The Oklahoma State and Education Employees Group Insurance Board, a division of the Office of State Finance
For Plan Year January 1 through December 31, 2012
Overview
The HealthChoice S-Account Plan is a qualified, high deductible health plan. Although you do not have to provide proof of a Health Savings Account (HSA) to enroll in the S-Account Plan, HealthChoice has contracted with American Fidelity Health Services Administration to make establishing and keeping an HSA easier and more convenient. The monthly maintenance fee is waived as long as you continue to participate through OSEEGIB.
The S-Account Plan provides access to one of the largest provider networks in Oklahoma, the HealthChoice Provider Network. This is the same network that is available to HealthChoice High, High Alternative, Basic, and Basic Alternative Basic Plan members.
Please refer to the HealthChoice High, High Alternative, Basic, and Basic Alternative Plans Handbook for information on covered services, claim procedures, eligibility, and Plan exclusions and limitations.
Combined Medical and Pharmacy Deductible
You must meet the calendar year deductible before any benefits are paid by the Plan. Both Network and non-Network medical and pharmacy costs count toward meeting the deductible.
Individual is $1,500
Family of two or more is $3,000
The entire individual or family deductible must be met before any benefits are paid by the Plan.
Additional Copays
Each non-Network hospital confinement* - $300
Each emergency room visit - $100
*The $300 non-Network hospital copay does not count toward the out-of-pocket limit.
Network Medical Services
After you meet the combined medical and pharmacy deductible of $1,500 for individual or $3,000 for family, you are responsible for the following costs:
$50 copay for office visits and certain other Network services
20% coinsurance for covered medical services
$100 emergency room copay
Amounts above the Plan’s maximum benefit limitations
Non-covered services or charges
Pharmacy copays
Cost differences between brand-name and generic medications
After you reach the Network out-of-pocket limit of $3,000 for individual or $6,000 for family, HealthChoice pays 100% of Allowed Charges for covered Network services for the remainder of the calendar year; however, you are still responsible for:
Non-covered services or charges
Amounts above the Plan’s maximum benefit limitations
Cost differences between brand-name and generic medications
Network Pharmