommunityCare, GlobalHealth, UnitedHealthcare
74038 CommunityCare, GlobalHealth, UnitedHealthcare
74039 CommunityCare, GlobalHealth, UnitedHealthcare
74041 CommunityCare, GlobalHealth, UnitedHealthcare
74042 CommunityCare, GlobalHealth, UnitedHealthcare
74043 CommunityCare, GlobalHealth, UnitedHealthcare
74044 CommunityCare, GlobalHealth, UnitedHealthcare
74045 CommunityCare, GlobalHealth, UnitedHealthcare
74046 CommunityCare, GlobalHealth, UnitedHealthcare
74047 CommunityCare, GlobalHealth, UnitedHealthcare
74048 CommunityCare, GlobalHealth, UnitedHealthcare
74050 CommunityCare, GlobalHealth, UnitedHealthcare
74051 CommunityCare, GlobalHealth, UnitedHealthcare
74052 CommunityCare, GlobalHealth, UnitedHealthcare
74053 CommunityCare, GlobalHealth, UnitedHealthcare
74054 CommunityCare, GlobalHealth, UnitedHealthcare
74055 CommunityCare, GlobalHealth, UnitedHealthcare
74056 CommunityCare, GlobalHealth, UnitedHealthcare
74058 CommunityCare, GlobalHealth, UnitedHealthcare
74059 CommunityCare, GlobalHealth, UnitedHealthcare
74060 CommunityCare, GlobalHealth, UnitedHealthcare
74061 CommunityCare, GlobalHealth, UnitedHealthcare
74062 CommunityCare, GlobalHealth, UnitedHealthcare
74063 CommunityCare, GlobalHealth, UnitedHealthcare
74066 CommunityCare, GlobalHealth, UnitedHealthcare
74067 CommunityCare, GlobalHealth, UnitedHealthcare
74068 CommunityCare, GlobalHealth, UnitedHealthcare
74070 CommunityCare, GlobalHealth, UnitedHealthcare
74071 CommunityCare, GlobalHealth, UnitedHealthcare
74072 CommunityCare, GlobalHealth, UnitedHealthcare
74073 CommunityCare, GlobalHealth, UnitedHealthcare
74074 CommunityCare, GlobalHealth, UnitedHealthcare
74075 CommunityCare, GlobalHealth, UnitedHealthcare
74076 CommunityCare, GlobalHealth, UnitedHealthcare
74077 CommunityCare, GlobalHealth, UnitedHealthcare
74078 CommunityCare, GlobalHealth, UnitedHealthcare
74079 GlobalHealth, UnitedHealthcare
74080 CommunityCare, GlobalHealth, UnitedHealthcare
74081 CommunityCare, GlobalHealth, UnitedHealthcare
74082 CommunityCare, GlobalHealth, UnitedHealthcare
74083 CommunityCare, GlobalHealth, UnitedHealthcare
74084 CommunityCare, GlobalHealth, UnitedHealthcare
74085 CommunityCare, GlobalHealth, UnitedHealthcare
74100 GlobalHealth, UnitedHealthcare
74101 CommunityCare, GlobalHealth, UnitedHealthcare
74102 CommunityCare, GlobalHealth, UnitedHealthcare
74103 CommunityCare, GlobalHealth, UnitedHealthcare
74104 CommunityCare, GlobalHealth, UnitedHealthcare
74105 CommunityCare, GlobalHealth, UnitedHealthcare
74106 CommunityCare, GlobalHealth, UnitedHealthcare
74107 CommunityCare, GlobalHealth, UnitedHealthcare
74108 CommunityCare, GlobalHealth, UnitedHealthcare
74110 CommunityCare, GlobalHealth, UnitedHealthcare
74112 CommunityCare, GlobalHealth, UnitedHealthcare
74114 CommunityCare, GlobalHealth, UnitedHealthcare
74115 CommunityCare, GlobalHealth, UnitedHealthcare
74116 CommunityCare, GlobalHealth, UnitedHealthcare
74117 CommunityCare, GlobalHealth, UnitedHealthcare
74119 CommunityCare, GlobalHealth, UnitedHealthcare
74120 CommunityCare, GlobalHealth, UnitedHealthcare
74121 CommunityCare, GlobalHealth, UnitedHealthcare
74126 CommunityCare, GlobalHealth, UnitedHealthcare
74127 CommunityCare, GlobalHealth, UnitedHealthcare
74128 CommunityCare, GlobalHealth, UnitedHealthcare
74129 CommunityCare, GlobalHealth, UnitedHealthcare
74130 CommunityCare, GlobalHealth, UnitedHealthcare
74131 CommunityCare, GlobalHealth, UnitedHealthcare
74132 CommunityCare, GlobalHealth, UnitedHealthcare
74133 CommunityCare, GlobalHealth, UnitedHealthcare
74134 CommunityCare, GlobalHealth, UnitedHealthcare
74135 CommunityCare, GlobalHealth, UnitedHealthcare
74136 CommunityCare, GlobalHealth, UnitedHealthcare
74137 CommunityCare, GlobalHealth, UnitedHealthcare
74138 GlobalHealth
74141 CommunityCare, GlobalHealth, UnitedHealthcare
74145 CommunityCare, GlobalHealth, UnitedHealthcare
74146 CommunityCare, GlobalHealth, UnitedHealthcare
74147 CommunityCare, GlobalHealth, UnitedHealthcare
74148 CommunityCare, GlobalHealth, UnitedHealthcare
74149 CommunityCare, GlobalHealth, UnitedHealthcare
74150 CommunityCare, GlobalHealth, UnitedHealthcare
74152 CommunityCare, GlobalHealth, UnitedHealthcare
74153 CommunityCare, GlobalHealth, UnitedHealthcare
74155 CommunityCare, GlobalHealth, UnitedHealthcare
74156 CommunityCare, GlobalHealth, UnitedHealthcare
74157 CommunityCare, GlobalHealth, UnitedHealthcare
74158 CommunityCare, GlobalHealth, UnitedHealthcare
74159 CommunityCare, GlobalHealth, UnitedHealthcare
74169 CommunityCare, GlobalHealth, UnitedHealthcare
74170 CommunityCare, GlobalHealth, UnitedHealthcare
74171 CommunityCare, GlobalHealth, UnitedHealthcare
74172 CommunityCare, GlobalHealth, UnitedHealthcare
74182 CommunityCare, GlobalHealth, UnitedHealthcare
74183 CommunityCare, GlobalHealth, UnitedHealthcare
74184 CommunityCare, GlobalHealth, UnitedHealthcare
74186 CommunityCare, GlobalHealth, UnitedHealthcare
74187 CommunityCare, GlobalHealth, UnitedHealthcare
74189 CommunityCare, GlobalHealth, UnitedHealthcare
74192 CommunityCare, GlobalHealth, UnitedHealthcare
74193 CommunityCare, GlobalHealth, UnitedHealthcare
74194 CommunityCare, GlobalHealth, UnitedHealthcare
74301 CommunityCare, GlobalHealth, UnitedHealthcare
74306 GlobalHealth
74317 GlobalHealth
74330 CommunityCare, GlobalHealth, UnitedHealthcare
74331 GlobalHealth, UnitedHealthcare
74332 CommunityCare, GlobalHealth, UnitedHealthcare
74333 CommunityCare, GlobalHealth, UnitedHealthcare
74335 CommunityCare, GlobalHealth, UnitedHealthcare
74336 CommunityCare, GlobalHealth
74337 CommunityCare, GlobalHealth, UnitedHealthcare
74338 CommunityCare, GlobalHealth
74339 CommunityCare, GlobalHealth, UnitedHealthcare
74340 CommunityCare, GlobalHealth, UnitedHealthcare
74342 CommunityCare, GlobalHealth
74343 CommunityCare, GlobalHealth, UnitedHealthcare
74344 CommunityCare, GlobalHealth
74345 GlobalHealth
74346 CommunityCare, GlobalHealth
74347 CommunityCare, GlobalHealth
74349 CommunityCare, GlobalHealth, UnitedHealthcare
74350 CommunityCare, GlobalHealth, UnitedHealthcare
74352 CommunityCare, GlobalHealth, UnitedHealthcare
74353 CommunityCare, GlobalHealth, UnitedHealthcare
74354 CommunityCare, GlobalHealth, UnitedHealthcare
74355 CommunityCare, GlobalHealth, UnitedHealthcare
74358 CommunityCare, GlobalHealth, UnitedHealthcare
74359 CommunityCare, GlobalHealth,
74360 CommunityCare, GlobalHealth, UnitedHealthcare
74361 CommunityCare, GlobalHealth, UnitedHealthcare
74362 CommunityCare, GlobalHealth, UnitedHealthcare
74363 CommunityCare, GlobalHealth, UnitedHealthcare
74364 CommunityCare, GlobalHealth, UnitedHealthcare
74365 CommunityCare, GlobalHealth, UnitedHealthcare
74366 CommunityCare, GlobalHealth, UnitedHealthcare
74367 CommunityCare, GlobalHealth, UnitedHealthcare
74368 CommunityCare, GlobalHealth,
74369 CommunityCare, GlobalHealth, UnitedHealthcare
74370 CommunityCare, GlobalHealth, UnitedHealthcare
74401 CommunityCare, GlobalHealth, UnitedHealthcare
74402 CommunityCare, GlobalHealth, UnitedHealthcare
74403 CommunityCare, GlobalHealth, UnitedHealthcare
74406 GlobalHealth
74408 GlobalHealth
74421 CommunityCare, GlobalHealth, UnitedHealthcare
74422 CommunityCare, GlobalHealth, UnitedHealthcare
74423 CommunityCare, GlobalHealth, UnitedHealthcare
74425 CommunityCare, GlobalHealth, UnitedHealthcare
74426 CommunityCare, GlobalHealth, UnitedHealthcare
74427 CommunityCare, GlobalHealth, UnitedHealthcare
74428 CommunityCare, GlobalHealth, UnitedHealthcare
74429 CommunityCare, GlobalHealth, UnitedHealthcare
74430 CommunityCare, GlobalHealth, UnitedHealthcare
74431 CommunityCare, GlobalHealth, UnitedHealthcare
74432 CommunityCare, GlobalHealth, UnitedHealthcare
74434 CommunityCare, GlobalHealth, UnitedHealthcare
74435 CommunityCare, GlobalHealth,
74436 CommunityCare, GlobalHealth, UnitedHealthcare
74437 CommunityCare, GlobalHealth, UnitedHealthcare
74438 CommunityCare, GlobalHealth, UnitedHealthcare
74439 GlobalHealth, UnitedHealthcare
74440 CommunityCare, GlobalHealth, UnitedHealthcare
74441 CommunityCare, GlobalHealth, UnitedHealthcare
74442 CommunityCare, GlobalHealth, UnitedHealthcare
74444 CommunityCare, GlobalHealth, UnitedHealthcare
74445 CommunityCare, GlobalHealth, UnitedHealthcare
74446 CommunityCare, GlobalHealth, UnitedHealthcare
74447 CommunityCare, GlobalHealth, UnitedHealthcare
74450 CommunityCare, GlobalHealth, UnitedHealthcare
74451 CommunityCare, GlobalHealth, UnitedHealthcare
74452 CommunityCare, GlobalHealth, UnitedHealthcare
74454 CommunityCare, GlobalHealth, UnitedHealthcare
74455 CommunityCare, GlobalHealth, UnitedHealthcare
74456 CommunityCare, GlobalHealth, UnitedHealthcare
74457 CommunityCare, GlobalHealth
74458 CommunityCare, GlobalHealth, UnitedHealthcare
74459 CommunityCare, GlobalHealth, UnitedHealthcare
74460 CommunityCare, GlobalHealth, UnitedHealthcare
74461 CommunityCare, GlobalHealth, UnitedHealthcare
74462 CommunityCare, GlobalHealth, UnitedHealthcare
74463 CommunityCare, GlobalHealth, UnitedHealthcare
74464 GlobalHealth, UnitedHealthcare
74465 CommunityCare, GlobalHealth, UnitedHealthcare
74466 CommunityCare, GlobalHealth, UnitedHealthcare
74467 CommunityCare, GlobalHealth, UnitedHealthcare
74468 CommunityCare, GlobalHealth, UnitedHealthcare
74469 CommunityCare, GlobalHealth, UnitedHealthcare
74470 CommunityCare, GlobalHealth, UnitedHealthcare
74471 CommunityCare, GlobalHealth, UnitedHealthcare
74472 CommunityCare, GlobalHealth, UnitedHealthcare
74477 CommunityCare, GlobalHealth, UnitedHealthcare
74501 CommunityCare, GlobalHealth, UnitedHealthcare
74502 CommunityCare, GlobalHealth, UnitedHealthcare
74521 CommunityCare, GlobalHealth, UnitedHealthcare
74522 CommunityCare, GlobalHealth, UnitedHealthcare
74523 CommunityCare, GlobalHealth, UnitedHealthcare
74525 GlobalHealth, UnitedHealthcare
74526 CommunityCare, GlobalHealth, UnitedHealthcare
74528 CommunityCare, GlobalHealth, UnitedHealthcare
74529 CommunityCare, GlobalHealth, UnitedHealthcare
74530 GlobalHealth, UnitedHealthcare
74531 GlobalHealth, UnitedHealthcare
74533 GlobalHealth, UnitedHealthcare
74534 GlobalHealth, UnitedHealthcare
74535 GlobalHealth, UnitedHealthcare
74536 CommunityCare, GlobalHealth, UnitedHealthcare
74538 GlobalHealth, UnitedHealthcare
74540 GlobalHealth, UnitedHealthcare
74542 GlobalHealth, UnitedHealthcare
74543 CommunityCare, GlobalHealth, UnitedHealthcare
74545 CommunityCare, GlobalHealth, UnitedHealthcare
74546 CommunityCare, GlobalHealth, UnitedHealthcare
74547 CommunityCare, GlobalHealth, UnitedHealthcare
74548 CommunityCare, GlobalHealth, UnitedHealthcare
74549 CommunityCare, GlobalHealth,
74552 CommunityCare, GlobalHealth, UnitedHealthcare
74553 CommunityCare, GlobalHealth, UnitedHealthcare
74554 CommunityCare, GlobalHealth, UnitedHealthcare
74555 GlobalHealth, UnitedHealthcare
74556 GlobalHealth, UnitedHealthcare
74557 CommunityCare, GlobalHealth, UnitedHealthcare
74558 CommunityCare, GlobalHealth, UnitedHealthcare
74559 CommunityCare, GlobalHealth, UnitedHealthcare
74560 CommunityCare, GlobalHealth, UnitedHealthcare
74561 CommunityCare, GlobalHealth, UnitedHealthcare
74562 CommunityCare, GlobalHealth, UnitedHealthcare
74563 CommunityCare, GlobalHealth, UnitedHealthcare
74565 CommunityCare, GlobalHealth, UnitedHealthcare
74567 CommunityCare, GlobalHealth, UnitedHealthcare
74569 GlobalHealth, UnitedHealthcare
74570 CommunityCare, GlobalHealth, UnitedHealthcare
74571 CommunityCare, GlobalHealth, UnitedHealthcare
74572 GlobalHealth, UnitedHealthcare
74574 CommunityCare, GlobalHealth, UnitedHealthcare
74576 CommunityCare, GlobalHealth, UnitedHealthcare
74577 CommunityCare, GlobalHealth
74578 CommunityCare, GlobalHealth, UnitedHealthcare
74601 GlobalHealth, UnitedHealthcare
74602 GlobalHealth, UnitedHealthcare
74603 GlobalHealth, UnitedHealthcare
74604 GlobalHealth, UnitedHealthcare
74630 CommunityCare, GlobalHealth, UnitedHealthcare
74631 GlobalHealth, UnitedHealthcare
74632 GlobalHealth, UnitedHealthcare
74633 CommunityCare, GlobalHealth, UnitedHealthcare
74636 GlobalHealth, UnitedHealthcare
74637 CommunityCare, GlobalHealth, UnitedHealthcare
74640 GlobalHealth, UnitedHealthcare
74641 GlobalHealth, UnitedHealthcare
74643 GlobalHealth, UnitedHealthcare
74644 CommunityCare, GlobalHealth, UnitedHealthcare
74646 GlobalHealth, UnitedHealthcare
74647 GlobalHealth, UnitedHealthcare
74650 CommunityCare, GlobalHealth, UnitedHealthcare
74651 CommunityCare, GlobalHealth, UnitedHealthcare
74652 CommunityCare, GlobalHealth, UnitedHealthcare
74653 CommunityCare, GlobalHealth, UnitedHealthcare
74701 GlobalHealth, UnitedHealthcare
74702 GlobalHealth, UnitedHealthcare
74720 GlobalHealth, UnitedHealthcare
74721 GlobalHealth, UnitedHealthcare
74722 GlobalHealth, UnitedHealthcare
74723 GlobalHealth, UnitedHealthcare
74724 GlobalHealth, UnitedHealthcare
74726 GlobalHealth, UnitedHealthcare
74727 CommunityCare, GlobalHealth, UnitedHealthcare
74728 GlobalHealth, UnitedHealthcare
74729 GlobalHealth, UnitedHealthcare
74730 GlobalHealth, UnitedHealthcare
74731 GlobalHealth, UnitedHealthcare
74733 GlobalHealth, UnitedHealthcare
74734 GlobalHealth, UnitedHealthcare
74735 CommunityCare, GlobalHealth, UnitedHealthcare
74736 GlobalHealth, UnitedHealthcare
74737 GlobalHealth, UnitedHealthcare
74738 CommunityCare, GlobalHealth, UnitedHealthcare
74740 GlobalHealth, UnitedHealthcare
74741 GlobalHealth, UnitedHealthcare
74743 CommunityCare, GlobalHealth, UnitedHealthcare
74745 GlobalHealth, UnitedHealthcare
74747 GlobalHealth, UnitedHealthcare
74748 GlobalHealth, UnitedHealthcare
74750 GlobalHealth, UnitedHealthcare
74752 GlobalHealth, UnitedHealthcare
74753 GlobalHealth, UnitedHealthcare
74754 GlobalHealth, UnitedHealthcare
74755 GlobalHealth, UnitedHealthcare
74756 GlobalHealth, CommunityCare, UnitedHealthcare
74759 CommunityCare, GlobalHealth, UnitedHealthcare
74760 CommunityCare, GlobalHealth, UnitedHealthcare
74761 CommunityCare, GlobalHealth, UnitedHealthcare
74764 GlobalHealth, UnitedHealthcare
74766 GlobalHealth, UnitedHealthcare
74801 CommunityCare, GlobalHealth, UnitedHealthcare
74802 CommunityCare, GlobalHealth, UnitedHealthcare
74804 CommunityCare, GlobalHealth, UnitedHealthcare
74818 CommunityCare, GlobalHealth, UnitedHealthcare
74820 GlobalHealth, UnitedHealthcare
74821 GlobalHealth, UnitedHealthcare
74824 GlobalHealth, UnitedHealthcare
74825 GlobalHealth, UnitedHealthcare
74826 CommunityCare, GlobalHealth, UnitedHealthcare
74827 GlobalHealth, UnitedHealthcare
74829 GlobalHealth, UnitedHealthcare
74830 CommunityCare, GlobalHealth, UnitedHealthcare
74831 GlobalHealth, UnitedHealthcare
74832 GlobalHealth, UnitedHealthcare
74833 GlobalHealth, UnitedHealthcare
74834 GlobalHealth, UnitedHealthcare
74836 GlobalHealth, UnitedHealthcare
74837 CommunityCare, GlobalHealth, UnitedHealthcare
74838 CommunityCare, GlobalHealth
74839 GlobalHealth, UnitedHealthcare
74840 CommunityCare, GlobalHealth, UnitedHealthcare
74842 GlobalHealth, UnitedHealthcare
74843 GlobalHealth, UnitedHealthcare
74844 GlobalHealth, UnitedHealthcare
74845 CommunityCare, GlobalHealth, UnitedHealthcare
74848 GlobalHealth, UnitedHealthcare
74849 CommunityCare, GlobalHealth, UnitedHealthcare
74850 GlobalHealth, UnitedHealthcare
74851 CommunityCare, GlobalHealth, UnitedHealthcare
74852 CommunityCare, GlobalHealth, UnitedHealthcare
74854 CommunityCare, GlobalHealth, UnitedHealthcare
74855 GlobalHealth, UnitedHealthcare
74856 GlobalHealth, UnitedHealthcare
74857 CommunityCare, GlobalHealth, UnitedHealthcare
74859 GlobalHealth, UnitedHealthcare
74860 GlobalHealth, UnitedHealthcare
74864 GlobalHealth, UnitedHealthcare
74865 GlobalHealth, UnitedHealthcare
74866 CommunityCare, GlobalHealth, UnitedHealthcare
74867 CommunityCare, GlobalHealth, UnitedHealthcare
74868 CommunityCare, GlobalHealth, UnitedHealthcare
74869 GlobalHealth, UnitedHealthcare
74871 GlobalHealth, UnitedHealthcare
74872 GlobalHealth, UnitedHealthcare
74873 CommunityCare, GlobalHealth, UnitedHealthcare
74875 GlobalHealth, UnitedHealthcare
74877 CommunityCare, GlobalHealth
74878 CommunityCare, GlobalHealth, UnitedHealthcare
74880 CommunityCare, GlobalHealth, UnitedHealthcare
74881 GlobalHealth, UnitedHealthcare
74883 GlobalHealth, UnitedHealthcare
74884 CommunityCare, GlobalHealth, UnitedHealthcare
74901 CommunityCare, GlobalHealth
74902 CommunityCare, GlobalHealth
74930 CommunityCare, GlobalHealth
74931 CommunityCare, GlobalHealth
74932 CommunityCare, GlobalHealth
74935 CommunityCare, GlobalHealth
74936 CommunityCare, GlobalHealth
74937 CommunityCare, GlobalHealth
74939 CommunityCare, GlobalHealth
74940 CommunityCare, GlobalHealth
74941 CommunityCare, GlobalHealth, UnitedHealthcare
74942 CommunityCare, GlobalHealth
74943 CommunityCare, GlobalHealth, UnitedHealthcare
74944 CommunityCare, GlobalHealth, UnitedHealthcare
74945 CommunityCare, GlobalHealth
74946 CommunityCare, GlobalHealth
74947 CommunityCare, GlobalHealth
74948 CommunityCare, GlobalHealth
74949 CommunityCare, GlobalHealth
74951 CommunityCare, GlobalHealth
74953 CommunityCare, GlobalHealth
74954 CommunityCare, GlobalHealth
74955 CommunityCare, GlobalHealth
74956 CommunityCare, GlobalHealth
74957 CommunityCare, GlobalHealth, UnitedHealthcare
74959 CommunityCare, GlobalHealth
74960 CommunityCare, GlobalHealth
74962 CommunityCare, GlobalHealth
74963 GlobalHealth, UnitedHealthcare
74964 CommunityCare, GlobalHealth
74965 CommunityCare, GlobalHealth
74966 CommunityCare, GlobalHealth
COMPARISON OF BENEFITS FOR HEALTH PLANS – ALL PLANS
This is only a sample of the services covered by each plan. For services that are not listed in this comparison chart, contact each plan. Refer to Help Lines for contact information.
HealthChoice members do not need to designate a primary care physician and can change physicians at any time.
For HealthChoice plans, the $30 copay applies to general practitioners, internal medicine physicians, OB/GYNs, pediatricians, physician assistants, and nurse practitioners.
This chart reflects your cost for the listed Network services.
Calendar Year Deductibles
HealthChoice High and USA Plans
$500 individual and $1,500 family
HealthChoice High Alternative Plan
$750 individual and $2,250 family
HealthChoice Basic Plan
$500 individual and $1,000 family; deductible applies after Plan pays first $500 of Allowed Charges
HealthChoice Basic Alternative Plan
$750 individual and $1,500 family; deductible applies after Plan pays first $250 of Allowed Charges
HealthChoice S-Account Plan
$1,500 individual and $3,000 family; the combined medical and pharmacy deductible must be met before benefits are paid
HMO Standard Option
No deductible
CommunityCare Alternative HMO
No deductible
CommunityCare Wellness Alternative Plus HMO
No deductible; To be eligible for this Plan, you must complete a Health Risk Assessment
GlobalHealth Alternative HMO
No deductible
GlobalHealth Wellness Alternative Plus HMO
No deductible; To be eligible for this Plan, you must complete a Health Risk Assessment
UnitedHealthcare Alternative HMO
No deductible
UnitedHealthcare Wellness Alternative Plus HMO
No deductible; To be eligible for this Plan, you must complete a Health Risk Assessment
Calendar Year Out-of-Pocket Maximum
HealthChoice High and USA Plans
$2,800 Network individual and $8,400 Network family; $3,300 non-Network individual and $9,900 non-Network family, plus amounts over Allowed Charges
HealthChoice High Alternative Plan
$3,050 Network individual and $9,150 Network family; $3,550 non-Network individual and $10,650 non-Network family, plus amounts over Allowed Charges
HealthChoice Basic Plan
$5,500 individual and $11,000 family
HealthChoice Basic Alternative Plan
$5,750 individual and $11,500 family
HealthChoice S-Account Plan
$3,000 individual and $6,000 family; non-Network charges do not apply
HMO Standard Option
$2,500 individual and $5,000 family
CommunityCare Alternative and Wellness Alternative Plus HMO
$3,000 individual and $6,000 family
GlobalHealth Alternative and Wellness Alternative Plus HMO
$3,000 individual and $5,000 family
UnitedHealthcare Alternative and Wellness Alternative Plus HMO
$2,500 individual and $5,000 family
Office Visit (Professional Services)
HealthChoice High, High Alternative, and USA Plans
$30 copay/physician office visit and $50 copay/specialist office visit
HealthChoice Basic Plan
Copays do not apply; refer to the HealthChoice Basic Plan Benefits for more specific plan information
HealthChoice Basic Alternative Plan
Copays do not apply; refer to the HealthChoice Basic Alternative Plan Benefits for more specific plan information
HealthChoice S-Account
You pay 100% of Allowed Charges until deductible is met; $50 copay applies after deductible
HMO Standard Option
$30 copay/PCP and $40 copay/specialist
CommunityCare Alternative and Wellness Alternative Plus HMO
$35 copay/PCP and $50 copay/specialist
GlobalHealth Alternative and Wellness Alternative Plus HMO
$25 copay/PCP and $50 copay/specialist
UnitedHealthcare Alternative and Wellness Alternative Plus HMO
$35 copay/PCP and $50 copay/specialist
Diagnostic X-ray and Lab
HealthChoice High, High Alternative, and USA Plans
20% of Allowed Charges after deductible
HealthChoice Basic Plan
Refer to the HealthChoice Basic Plan Benefits for more specific plan information
HealthChoice Basic Alternative Plan
Refer to the HealthChoice Basic Alternative Plan Benefits for more specific plan information
HealthChoice S-Account
20% of Allowed Charges after deductible
HMO Standard Option
No copay for laboratory services or outpatient radiology; $150 copay per MRI, CAT, MRA, or PET scan
CommunityCare Alternative and Wellness Alternative Plus HMO
No additional copay for laboratory services or outpatient radiology; $200 copay per MRI, CAT, MRA, or PET scan
GlobalHealth Alternative and Wellness Alternative Plus HMO
$0 copay; $250 copay per MRI, MRA, PET, CAT, or nuclear scan
UnitedHealthcare Alternative and Wellness Alternative Plus HMO
$0 copay for standard lab and radiology; $200 copay per MRI, MRA, PET, or CAT scan
Hospital Inpatient Admission
HealthChoice High, High Alternative, and USA Plans
20% of Allowed Charges after deductible; additional $300 deductible per non-Network admission
HealthChoice Basic Plan
Refer to the HealthChoice Basic Plan Benefits for more specific plan information
HealthChoice Basic Alternative Plan
Refer to the HealthChoice Basic Alternative Plan Benefits for more specific plan information
HealthChoice S-Account
20% of Allowed Charges after deductible; additional $300 deductible per non-Network admission
HMO Standard Option
$350 copay; preauthorization required
CommunityCare Alternative and Wellness Alternative Plus HMO
$500 copay; preauthorization required
GlobalHealth Alternative and Wellness Alternative Plus HMO
$250 copay per day; $750 maximum per admission; preauthorization required
UnitedHealthcare Alternative and Wellness Alternative Plus HMO
$1,000 copay/admission
Hospital Outpatient Visit
HealthChoice High, High Alternative, and USA Plans
20% of Allowed Charges after deductible
HealthChoice Basic Plan
Refer to the HealthChoice Basic Plan Benefits for more specific plan information
HealthChoice Basic Alternative Plan
Refer to the HealthChoice Basic Alternative Plan Benefits for more specific plan information
HealthChoice S-Account
20% of Allowed Charges after deductible
HMO Standard Option
$250 copay; preauthorization required
CommunityCare Alternative and Wellness Alternative Plus HMO
$300 copay
GlobalHealth Alternative and Wellness Alternative Plus HMO
$250 copay; preauthorization required
UnitedHealthcare Alternative and Wellness Alternative Plus HMO
$500 copay
Well Child Care Visit
HealthChoice High, High Alternative, and USA Plans
$0 copay; no deductible applies
HealthChoice Basic Plan
Refer to the HealthChoice Basic Plan Benefits for more specific plan information
HealthChoice Basic Alternative Plan
Refer to the HealthChoice Basic Alternative Plan Benefits for more specific plan information
HealthChoice S-Account
$0 copay; no deductible applies
HMO Standard Option
$0 copay
CommunityCare Alternative and Wellness Alternative Plus HMO
$0 copay
GlobalHealth Alternative and Wellness Alternative Plus HMO
$0 copay ages 0-21
UnitedHealthcare Alternative and Wellness Alternative Plus HMO
$0 copay
Immunizations
HealthChoice High, High Alternative, and USA Plans
No charge for well child and adult immunizations; $30/$50 office visit copay and/or administration fee may apply
HealthChoice Basic Plan
Refer to the HealthChoice Basic Plan Benefits for more specific plan information
HealthChoice Basic Alternative Plan
Refer to the HealthChoice Basic Alternative Plan Benefits for more specific plan information
HealthChoice S-Account
No charge for well child and adult immunizations; $50 office visit copay and/or administration fee may apply
HMO Standard Option
$0 copay ages birth through age 18; $0 copay ages 19 and over
CommunityCare Alternative and Wellness Alternative Plus HMO
$0 copay ages birth through age 18 years; $0 copay ages 19 and over; when medically necessary
GlobalHealth Alternative and Wellness Alternative Plus HMO
$0 copay; office visit copay may apply
UnitedHealthcare Alternative and Wellness Alternative Plus HMO
$0 copay; In accordance with the US Preventive Services Task Force and other health organizations required guidelines
Periodic Health Exams
HealthChoice High, High Alternative, and USA Plans
$0 copay for one preventive service office visit per calendar year for members and dependents age 20 and older; one mammogram per year at no charge for women age 40 and older
HealthChoice Basic Plan
$0 copay for one preventive service office visit per calendar year for members and dependents age 20 and older; One mammogram per year at no charge for women age 40 and over; refer to the HealthChoice Basic Plan Benefits for more specific plan information
HealthChoice Basic Alternative Plan
$0 copay for one preventive service office visit per calendar year for members and dependents age 20 and older; One mammogram per year at no charge for women age 40 and over; refer to the HealthChoice Basic Alternative Plan Benefits for more specific plan information
HealthChoice S-Account
$0 copay for one preventive service office visit per calendar year for members and dependents age 20 and older; One mammogram per year at no charge for women age 40 and older
HMO Standard Option
$0 copay per visit for routine physicals
CommunityCare Alternative and Wellness Alternative Plus HMO
$0 copay
GlobalHealth Alternative and Wellness Alternative Plus HMO
$0 copay/PCP; Limit: one per year
UnitedHealthcare Alternative and Wellness Alternative Plus HMO
$0 copay; In accordance with the US Preventive Services Task Force and other health organizations required guidelines
Allergy Treatment and Testing
HealthChoice High, High Alternative, and USA Plans
20% of Allowed Charges after deductible; Limit: 60 tests every 24 months
HealthChoice Basic Plan
Refer to the HealthChoice Basic Plan Benefits for more specific plan information
HealthChoice Basic Alternative Plan
Refer to the HealthChoice Basic Alternative Plan Benefits for more specific plan information
HealthChoice S-Account
20% of Allowed Charges after deductible; Limit: 60 tests every 24 months
HMO Standard Option
$30 copay/PCP; $40 copay/specialist; $30 serum and shots including a 6-week supply of antigen
CommunityCare Alternative and Wellness Alternative Plus HMO
$35 copay/PCP; $50 copay/specialist; $30 serum and shots including a 6-week supply of antigen
GlobalHealth Alternative and Wellness Alternative Plus HMO
$25 copay/PCP; $50 copay/specialist; $30 serum and shots including a 6-week supply of antigen
UnitedHealthcare Alternative and Wellness Alternative Plus HMO
$35 copay/PCP; $50 copay/specialist; $35 serum and shots including a 6-week supply of antigen
Emergency Health Care Facility Visit
HealthChoice High, High Alternative, and USA Plans
20% of Allowed Charges after deductible; Additional $100 ER deductible, waived if admitted
HealthChoice Basic Plan
Refer to the HealthChoice Basic Plan Benefits for more specific plan information
HealthChoice Basic Alternative Plan
Refer to the HealthChoice Basic Alternative Plan Benefits for more specific plan information
HealthChoice S-Account
20% of Allowed Charges after deductible; Additional $100 ER deductible, waived if admitted
HMO Standard Option
$150 copay; waived if admitted
CommunityCare Alternative and Wellness Alternative Plus HMO
$200 copay; waived if admitted
GlobalHealth Alternative and Wellness Alternative Plus HMO
$150 copay; waived if admitted
UnitedHealthcare Alternative and Wellness Alternative Plus HMO
$200 copay; waived if admitted
After Hours Urgent Care
HealthChoice High, High Alternative, and USA Plans
20% of Allowed Charges after deductible
HealthChoice Basic Plan
Refer to the HealthChoice Basic Plan Benefits for more specific plan information
HealthChoice Basic Alternative Plan
Refer to the HealthChoice Basic Alternative Plan Benefits for more specific plan information
HealthChoice S-Account
20% of Allowed Charges after deductible
HMO Standard Option
$40 copay per visit
CommunityCare Alternative and Wellness Alternative Plus HMO
$50 copay per visit; preauthorization required
GlobalHealth Alternative and Wellness Alternative Plus HMO
$25 copay/PCP; $50 copay/all others; must use Network facilities
UnitedHealthcare Alternative and Wellness Alternative Plus HMO
$50 copay per visit
Mental Health or Substance Abuse Inpatient Admission
HealthChoice High, High Alternative, and USA Plans
20% of Allowed Charges after deductible; no limit on the number of days per year
HealthChoice Basic Plan
Refer to the HealthChoice Basic Plan Benefits for more specific plan information
HealthChoice Basic Alternative Plan
Refer to the HealthChoice Basic Alternative Plan Benefits for more specific plan information
HealthChoice S-Account
20% of Allowed Charges after deductible; no limit on the number of days per year
HMO Standard Option
$350 copay
CommunityCare Alternative and Wellness Alternative Plus HMO
$500 copay; must be preauthorized and approved through CCOK Behavioral Health Services
GlobalHealth Alternative and Wellness Alternative Plus HMO
$250 per day; $750 maximum per admission; must be preauthorized
UnitedHealthcare Alternative and Wellness Alternative Plus HMO
$1,000 copay per admission
Mental Health or Substance Abuse Outpatient Visit
HealthChoice High, High Alternative, and USA Plans
20% of Allowed Charges after deductible; no limit on the number of days per year
HealthChoice Basic Plan
Refer to the HealthChoice Basic Plan Benefits for more specific plan information
HealthChoice Basic Alternative Plan
Refer to the HealthChoice Basic Alternative Plan Benefits for more specific plan information
HealthChoice S-Account
20% of Allowed Charges after deductible; no limit on the number of days per year
HMO Standard Option
$30 copay/PCP; $40 copay/specialist
CommunityCare Alternative and Wellness Alternative Plus HMO
$35 copay/PCP; $50 copay/specialist; must be preauthorized and approved through CCOK Behavioral Health Services
GlobalHealth Alternative and Wellness Alternative Plus HMO
$25 copay; must be preauthorized
UnitedHealthcare Alternative and Wellness Alternative Plus HMO
$35 copay/PCP and specialist
Durable Medical Equipment (DME)
HealthChoice High, High Alternative, and USA Plans
20% of Allowed Charges after deductible for purchase, rental, repair, or replacement
HealthChoice Basic Plan
Refer to the HealthChoice Basic Plan Benefits for more specific plan information
HealthChoice Basic Alternative Plan
Refer to the HealthChoice Basic Alternative Plan Benefits for more specific plan information
HealthChoice S-Account
20% of Allowed Charges after deductible for purchase, rental, repair, or replacement
HMO Standard Option
20% coinsurance initial device; 20% coinsurance repair and replacement
CommunityCare Alternative and Wellness Alternative Plus HMO
20% coinsurance initial device; 20% coinsurance repair and replacement
GlobalHealth Alternative and Wellness Alternative Plus HMO
20% coinsurance
UnitedHealthcare Alternative and Wellness Alternative Plus HMO
20% coinsurance; $10,000 maximum benefit per calendar year
Occupational or Speech Therapy Visits
HealthChoice High, High Alternative, and USA Plans
20% of Allowed Charges after deductible
Occupational therapy – Limit: 20 visits per year without certification with maximum of 60 visits per year
Speech therapy – Certification not required for age 18 and older, maximum of 60 visits per year
HealthChoice Basic Plan
Refer to the HealthChoice Basic Plan Benefits for more specific plan information
HealthChoice Basic Alternative Plan
Refer to the HealthChoice Basic Alternative Plan Benefits for more specific plan information
HealthChoice S-Account
20% of Allowed Charges after deductible
Occupational therapy – Limit: 20 visits per year without certification with maximum of 60 visits per year
Speech therapy – Certification not required for age 18 and older, maximum of 60 visits per year
HMO Standard Option
No copay inpatient; $30 copay/PCP; $40 copay/specialist; Limit: 60 treatment days per illness
CommunityCare Alternative and Wellness Alternative Plus HMO
No copay inpatient; $50 copay outpatient therapy; Limit: 60 days per illness
GlobalHealth Alternative and Wellness Alternative Plus HMO
No copay inpatient; $50 copay per outpatient therapy; Limit: 60 consecutive days per illness
UnitedHealthcare Alternative and Wellness Alternative Plus HMO
$0 copay inpatient; $35 copay/PCP; $50 copay/specialist; Limit: 60 days per illness
Physical Therapy/Physical Medicine Visit
HealthChoice High, High Alternative, and USA Plans
20% of Allowed Charges after deductible; Limit: 20 visits per year without certification; maximum of 60 visits per year
HealthChoice Basic Plan
Refer to the HealthChoice Basic Plan Benefits for more specific plan information
HealthChoice Basic Alternative Plan
Refer to the HealthChoice Basic Alternative Plan Benefits for more specific plan information
HealthChoice S-Account
20% of Allowed Charges after deductible; Limit: 20 visits per year without certification; maximum of 60 visits per year
HMO Standard Option
No copay inpatient; $30 copay/PCP; $40 copay/specialist; Limit: 60 treatment days per illness
CommunityCare Alternative and Wellness Alternative Plus HMO
No copay inpatient; $50 copay outpatient therapy; Limit: 60 days per illness
GlobalHealth Alternative and Wellness Alternative Plus HMO
No copay inpatient; $50 copay per outpatient visit; Limit: 60 consecutive days per illness
UnitedHealthcare Alternative and Wellness Alternative Plus HMO
$0 copay inpatient; $35 copay/PCP; $50 copay/specialist; Limit: 60 days per medical episode
Chiropractic and Manipulative Therapy Visit
HealthChoice High, High Alternative, and USA Plans
Chiropractic services - 20% of Allowed Charges after deductible; Limit: 20 visits per year without certification; maximum of 60 visits per year
Manipulative therapy - Refer to Physical Therapy/Physical Medicine
HealthChoice Basic Plan
Refer to the HealthChoice Basic Plan Benefits for more specific plan information
HealthChoice Basic Alternative Plan
Refer to the HealthChoice Basic Alternative Plan Benefits for more specific plan information
HealthChoice S-Account
Chiropractic services - 20% of Allowed Charges after deductible; Limit: 20 visits per year without certification; maximum of 60 visits per year
Manipulative therapy - Refer to Physical Therapy/Physical Medicine
HMO Standard Option
$40 copay; Limit: 15 visits per year; PCP referral required
CommunityCare Alternative and Wellness Alternative Plus HMO
$50 copay; Limit: 15 visits per year; PCP referral required
GlobalHealth Alternative and Wellness Alternative Plus HMO
$50 copay; must be preauthorized
UnitedHealthcare Alternative and Wellness Alternative Plus HMO
$50 copay; Limit: 15 visits per year – referral required; Limited to treatment of neurological and orthopedic conditions
Maternity Pre and Post Natal Care
HealthChoice High, High Alternative, and USA Plans
20% of Allowed Charges after deductible; Includes one postpartum home visit – criteria must be met
HealthChoice Basic Plan
Refer to the HealthChoice Basic Plan Benefits for more specific plan information
HealthChoice Basic Alternative Plan
Refer to the HealthChoice Basic Alternative Plan Benefits for more specific plan information
HealthChoice S-Account
20% of Allowed Charges after deductible; Includes one postpartum home visit – criteria must be met
HMO Standard Option
$30 copay for initial visit; $350 copay per hospital admission
CommunityCare Alternative and Wellness Alternative Plus HMO
$35 copay for initial visit; $500 copay per hospital admission
GlobalHealth Alternative and Wellness Alternative Plus HMO
$25 copay for initial visit only; $250 copay per hospital admission per day; $750 maximum per admission
UnitedHealthcare Alternative and Wellness Alternative Plus HMO
$35 copay/PCP; $50 copay/specialist for initial visit once diagnosis of pregnancy is confirmed; $1,000 copay per hospital admission
Hearing Screening and Hearing Aids
HealthChoice High, High Alternative, and USA Plans
$30 copay/primary care physician; $50 copay/specialist basic hearing screening; Limit: one per year; Hearing aids are covered as durable medical equipment for children up to age 18
HealthChoice Basic Plan
Refer to the HealthChoice Basic Plan Benefits for more specific plan information
HealthChoice Basic Alternative Plan
Refer to the HealthChoice Basic Alternative Plan Benefits for more specific plan information
HealthChoice S-Account
$50 copay after deductible/basic hearing screening; Limit: one per year; Hearing aids are covered as durable medical equipment for children up to age 18
HMO Standard Option
$0 copay children birth through age 21; $30 copay age 22 and over; Limit: one per year; Hearing aids – 20% coinsurance for children up to age 18
CommunityCare Alternative and Wellness Alternative Plus HMO
$0 copay; Limit: one per year; Hearing aids – 20% coinsurance for children up to age 18
GlobalHealth Alternative and Wellness Alternative Plus HMO
$0 copay children birth through age 21; $25 copay age 22 and over; Limit: one per year; Hearing aids – 20% coinsurance for children up to age 18
UnitedHealthcare Alternative and Wellness Alternative Plus HMO
$0 copay/PCP ages 0 through 17; 20% coinsurance ages 18 and over; Limited to a single hearing aid every 3 years – maximum benefit of $5,000 per calendar year
Pharmacy Benefits
HealthChoice High, High Alternative, Basic, Basic Alternative, and USA Plans
NETWORK
RETAIL PHARMACY
Up to a 30-day supply
Generic medication - $10 copay or cost of medication if less
Preferred brand-name medication – cost of medication up to $15 or a maximum copay of $30
Non-Preferred brand-name medication – cost of medication up to $30 or a maximum copay of $60
Maintenance medication – 50% of ingredient cost plus dispensing fee for fourth and all subsequent fills; minimum copay of $10 for generics, $15 for Preferred brand-name, and $30 for non-Preferred brand-name medication
MAIL ORDER AND RETAIL MAINTENANCE PHARMACIES
Up to a 90-day supply
Generic medication - $25 copay or cost of medication if less
Preferred brand-name medication – cost of medication up to $30 or a maximum copay of $60
Non-Preferred brand-name medication – cost of medication up to $60 or a maximum copay of $120
Specialty medication covered only when ordered through Accredo health Group
Preferred medication $60 per 30-day supply
Non-Preferred $120 per 30-day supply
Pharmacy out-of-pocket maximum is $2,500 per person using Preferred products at Network pharmacies, then you pay $0
HealthChoice S-Account
After combined medical and pharmacy deductible - $1,500 individual or $3,000 family - has been met, the pharmacy benefits are:
NETWORK
RETAIL PHARMACY
Up to a 30-day supply
Generic medication - $10 copay or cost of medication if less
Preferred brand-name medication – cost of medication up to $15 or a maximum copay of $30
Non-Preferred brand-name medication – cost of medication up to $30 or a maximum copay of $60
Maintenance medication – 50% of ingredient cost plus dispensing fee for fourth and all subsequent fills; minimum copay of $10 for generics, $15 for Preferred brand-name, and $30 for non-Preferred brand-name medication
MAIL ORDER AND RETAIL MAINTENANCE PHARMACIES
Up to a 90-day supply
Generic medication - $25 copay or cost of medication if less
Preferred brand-name medication – cost of medication up to $30 or a maximum copay of $60
Non-Preferred brand-name medication – cost of medication up to $60 or a maximum copay of $120
Specialty medication covered only when ordered through Accredo health Group
Preferred medication $60 per 30-day supply
Non-Preferred $120 per 30-day supply
HMO Standard Option
Up to $5 generic formulary
Up to $30 brand formulary (when no generic is available)
Up to $60 brand formulary (when generic is available)
30-day supply
Certain medications have restricted quantities
Mail order may be available, contact plans for details
Please note: Tier categories will be determined by each HMO based on its formulary design
CommunityCare Alternative and Wellness Alternative Plus HMO
Tier 1: $10
Tier 2: $40
Tier 3: $65
$0 copay for selected generics
Up to $65 non-formulary (non-Preferred)
These copays do not apply to the maximum out-of-pocket
30-day supply
Certain medications have restricted quantities
Convenient mail-order is available; contact Plan for details
GlobalHealth Alternative and Wellness Alternative Plus HMO
Tier 1: $10
Tier 2: $50
Tier 3: $75
$4 copay for selected generics
30-day supply
Certain medications may have restricted quantities
These copays do not apply to the maximum out-of-pocket
UnitedHealthcare Alternative and Wellness Alternative Plus HMO
$5 copay for formulary generic drugs
$30 copay for formulary brand-name drugs
$60 copay for non-formulary generic and non-formulary brand drugs
Lesser of 30-day supply or 100 units
Certain medications have restricted quantities
HEALTHCHOICE HIGH, HIGH ALTERNATIVE, AND USA PLAN BENEFITS
This is only a sample of the services covered by each plan. For services that are not listed in this comparison chart, contact each plan. Refer to Help Lines for contact information.
HealthChoice members do not need to designate a primary care physician and can change physicians at any time.
For HealthChoice plans, the $30 copay applies to general practitioners, internal medicine physicians, OB/GYNs, pediatricians, physician assistants, and nurse practitioners.
This chart reflects your cost for the listed Network services.
Calendar Year Deductibles
HealthChoice High and USA Plans
$500 individual and $1,500 family
HealthChoice High Alternative Plan
$750 individual and $2,250 family
Calendar Year Out-of-Pocket Maximum
HealthChoice High and USA Plans
$2,800 Network individual and $8,400 Network family; $3,300 non-Network individual and $9,900 non-Network family, plus amounts over Allowed Charges
HealthChoice High Alternative Plan
$3,050 Network individual and $9,150 Network family; $3,550 non-Network individual and $10,650 non-Network family, plus amounts over Allowed Charges
Office Visit (Professional Services)
$30 copay/physician office visit and $50 copay/specialist office visit
Diagnostic X-ray and Lab
20% of Allowed Charges after deductible
Hospital Inpatient Admission
20% of Allowed Charges after deductible; additional $300 deductible per non-Network admission
Hospital Outpatient Visit
20% of Allowed Charges after deductible
Well Child Care Visit
$0 copay; no deductible applies
Immunizations
No charge for well child and adult immunizations; $30/$50 office visit copay and/or administration fee may apply
Periodic Health Exams
$0 copay for one preventive service office visit per calendar year for members and dependents age 20 and older; one mammogram per year at no charge for women age 40 and older
Allergy Treatment and Testing
20% of Allowed Charges after deductible; Limit: 60 tests every 24 months
Emergency Health Care Facility Visit
20% of Allowed Charges after deductible; Additional $100 ER deductible, waived if admitted
After Hours Urgent Care
20% of Allowed Charges after deductible
Mental Health or Substance Abuse Inpatient Admission
20% of Allowed Charges after deductible; no limit on the number of days per year
Mental Health or Substance Abuse Outpatient Visit
20% of Allowed Charges after deductible; no limit on the number of days per year
Durable Medical Equipment (DME)
20% of Allowed Charges after deductible for purchase, rental, repair, or replacement
Occupational or Speech Therapy Visits
20% of Allowed Charges after deductible
Occupational therapy – Limit: 20 visits per year without certification with maximum of 60 visits per year
Speech therapy – Certification not required for age 18 and older, maximum of 60 visits per year
Physical Therapy/Physical Medicine Visit
20% of Allowed Charges after deductible; Limit: 20 visits per year without certification; maximum of 60 visits per year
Chiropractic and Manipulative Therapy Visit
Chiropractic services - 20% of Allowed Charges after deductible; Limit: 20 visits per year without certification; maximum of 60 visits per year
Manipulative therapy - Refer to Physical Therapy/Physical Medicine
Maternity Pre and Post Natal Care
20% of Allowed Charges after deductible; Includes one postpartum home visit – criteria must be met
Hearing Screening and Hearing Aids
$30 copay/primary care physician; $50 copay/specialist basic hearing screening; Limit: one per year; Hearing aids are covered as durable medical equipment for children up to age 18
Pharmacy Benefits
NETWORK
RETAIL PHARMACY
Up to a 30-day supply
Generic medication - $10 copay or cost of medication if less
Preferred brand-name medication – cost of medication up to $15 or a maximum copay of $30
Non-Preferred brand-name medication – cost of medication up to $30 or a maximum copay of $60
Maintenance medication – 50% of ingredient cost plus dispensing fee for fourth and all subsequent fills; minimum copay of $10 for generics, $15 for Preferred brand-name, and $30 for non-Preferred brand-name medication
MAIL ORDER AND RETAIL MAINTENANCE PHARMACIES
Up to a 90-day supply
Generic medication - $25 copay or cost of medication if less
Preferred brand-name medication – cost of medication up to $30 or a maximum copay of $60
Non-Preferred brand-name medication – cost of medication up to $60 or a maximum copay of $120
Specialty medication covered only when ordered through Accredo health Group
Preferred medication $60 per 30-day supply
Non-Preferred $120 per 30-day supply
Pharmacy out-of-pocket maximum is $2,500 per person using Preferred products at Network pharmacies, then you pay $0
HEALTHCHOICE BASIC PLAN BENEFITS
This is only a sample of the services covered by each plan. For services that are not listed in this comparison chart, contact each plan. Refer to Help Lines for contact information.
HealthChoice members do not need to designate a primary care physician and can change physicians at any time.
For HealthChoice plans, the $30 copay applies to general practitioners, internal medicine physicians, OB/GYNs, pediatricians, physician assistants, and nurse practitioners.
This chart reflects your cost for the listed Network services.
Calendar Year Deductibles
$500 individual and $1,000 family; deductible applies after Plan pays first $500 of Allowed Charges
Calendar Year Out-of-Pocket Maximum
$5,500 individual and $11,000 family
HealthChoice Basic Plan Description
$0 copay for one preventive service office visit per calendar year for members and dependents age 20 and older
One mammogram per year at no charge for women age 40 and over
Copays do not apply
All services, benefits, exceptions, limitations, and conditions are identical to the HealthChoice High Plan
For Network Services, you pay:
$0 the first $500 of Allowed Charges
100% of the next $500 of Allowed Charges (deductible); only Allowed Charges apply to the deductible
50% of the next $10,000 of Allowed Charges
$0 of Allowed Charges over the individual or family out-of-pocket limit
You may use non-Network providers, but it will be more costly
Pharmacy Benefits
NETWORK
RETAIL PHARMACY
Up to a 30-day supply
Generic medication - $10 copay or cost of medication if less
Preferred brand-name medication – cost of medication up to $15 or a maximum copay of $30
Non-Preferred brand-name medication – cost of medication up to $30 or a maximum copay of $60
Maintenance medication – 50% of ingredient cost plus dispensing fee for fourth and all subsequent fills; minimum copay of $10 for generics, $15 for Preferred brand-name, and $30 for non-Preferred brand-name medication
MAIL ORDER AND RETAIL MAINTENANCE PHARMACIES
Up to a 90-day supply
Generic medication - $25 copay or cost of medication if less
Preferred brand-name medication – cost of medication up to $30 or a maximum copay of $60
Non-Preferred brand-name medication – cost of medication up to $60 or a maximum copay of $120
Specialty medication covered only when ordered through Accredo health Group
Preferred medication $60 per 30-day supply
Non-Preferred $120 per 30-day supply
Pharmacy out-of-pocket maximum is $2,500 per person using Preferred products at Network pharmacies, then you pay $0
HEALTHCHOICE BASIC ALTERNATIVE PLAN BENEFITS
This is only a sample of the services covered by each plan. For services that are not listed in this comparison chart, contact each plan. Refer to Help Lines for contact information.
HealthChoice members do not need to designate a primary care physician and can change physicians at any time.
For HealthChoice plans, the $30 copay applies to general practitioners, internal medicine physicians, OB/GYNs, pediatricians, physician assistants, and nurse practitioners.
This chart reflects your cost for the listed Network services.
Calendar Year Deductibles
$750 individual and $1,500 family; deductible applies after Plan pays first $250 of Allowed Charges
Calendar Year Out-of-Pocket Maximum
$5,750 individual and $11,500 family
HealthChoice Basic Alternative Plan Description
$0 copay for one preventive service office visit per calendar year for members and dependents age 20 and older
One mammogram per year at no charge for women age 40 and over
Copays do not apply
All services, benefits, exceptions, limitations, and conditions are identical to the HealthChoice High Plan
For Network Services, you pay:
$0 the first $250 of Allowed Charges
100% of the next $750 of Allowed Charges (deductible); only Allowed Charges apply to the deductible
50% of the next $10,000 of Allowed Charges
$0 of Allowed Charges over the individual or family out-of-pocket limit
You may use non-Network providers, but it will be more costly
Pharmacy Benefits
NETWORK
RETAIL PHARMACY
Up to a 30-day supply
Generic medication - $10 copay or cost of medication if less
Preferred brand-name medication – cost of medication up to $15 or a maximum copay of $30
Non-Preferred brand-name medication – cost of medication up to $30 or a maximum copay of $60
Maintenance medication – 50% of ingredient cost plus dispensing fee for fourth and all subsequent fills; minimum copay of $10 for generics, $15 for Preferred brand-name, and $30 for non-Preferred brand-name medication
MAIL ORDER AND RETAIL MAINTENANCE PHARMACIES
Up to a 90-day supply
Generic medication - $25 copay or cost of medication if less
Preferred brand-name medication – cost of medication up to $30 or a maximum copay of $60
Non-Preferred brand-name medication – cost of medication up to $60 or a maximum copay of $120
Specialty medication covered only when ordered through Accredo health Group
Preferred medication $60 per 30-day supply
Non-Preferred $120 per 30-day supply
Pharmacy out-of-pocket maximum is $2,500 per person using Preferred products at Network pharmacies, then you pay $0
HEALTHCHOICE S-ACCOUNT PLAN BENEFITS
This is only a sample of the services covered by each plan. For services that are not listed in this comparison chart, contact each plan. Refer to Help Lines for contact information.
HealthChoice members do not need to designate a primary care physician and can change physicians at any time.
For HealthChoice plans, the $30 copay applies to general practitioners, internal medicine physicians, OB/GYNs, pediatricians, physician assistants, and nurse practitioners.
This chart reflects your cost for the listed Network services.
Calendar Year Deductibles
$1,500 individual and $3,000 family; the combined medical and pharmacy deductible must be met before benefits are paid
Calendar Year Out-of-Pocket Maximum
$3,000 individual and $6,000 family; non-Network charges do not apply
Office Visit (Professional Services)
You pay 100% of Allowed Charges until deductible is met; $50 copay applies after deductible
Diagnostic X-ray and Lab
20% of Allowed Charges after deductible
Hospital Inpatient Admission
20% of Allowed Charges after deductible; additional $300 deductible per non-Network admission
Hospital Outpatient Visit
20% of Allowed Charges after deductible
Well Child Care Visit
$0 copay; no deductible applies
Immunizations
No charge for well child and adult immunizations; $50 office visit copay and/or administration fee may apply
Periodic Health Exams
$0 copay for one preventive service office visit per calendar year for members and dependents age 20 and older; One mammogram per year at no charge for women age 40 and older
Allergy Treatment and Testing
20% of Allowed Charges after deductible; Limit: 60 tests every 24 months
Emergency Health Care Facility Visit
20% of Allowed Charges after deductible; Additional $100 ER deductible, waived if admitted
After Hours Urgent Care
20% of Allowed Charges after deductible
Mental Health or Substance Abuse Inpatient Admission
20% of Allowed Charges after deductible; no limit on the number of days per year
Mental Health or Substance Abuse Outpatient Visit
20% of Allowed Charges after deductible; no limit on the number of days per year
Durable Medical Equipment (DME)
20% of Allowed Charges after deductible for purchase, rental, repair, or replacement
Occupational or Speech Therapy Visits
20% of Allowed Charges after deductible
Occupational therapy – Limit: 20 visits per year without certification with maximum of 60 visits per year
Speech therapy – Certification not required for age 18 and older, maximum of 60 visits per year
Physical Therapy/Physical Medicine Visit
20% of Allowed Charges after deductible; Limit: 20 visits per year without certification; maximum of 60 visits per year
Chiropractic and Manipulative Therapy Visit
Chiropractic services - 20% of Allowed Charges after deductible; Limit: 20 visits per year without certification; maximum of 60 visits per year
Manipulative therapy - Refer to Physical Therapy/Physical Medicine
Maternity Pre and Post Natal Care
20% of Allowed Charges after deductible; Includes one postpartum home visit – criteria must be met
Hearing Screening and Hearing Aids
$50 copay after deductible/basic hearing screening; Limit: one per year; Hearing aids are covered as durable medical equipment for children up to age 18
Pharmacy Benefits
After combined medical and pharmacy deductible - $1,500 individual or $3,000 family - has been met, the pharmacy benefits are:
NETWORK
RETAIL PHARMACY
Up to a 30-day supply
Generic medication - $10 copay or cost of medication if less
Preferred brand-name medication – cost of medication up to $15 or a maximum copay of $30
Non-Preferred brand-name medication – cost of medication up to $30 or a maximum copay of $60
Maintenance medication – 50% of ingredient cost plus dispensing fee for fourth and all subsequent fills; minimum copay of $10 for generics, $15 for Preferred brand-name, and $30 for non-Preferred brand-name medication
MAIL ORDER AND RETAIL MAINTENANCE PHARMACIES
Up to a 90-day supply
Generic medication - $25 copay or cost of medication if less
Preferred brand-name medication – cost of medication up to $30 or a maximum copay of $60
Non-Preferred brand-name medication – cost of medication up to $60 or a maximum copay of $120
Specialty medication covered only when ordered through Accredo health Group
Preferred medication $60 per 30-day supply
Non-Preferred $120 per 30-day supply
HMO STANDARD OPTION BENEFITS
This is only a sample of the services covered by each plan. For services that are not listed in this comparison chart, contact each plan. Refer to Help Lines for contact information.
This chart reflects your cost for the listed Network services.
Calendar Year Deductibles
No deductible
Calendar Year Out-of-Pocket Maximum
$2,500 individual and $5,000 family
Office Visit (Professional Services)
$30 copay/PCP and $40 copay/specialist
Diagnostic X-ray and Lab
No copay for laboratory services or outpatient radiology; $150 copay per MRI, CAT, MRA, or PET scan
Hospital Inpatient Admission
$350 copay; preauthorization required
Hospital Outpatient Visit
$250 copay; preauthorization required
Well Child Care Visit
$0 copay
Immunizations
$0 copay ages birth through age 18; $0 copay ages 19 and over
Periodic Health Exams
$0 copay per visit for routine physicals
Allergy Treatment and Testing
$30 copay/PCP; $40 copay/specialist; $30 serum and shots including a 6-week supply of antigen
Emergency Health Care Facility Visit
$150 copay; waived if admitted
After Hours Urgent Care
$40 copay per visit
Mental Health or Substance Abuse Inpatient Admission
$350 copay
Mental Health or Substance Abuse Outpatient Visit
$30 copay/PCP; $40 copay/specialist
Durable Medical Equipment (DME)
20% coinsurance initial device; 20% coinsurance repair and replacement
Occupational or Speech Therapy Visits
No copay inpatient; $30 copay/PCP; $40 copay/specialist; Limit: 60 treatment days per illness
Physical Therapy/Physical Medicine Visit
No copay inpatient; $30 copay/PCP; $40 copay/specialist; Limit: 60 treatment days per illness
Chiropractic and Manipulative Therapy Visit
$40 copay; Limit: 15 visits per year; PCP referral required
Maternity Pre and Post Natal Care
$30 copay for initial visit; $350 copay per hospital admission
Hearing Screening and Hearing Aids
$0 copay children birth through age 21; $30 copay age 22 and over; Limit: one per year; Hearing aids – 20% coinsurance for children up to age 18
Pharmacy Benefits
Up to $5 generic formulary
Up to $30 brand formulary (when no generic is available)
Up to $60 brand formulary (when generic is available)
30-day supply
Certain medications have restricted quantities
Mail order may be available, contact plans for details
Please note: Tier categories will be determined by each HMO based on its formulary design
COMMUNITYCARE ALTERNATIVE AND WELLNESS ALTERNATIVE PLUS HMO BENEFITS
This is only a sample of the services covered by each plan. For services that are not listed in this comparison chart, contact each plan. Refer to Help Lines for contact information.
This chart reflects your cost for the listed Network services.
Calendar Year Deductibles
CommunityCare Alternative HMO
No deductible
CommunityCare Wellness Alternative Plus HMO
No deductible; To be eligible for this Plan, you must complete a Health Risk Assessment
Calendar Year Out-of-Pocket Maximum
$3,000 individual and $6,000 family
Office Visit (Professional Services)
$35 copay/PCP and $50 copay/specialist
Diagnostic X-ray and Lab
No additional copay for laboratory services or outpatient radiology; $200 copay per MRI, CAT, MRA, or PET scan
Hospital Inpatient Admission
$500 copay; preauthorization required
Hospital Outpatient Visit
$300 copay
Well Child Care Visit
$0 copay
Immunizations
$0 copay ages birth through age 18 years; $0 copay ages 19 and over; when medically necessary
Periodic Health Exams
$0 copay
Allergy Treatment and Testing
$35 copay/PCP; $50 copay/specialist; $30 serum and shots including a 6-week supply of antigen
Emergency Health Care Facility Visit
$200 copay; waived if admitted
After Hours Urgent Care
$50 copay per visit; preauthorization required
Mental Health or Substance Abuse Inpatient Admission
$500 copay; must be preauthorized and approved through CCOK Behavioral Health Services
Mental Health or Substance Abuse Outpatient Visit
$35 copay/PCP; $50 copay/specialist; must be preauthorized and approved through CCOK Behavioral Health Services
Durable Medical Equipment (DME)
20% coinsurance initial device; 20% coinsurance repair and replacement
Occupational or Speech Therapy Visits
No copay inpatient; $50 copay outpatient therapy; Limit: 60 days per illness
Physical Therapy/Physical Medicine Visit
No copay inpatient; $50 copay outpatient therapy; Limit: 60 days per illness
Chiropractic and Manipulative Therapy Visit
$50 copay; Limit: 15 visits per year; PCP referral required
Maternity Pre and Post Natal Care
$35 copay for initial visit; $500 copay per hospital admission
Hearing Screening and Hearing Aids
$0 copay; Limit: one per year; Hearing aids – 20% coinsurance for children up to age 18
Pharmacy Benefits
Tier 1: $10
Tier 2: $40
Tier 3: $65
$0 copay for selected generics
Up to $65 non-formulary (non-Preferred)
These copays do not apply to the maximum out-of-pocket
30-day supply
Certain medications have restricted quantities
Convenient mail-order is available; contact Plan for details
GLOBALHEALTH ALTERNATIVE AND WELLNESS ALTERNATIVE PLUS HMO BENEFITS
This is only a sample of the services covered by each plan. For services that are not listed in this comparison chart, contact each plan. Refer to Help Lines for contact information.
This chart reflects your cost for the listed Network services.
Calendar Year Deductibles
GlobalHealth Alternative HMO
No deductible
GlobalHealth Wellness Alternative Plus HMO
No deductible; To be eligible for this Plan, you must complete a Health Risk Assessment
Calendar Year Out-of-Pocket Maximum
$3,000 individual and $5,000 family
Office Visit (Professional Services)
$25 copay/PCP and $50 copay/specialist
Diagnostic X-ray and Lab
$0 copay; $250 copay per MRI, MRA, PET, CAT, or nuclear scan
Hospital Inpatient Admission
$250 copay per day; $750 maximum per admission; preauthorization required
Hospital Outpatient Visit
$250 copay; preauthorization required
Well Child Care Visit
$0 copay ages 0-21
Immunizations
$0 copay; office visit copay may apply
Periodic Health Exams
$0 copay/PCP; Limit: one per year
Allergy Treatment and Testing
$25 copay/PCP; $50 copay/specialist; $30 serum and shots including a 6-week supply of antigen
Emergency Health Care Facility Visit
$150 copay; waived if admitted
After Hours Urgent Care
$25 copay/PCP; $50 copay/all others; must use Network facilities
Mental Health or Substance Abuse Inpatient Admission
$250 per day; $750 maximum per admission; must be preauthorized
Mental Health or Substance Abuse Outpatient Visit
$25 copay; must be preauthorized
Durable Medical Equipment (DME)
20% coinsurance
Occupational or Speech Therapy Visits
No copay inpatient; $50 copay per outpatient therapy; Limit: 60 consecutive days per illness
Physical Therapy/Physical Medicine Visit
No copay inpatient; $50 copay per outpatient visit; Limit: 60 consecutive days per illness
Chiropractic and Manipulative Therapy Visit
$50 copay; must be preauthorized
Maternity Pre and Post Natal Care
$25 copay for initial visit only; $250 copay per hospital admission per day; $750 maximum per admission
Hearing Screening and Hearing Aids
$0 copay children birth through age 21; $25 copay age 22 and over; Limit: one per year; Hearing aids – 20% coinsurance for children up to age 18
Pharmacy Benefits
Tier 1: $10
Tier 2: $50
Tier 3: $75
$4 copay for selected generics
30-day supply
Certain medications may have restricted quantities
These copays do not apply to the maximum out-of-pocket
UNITEDHEALTHCARE ALTERNATIVE AND WELLNESS ALTERNATIVE PLUS HMO BENEFITS
This is only a sample of the services covered by each plan. For services that are not listed in this comparison chart, contact each plan. Refer to Help Lines for contact information.
This chart reflects your cost for the listed Network services.
Calendar Year Deductibles
UnitedHealthcare Alternative HMO
No deductible
UnitedHealthcare Wellness Alternative Plus HMO
No deductible; To be eligible for this Plan, you must complete a Health Risk Assessment
Calendar Year Out-of-Pocket Maximum
$2,500 individual and $5,000 family
Office Visit (Professional Services)
$35 copay/PCP and $50 copay/specialist
Diagnostic X-ray and Lab
$0 copay for standard lab and radiology; $200 copay per MRI, MRA, PET, or CAT scan
Hospital Inpatient Admission
$1,000 copay/admission
Hospital Outpatient Visit
$500 copay
Well Child Care Visit
$0 copay
Immunizations
$0 copay; In accordance with the US Preventive Services Task Force and other health organizations required guidelines
Periodic Health Exams
$0 copay; In accordance with the US Preventive Services Task Force and other health organizations required guidelines
Allergy Treatment and Testing
$35 copay/PCP; $50 copay/specialist; $35 serum and shots including a 6-week supply of antigen
Emergency Health Care Facility Visit
$200 copay; waived if admitted
After Hours Urgent Care
$50 copay per visit
Mental Health or Substance Abuse Inpatient Admission
$1,000 copay per admission
Mental Health or Substance Abuse Outpatient Visit
$35 copay/PCP and specialist
Durable Medical Equipment (DME)
20% coinsurance; $10,000 maximum benefit per calendar year
Occupational or Speech Therapy Visits
$0 copay inpatient; $35 copay/PCP; $50 copay/specialist; Limit: 60 days per illness
Physical Therapy/Physical Medicine Visit
$0 copay inpatient; $35 copay/PCP; $50 copay/specialist; Limit: 60 days per medical episode
Chiropractic and Manipulative Therapy Visit
$50 copay; Limit: 15 visits per year – referral required; Limited to treatment of neurological and orthopedic conditions
Maternity Pre and Post Natal Care
$35 copay/PCP; $50 copay/specialist for initial visit once diagnosis of pregnancy is confirmed; $1,000 copay per hospital admission
Hearing Screening and Hearing Aids
$0 copay/PCP ages 0 through 17; 20% coinsurance ages 18 and over; Limited to a single hearing aid every 3 years – maximum benefit of $5,000 per calendar year
Pharmacy Benefits
$5 copay for formulary generic drugs
$30 copay for formulary brand-name drugs
$60 copay for non-formulary generic and non-formulary brand drugs
Lesser of 30-day supply or 100 units
Certain medications have restricted quantities
COMPARISON OF BENEFITS FOR DENTAL PLANS – ALL PLANS
For services that are not listed in this comparison chart, contact your plan. Refer to Help Lines for contact information.
Annual Deductible
HealthChoice Dental
Network: $25 Basic and Major services combined
Non-Network: $25 Preventive, Basic, and Major services combined
Assurant Freedom Preferred
$25 per person, per calendar year; waived for preventive services in-network
Assurant Heritage Plus with SBA Prepaid
No deductibles
Assurant Heritage Secure Prepaid
No deductibles
CIGNA Dental Care Plan Prepaid
No deductible or plan maximum; $5 office copay applies
Delta Dental PPO
In-Network and Out-of-Network
$25 per person, per year applies to Basic and Major Care only
Delta Dental Premier
In-Network and Out-of-Network
$50 per person, per year applies to diagnostic, Preventive, Basic, and Major Care
Delta Dental PPO - Choice
PPO Network
$100 per person, per year applies to Major Care (Level 4) only
Preventive Care
Examples – cleaning, routine oral exam; Allowed Charges apply
HealthChoice Dental
Network: $0
Non-Network: $0 of Allowed Charges after deductible
Assurant Freedom Preferred
$0 with no deductible when in-network
Assurant Heritage Plus with SBA Prepaid
No charge for routine cleaning (once every 6 months); No charge for topical fluoride application (up to age 18); No charge for periodic oral evaluations
Assurant Heritage Secure Prepaid
No charge for routine cleaning (once every 6 months); No charge for topical fluoride application (up to age 18); No charge for periodic oral evaluations
CIGNA Dental Care Plan Prepaid
Sealant - $15 per tooth; No charge for routine cleaning once every 6 months; No charge for topical fluoride application (through age 18); No charge for periodic oral evaluations
Delta Dental PPO
In-Network and Out-of-Network
$0 of allowable amounts; No deductible applies; Includes diagnostic
Delta Dental Premier
In-Network and Out-of-Network
$0 of allowable amounts after deductible; Includes diagnostic
Delta Dental PPO - Choice
PPO Network
Schedule of covered services and copays; Copay examples – Routine cleaning $5, Periodic oral evaluation $5, Topical fluoride application (up to age 19) $5; Includes diagnostic
Basic Care
Examples – extractions, oral surgery; Allowed Charges apply
HealthChoice Dental
Network: 15%
Non-Network: 30%
Deductible applies
Assurant Freedom Preferred
Network: 15%
Non-Network: 30%
Plan pays 85% of usual and customary when in-network, Deductible applies
Assurant Heritage Plus with SBA Prepaid
Fillings; Minor oral surgery; Refer to the copay schedule for each plan
Assurant Heritage Secure Prepaid
Fillings; Minor oral surgery; Refer to the copay schedule for each plan
CIGNA Dental Care Plan Prepaid
Amalgam: One surface, permanent teeth $21
Delta Dental PPO
In-Network and Out-of-Network
15% of allowable amounts after deductible
Delta Dental Premier
In-Network and Out-of-Network
30% of allowable amounts after deductible
Delta Dental PPO - Choice
PPO Network
Schedule of covered services and copays; Copay example – Amalgam - one surface, primary or permanent tooth $12
Major Care
Examples – dentures, bridge work; Allowed Charges apply
HealthChoice Dental
Network: 40%
Non-Network: 50%
Deductible applies
Assurant Freedom Preferred
Network: 40%
Non-Network: 50%
Plan pays 60% of usual and customary when in-network, Deductible applies
Assurant Heritage Plus with SBA Prepaid
Root canal; Periodontal; Crowns; Refer to the copay schedule for each plan
Assurant Heritage Secure Prepaid
Root canal; Periodontal; Crowns; Refer to the copay schedule for each plan
CIGNA Dental Care Plan Prepaid
Root canal, anterior: $355; Periodontal/scaling/root planning 1-3 teeth (per quadrant): $71
Delta Dental PPO
In-Network and Out-of-Network
40% of allowable amounts after deductible
Delta Dental Premier
In-Network and Out-of-Network
50% of allowable amounts after deductible
Delta Dental PPO - Choice
PPO Network
Schedule of covered services and copays; Copay examples – Crown – porcelain/ceramic substrate $241; Complete denture – maxillary $320
Orthodontic Care
Allowed Charges apply
HealthChoice Dental
Network: 50%
Non-Network: 50%
12-month waiting period may apply; No lifetime orthodontic maximum for Network or non-Network; Covered for members under age 19 and members age 19 and older with TMD
Assurant Freedom Preferred
Network: 40%
Non-Network: 50%
Up to $2,000 lifetime maximum for members under age 19; 12-month waiting period may apply
Assurant Heritage Plus with SBA Prepaid
25% discount; Adults and children
Assurant Heritage Secure Prepaid
25% discount, Adults and children
CIGNA Dental Care Plan Prepaid
$2,280 out-of-pocket for children through age 18; $3,120 out-of-pocket for adults; 24-month treatment excludes orthodontic treatment plan and banding
Delta Dental PPO
In-Network and Out-of-Network
40% of allowable amounts, up to lifetime maximum of $2,000; No deductible; No waiting period; Orthodontic benefits are available to the member and their lawful spouse and eligible dependent children
Delta Dental Premier
In-Network and Out-of-Network
40% of allowable amounts, up to lifetime maximum of $2,000; No deductible; No waiting period; Orthodontic benefits are available to the member and their lawful spouse and eligible dependent children
Delta Dental PPO - Choice
PPO Network
You pay amounts in excess of $50 per month; Lifetime maximum up to $1,800; No deductible; No waiting period; Orthodontic benefits are available to the member and their lawful spouse and eligible dependent children
Plan Year Maximum
HealthChoice Dental
Network: $2,000 per person, per year
Non-Network: $2,000 per person, per year
Assurant Freedom Preferred
$2,000
Assurant Heritage Plus with SBA Prepaid
No annual maximum for general dentist
Assurant Heritage Secure Prepaid
No annual maximum for general dentist
CIGNA Dental Care Plan Prepaid
No maximum
Delta Dental PPO
In-Network and Out-of-Network
$2,500 per person, per year
Delta Dental Premier
In-Network and Out-of-Network
$3,000 per person, per year
Delta Dental PPO - Choice
PPO Network
$2,000 per person, per year
Filing Claims
HealthChoice Dental
Network: No claims to file
Non-Network: You file claims
Assurant Freedom Preferred
Member/Provider must file claims
Assurant Heritage Plus with SBA Prepaid
No claims to file
Assurant Heritage Secure Prepaid
No claims to file
CIGNA Dental Care Plan Prepaid
No claims to file
Delta Dental PPO
In-Network and Out-of-Network
Claims are filed by participating dentists
Delta Dental Premier
In-Network and Out-of-Network
Claims are filed by participating dentists
Delta Dental PPO - Choice
PPO Network
Claims are filed by participating dentists
HEALTHCHOICE DENTAL
For services that are not listed, contact HealthChoice. Refer to Help Lines for contact information.
Annual Deductible
Network: $25 Basic and Major services combined
Non-Network: $25 Preventive, Basic, and Major services combined
Preventive Care
Examples – cleaning, routine oral exam; Allowed Charges apply
Network: $0
Non-Network: $0 of Allowed Charges after deductible
Basic Care
Examples – extractions, oral surgery; Allowed Charges apply
Network: 15%
Non-Network: 30%
Deductible applies
Major Care
Examples – dentures, bridge work; Allowed Charges apply
Network: 40%
Non-Network: 50%
Deductible applies
Orthodontic Care
Allowed Charges apply
Network: 50%
Non-Network: 50%
12-month waiting period may apply; No lifetime orthodontic maximum for Network or non-Network; Covered for members under age 19 and members age 19 and older with TMD
Plan Year Maximum
Network: $2,000 per person, per year
Non-Network: $2,000 per person, per year
Filing Claims
Network: No claims to file
Non-Network: You file claims
ASSURANT FREEDOM PREFERRED
For services that are not listed, contact Assurant. Refer to Help Lines for contact information.
Annual Deductible
$25 per person, per calendar year; waived for preventive services in-network
Preventive Care
Examples – cleaning, routine oral exam; Allowed Charges apply
$0 with no deductible when in-network
Basic Care
Examples – extractions, oral surgery; Allowed Charges apply
Network: 15%
Non-Network: 30%
Plan pays 85% of usual and customary when in-network, Deductible applies
Major Care
Examples – dentures, bridge work; Allowed Charges apply
Network: 40%
Non-Network: 50%
Plan pays 60% of usual and customary when in-network, Deductible applies
Orthodontic Care
Allowed Charges apply
Network: 40%
Non-Network: 50%
Up to $2,000 lifetime maximum for members under age 19; 12-month waiting period may apply
Plan Year Maximum
$2,000
Filing Claims
Member/Provider must file claims
ASSURANT HERITAGE PLUS WITH SBA PREPAID
For services that are not listed, contact Assurant. Refer to Help Lines for contact information.
Annual Deductible
No deductibles
Preventive Care
Examples – cleaning, routine oral exam; Allowed Charges apply
No charge for routine cleaning (once every 6 months); No charge for topical fluoride application (up to age 18); No charge for periodic oral evaluations
Basic Care
Examples – extractions, oral surgery; Allowed Charges apply
Fillings; Minor oral surgery; Refer to the copay schedule for each plan
Major Care
Examples – dentures, bridge work; Allowed Charges apply
Root canal; Periodontal; Crowns; Refer to the copay schedule for each plan
Orthodontic Care
Allowed Charges apply
25% discount; Adults and children
Plan Year Maximum
No annual maximum for general dentist
Filing Claims
No claims to file
ASSURANT HERITAGE SECURE PREPAID
For services that are not listed, contact Assurant. Refer to Help Lines for contact information.
Annual Deductible
No deductibles
Preventive Care
Examples – cleaning, routine oral exam; Allowed Charges apply
No charge for routine cleaning (once every 6 months); No charge for topical fluoride application (up to age 18); No charge for periodic oral evaluations
Basic Care
Examples – extractions, oral surgery; Allowed Charges apply
Fillings; Minor oral surgery; Refer to the copay schedule for each plan
Major Care
Examples – dentures, bridge work; Allowed Charges apply
Root canal; Periodontal; Crowns; Refer to the copay schedule for each plan
Orthodontic Care
Allowed Charges apply
25% discount, Adults and children
Plan Year Maximum
No annual maximum for general dentist
Filing Claims
No claims to file
CIGNA DENTAL CARE PLAN PREPAID
For services that are not listed, contact CIGNA. Refer to Help Lines for contact information.
Annual Deductible
No deductible or plan maximum; $5 office copay applies
Preventive Care
Examples – cleaning, routine oral exam; Allowed Charges apply
Sealant - $15 per tooth; No charge for routine cleaning once every 6 months; No charge for topical fluoride application (through age 18); No charge for periodic oral evaluations
Basic Care
Examples – extractions, oral surgery; Allowed Charges apply
Amalgam: One surface permanent teeth $21
Major Care
Examples – dentures, bridge work; Allowed Charges apply
Root canal, anterior: $355; Periodontal/scaling/root planning 1-3 teeth (per quadrant): $71
Orthodontic Care
Allowed Charges apply
$2,280 out-of-pocket for children through age 18; $3,120 out-of-pocket for adults; 24-month treatment excludes orthodontic treatment plan and banding
Plan Year Maximum
No maximum
Filing Claims
No claims to file
DELTA DENTAL PPO
For services that are not listed, contact Delta. Refer to Help Lines for contact information.
Annual Deductible
In-Network and Out-of-Network
$25 per person, per year applies to Basic and Major Care only
Preventive Care
Examples – cleaning, routine oral exam; Allowed Charges apply
In-Network and Out-of-Network
$0 of allowable amounts; No deductible applies; Includes diagnostic
Basic Care
Examples – extractions, oral surgery; Allowed Charges apply
In-Network and Out-of-Network
15% of allowable amounts after deductible
Major Care
Examples – dentures, bridge work; Allowed Charges apply
In-Network and Out-of-Network
40% of allowable amounts after deductible
Orthodontic Care
Allowed Charges apply
In-Network and Out-of-Network
40% of allowable amounts, up to lifetime maximum of $2,000; No deductible; No waiting period; Orthodontic benefits are available to the member and their lawful spouse and eligible dependent children
Plan Year Maximum
In-Network and Out-of-Network
$2,500 per person, per year
Filing Claims
In-Network and Out-of-Network
Claims are filed by participating dentists
DELTA DENTAL PREMIER
For services that are not listed, contact Delta. Refer to Help Lines for contact information.
Annual Deductible
In-Network and Out-of-Network
$50 per person, per year applies to diagnostic, Preventive, Basic, and Major Care
Preventive Care
Examples – cleaning, routine oral exam; Allowed Charges apply
In-Network and Out-of-Network
$0 of allowable amounts after deductible; Includes diagnostic
Basic Care
Examples – extractions, oral surgery; Allowed Charges apply
In-Network and Out-of-Network
30% of allowable amounts after deductible
Major Care
Examples – dentures, bridge work; Allowed Charges apply
In-Network and Out-of-Network
50% of allowable amounts after deductible
Orthodontic Care
Allowed Charges apply
In-Network and Out-of-Network
40% of allowable amounts, up to lifetime maximum of $2,000; No deductible; No waiting period; Orthodontic benefits are available to the member and their lawful spouse and eligible dependent children
Plan Year Maximum
In-Network and Out-of-Network
$3,000 per person, per year
Filing Claims
In-Network and Out-of-Network
Claims are filed by participating dentists
DELTA DENTAL PPO - CHOICE
For services that are not listed, contact Delta. Refer to Help Lines for contact information.
Annual Deductible
PPO Network
$100 per person, per year applies to Major Care (Level 4) only
Preventive Care
Examples – cleaning, routine oral exam; Allowed Charges apply
PPO Network
Schedule of covered services and copays; Copay examples – Routine cleaning $5, Periodic oral evaluation $5, Topical fluoride application (up to age 19) $5; Includes diagnostic
Basic Care
Examples – extractions, oral surgery; Allowed Charges apply
PPO Network
Schedule of covered services and copays; Copay example – Amalgam - one surface, primary or permanent tooth $12
Major Care
Examples – dentures, bridge work; Allowed Charges apply
PPO Network
Schedule of covered services and copays; Copay examples – Crown – porcelain/ceramic substrate $241; Complete denture – maxillary $320
Orthodontic Care
Allowed Charges apply
PPO Network
You pay amounts in excess of $50 per month; Lifetime maximum up to $1,800; No deductible; No waiting period; Orthodontic benefits are available to the member and their lawful spouse and eligible dependent children
Plan Year Maximum
PPO Network
$2,000 per person, per year
Filing Claims
PPO Network
Claims are filed by participating dentists
COMPARISON OF BENEFITS FOR VISION PLANS – ALL PLANS
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 Help Lines for contact information.
Eye Exams
Humana/CompBenefits VisionCare Plan
In-Network: $10 copay; One exam for eyeglasses or contacts per year
Out-of-Network: Copays do not apply; Plan pays up to $35; One exam per year
Primary Vision Care Services, Inc.
In-Network: $0 copay; No limit on exams per year
Out-of-Network: Plan pays up to $40; One exam per year
Superior Vision Plan
In-Network: $10 copay; One exam per year
Out-of-Network: OD - $26 max; MD - $34 max
UnitedHealthcare Vision
In-Network: $10 copay; One exam per year
Out-of-Network: Plan pays up to $40
Vision Service Plan (VSP)
In-Network: $10 copay; One exam per year
Out-of-Network: $10 copay; Plan pays up to $35
Lenses Each Pair
Humana/CompBenefits VisionCare Plan
In-Network: $25 material copay applies to lenses and/or frames (single, lined bifocal, trifocal, lenticular are covered at 100%); A discount applies to progressive lenses; One pair of lenses per year
Out-of-Network: Plan pays up to $25 single, $40 bifocals, $60 trifocals, $100 lenticular; One pair of lenses per year
Primary Vision Care Services
In-Network: You pay wholesale cost with no limit on number of pairs
Out-of-Network: You pay normal doctor’s fee, reimbursed up to $60 for one set of lenses and frames per year
Superior Vision Plan
In-Network: $25 copay; One pair of lenses per year
Out-of-Network: Plan pays up to $26 single, $39 bifocals, $49 trifocals, $78 lenticular
UnitedHealthcare Vision
In-Network: $25 copay; One pair of lenses per year; Lens options covered in full include UV coating and tints
Out-of-Network: Plan pays up to $40 single, $60 bifocals, $80 trifocals, $80 lenticular
Vision Service Plan (VSP)
In-Network: $25 annual material copay; One set of lenses per year; Polycarbonate lenses covered in full for dependent children; Average 35-40% savings on all non-covered lens options
Out-of-Network: $25 annual material copay; Plan pays up to $25 single, $40 bifocals, $55 trifocals, $80 lenticular
Frames
Humana/CompBenefits VisionCare Plan
In-Network: $25 material copay applies to lenses and/or frames; $45 wholesale frame allowance; One pair of frames per year
Out-of-Network: $25 copay; Plan pays up to $45; One pair of frames per year
Primary Vision Care Services
In-Network: You pay wholesale cost; no limit on number of frames
Out-of-Network: You pay normal doctor’s fee, reimbursed up to $60 for one set of lenses and frames per year
Superior Vision Plan
In-Network: $25 copay; Plan pays up to $125; One pair of frames per year
Out-of-Network: Plan pays up to $68
UnitedHealthcare Vision
In-Network: $25 copay; $130 allowance; One set of frames per year
Out-of-Network: Plan pays up to $45
Vision Service Plan (VSP)
In-Network: $25 annual material copay; $120 allowance; 20% off any out-of-pocket costs above the allowance; One pair of frames per year
Out-of-Network: $25 annual material copay; Plan pays up to $45
Contact Lenses
Humana/CompBenefits VisionCare Plan
In-Network: $130 allowance for conventional or disposable contact lenses and fitting fee; In lieu of all other benefits; Medically necessary, plan pays 100%; One set of contacts per year
Out-of-Network: $130 allowance for exam, contacts, and fitting fee; In lieu of all other benefits; Medically necessary, plan pays $210; One set of contacts per year
Primary Vision Care Services
In-Network: You pay wholesale cost for an annual supply of contacts; $50 service fee applies to all soft contact lens fittings; $75 to rigid or gas permeable lens fittings; $150 to hybrid contact lens fittings; Replacement lenses do not have these fees
Out-of-Network: Limit of one set annually in lieu of glasses; You pay normal doctor fees, reimbursed up to $60
Superior Vision Plan
In-Network: $25 standard fitting copay, after copay, plan pays 100%; $25 specialty fitting copay, after copay, plan pays up to $50; Plan pays up to $120 for elective contacts; Medically necessary contacts are covered in full (in lieu of glasses)
Out-of-Network: Fitting fee is not a covered benefit; $0 copay; Plan pays up to $100; Medically necessary contacts, plan pays up to $210 (in lieu of glasses)
UnitedHealthcare Vision
In-Network: $25 copay covers fitting/evaluation fees, contacts (including disposables), and up to two follow-up visits (in lieu of glasses)
Out-of-Network: Plan pays up to $150; For medically necessary contacts, plan pays up to $210 (in lieu of glasses)
Vision Service Plan (VSP)
In-Network: $0 copay; $120 allowance applied to the cost of your contact lens exam and the contact lenses; 15% discount on contact lens exam (in lieu of glasses); contact lens exam covered in full after a copay of up to $60
Out-of-Network: $0 copay; Plan pays up to $105 for disposable or conventional contact lenses (in lieu of glasses)
Laser Vision Correction
Humana/CompBenefits VisionCare Plan
In-Network: $895 copay conventional; $1,295 copay custom; $1,895 copay custom plus bladeless when services are rendered by a TLC Network Provider
Out-of-Network: No benefit
Primary Vision Care Services
In-Network: Discount nationwide at The Laser Center (TLC)
Out-of-Network: No benefit
Superior Vision Plan
In-Network: 20% to 50% savings on LASIK surgery
Out-of-Network: No benefit
UnitedHealthcare Vision
In-Network: Members have access to discounted refractive eye surgery from numerous provider locations throughout the U.S.
Out-of-Network: No benefit
Vision Service Plan (VSP)
In-Network: Laser vision correction services (PRK, LASIK, and Custom LASIK) are provided at a reduced cost through VSP’s contracted laser surgery centers
Out-of-Network: No benefit
HUMANA/COMPBENEFITS VISIONCARE PLAN
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 Help Lines at the end of this document for contact information.
Eye Exams
In-Network: $10 copay; One exam for eyeglasses or contacts per year
Out-of-Network: Copays do not apply; Plan pays up to $35; One exam per year
Lenses Each Pair
In-Network: $25 material copay applies to lenses and/or frames (single, lined bifocal, trifocal, lenticular are covered at 100%); A discount applies to progressive lenses; One pair of lenses per year
Out-of-Network: Plan pays up to $25 single, $40 bifocals, $60 trifocals, $100 lenticular; One pair of lenses per year
Frames
In-Network: $25 material copay applies to lenses and/or frames; $45 wholesale frame allowance; One pair of frames per year
Out-of-Network: $25 copay; Plan pays up to $45; One pair of frames per year
Contact Lenses
In-Network: $130 allowance for conventional or disposable contact lenses and fitting fee; In lieu of all other benefits; Medically necessary, plan pays 100%; One set of contacts per year
Out-of-Network: $130 allowance for exam, contacts, and fitting fee; In lieu of all other benefits; Medically necessary, plan pays $210; One set of contacts per year
Laser Vision Correction
In-Network: $895 copay conventional; $1,295 copay custom; $1,895 copay custom plus bladeless when services are rendered by a TLC Network Provider
Out-of-Network: No benefit
PRIMARY VISION CARE SERVICES, INC.
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 Help Lines at the end of this document for contact information.
Eye Exams
In-Network: $0 copay; No limit on exams per year
Out-of-Network: Plan pays up to $40; One exam per year
Lenses Each Pair
In-Network: You pay wholesale cost with no limit on number of pairs
Out-of-Network: You pay normal doctor’s fee, reimbursed up to $60 for one set of lenses and frames per year
Frames
In-Network: You pay wholesale cost; no limit on number of frames
Out-of-Network: You pay normal doctor’s fee, reimbursed up to $60 for one set of lenses and frames per year
Contact Lenses
In-Network: You pay wholesale cost for an annual supply of contacts; $50 service fee applies to all soft contact lens fittings; $75 to rigid or gas permeable lens fittings; $150 to hybrid contact lens fittings; Replacement lenses do not have these fees
Out-of-Network: Limit of one set annually in lieu of glasses; You pay normal doctor fees, reimbursed up to $60
Laser Vision Correction
In-Network: Discount nationwide at The Laser Center (TLC)
Out-of-Network: No benefit
SUPERIOR VISION PLAN
Vision benefits apply from January 1 through December 31, 2011.
For services that are not listed in this comparison chart, contact your plan. Refer to Help Lines at the end of this document for contact information.
Eye Exams
In-Network: $10 copay; One exam per year
Out-of-Network: OD - $26 max; MD - $34 max
Lenses Each Pair
In-Network: $25 copay; One pair of lenses per year
Out-of-Network: Plan pays up to $26 single, $39 bifocals, $49 trifocals, $78 lenticular
Frames
In-Network: $25 copay; Plan pays up to $125; One pair of frames per year
Out-of-Network: Plan pays up to $68
Contact Lenses
In-Network: $25 standard fitting copay, after copay, plan pays 100%; $25 specialty fitting copay, after copay, plan pays up to $50; Plan pays up to $120 for elective contacts; Medically necessary contacts are covered in full (in lieu of glasses)
Out-of-Network: Fitting fee is not a covered benefit; $0 copay; Plan pays up to $100; Medically necessary contacts, plan pays up to $210 (in lieu of glasses)
Laser Vision Correction
In-Network: 20% - 50% savings on LASIK surgery
Out-of-Network: No benefit
UNITEDHEALTHCARE VISION
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 Help Lines at the end of this document for contact information.
Eye Exams
In-Network: $10 copay; One exam per year
Out-of-Network: Plan pays up to $40
Lenses Each Pair
In-Network: $25 copay; One pair of lenses per year; Lens options covered in full include UV coating and tints
Out-of-Network: Plan pays up to $40 single, $60 bifocals, $80 trifocals, $80 lenticular
Frames
In-Network: $25 copay; $130 allowance; One set of frames per year
Out-of-Network: Plan pays up to $45
Contact Lenses
In-Network: $25 copay covers fitting/evaluation fees, contacts (including disposables), and up to two follow-up visits (in lieu of glasses)
Out-of-Network: Plan pays up to $150; For medically necessary contacts, plan pays up to $210 (in lieu of glasses)
Laser Vision Correction
In-Network: Members have access to discounted refractive eye surgery from numerous provider locations throughout the U.S.
Out-of-Network: No benefit
VISION SERVICE PLAN (VSP)
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 Help Lines at the end of this document for contact information.
Eye Exams
In-Network: $10 copay; One exam per year
Out-of-Network: $10 copay; Plan pays up to $35
Lenses Each Pair
In-Network: $25 annual material copay; One set of lenses per year; Polycarbonate lenses covered in full for dependent children; Average 35-40% savings on all non-covered lens options
Out-of-Network: $25 annual material copay; Plan pays up to $25 single, $40 bifocals, $55 trifocals, $80 lenticular
Frames
In-Network: $25 annual material copay; $120 allowance; 20% off any out-of-pocket costs above the allowance; One pair of frames per year
Out-of-Network: $25 annual material copay; Plan pays up to $45
Contact Lenses
In-Network: $0 copay; $120 allowance applied to the cost of your contact lens exam and the contact lenses; 15% discount on contact lens exam (in lieu of glasses); Contact lens exam covered in full after a copay of up to $60
Out-of-Network: $0 copay; Plan pays up to $105 for disposable or conventional contact lenses (in lieu of glasses)
Laser Vision Correction
In-Network: Laser vision correction services (PRK, LASIK, and Custom LASIK) are provided at a reduced cost through VSP’s contracted laser surgery centers
Out-of-Network: No benefit
HELP LINES
HealthChoice (OSEEGIB) Help Lines
Health, Dental, and Life Claims, Benefits, Verification of Coverage, and ID Cards
Oklahoma City Area 1-405-416-1800
All Other Areas 1-800-782-5218
TDD Oklahoma City Area 1-405-416-1525
TDD All Other Areas 1-800-941-2160
Website www.sib.ok.gov or www.healthchoiceok.com
Pharmacy Claims/Pharmacy ID Cards
All Areas 1-800-903-8113
TDD All Areas 1-800-825-1230
Member Services/Provider Directory
Oklahoma City Area 1-405-717-8780
All Other Areas 1-800-752-9475
TDD Oklahoma City Area 1-405-949-2281
TDD All Other Areas 1-866-447-0436
HealthChoice USA
Customer Service and Claims 1-800-782-5218
Provider Information 1-877-877-0715 ext. 4059
TDD All Areas 1-800-941-2160
Website www.choicecarenetwork.com
American Fidelity Health Services Administration
Health Savings Account
Oklahoma City Area 1-405-523-5699
All Areas 1-866-326-3600
Fax 1-405-523-5072
HMO Plans’ Help Lines
CommunityCare
All Areas 1-800-777-4890
TDD All Areas 1-800-722-0353
Website www.ccok.com
GlobalHealth, Inc.
Oklahoma City Area 1-405-280-5600
All Other Areas 1-877-280-5600
TDD All Areas 1-800-522-8506
Website www.globalhealth.com
UnitedHealthcare
All Areas 1-800-825-9355
TDD All Areas 1-800-557-7595
Website www.UHCwest.com
Dental Plans’ Help Lines
Assurant, Inc. Dental
Prepaid Plan 1-800-443-2995
Indemnity Plan 1-800-442-7742
Website www.assurantemployeebenefits.com
CIGNA Prepaid Dental
All Areas 1-800-244-6224
Toll-free Hearing Impaired Relay Service 1-800-654-5988
Website www.cigna.com
Delta Dental
Oklahoma City Area 1-405-607-2100
All Other Areas 1-800-522-0188
Website www.DeltaDentalOK.org
Vision Plans’ Help Lines
Humana/CompBenefits
All Areas 1-800-865-3676
TDD All Areas 1-877-553-4327
Website www.compbenefits.com/custom/stateofoklahoma
Primary Vision Care Services
All Areas 1-888-357-6912
TDD All Areas 1-800-722-0353
Website www.pvcs-usa.com
Superior Vision Plan
All Areas 1-800-507-3800
TDD All Areas 1-916-852-2382
Website www.superiorvision.com
UnitedHealthcare Vision
All Areas 1-800-638-3120
TDD All Areas 1-800-524-3157
Website www.myuhcvision.com
Vision Service Plan (VSP)
All Areas 1-800-877-7195
TDD All Areas 1-800-428-4833
Website www.vsp.com
Last Modified on 10/24/2011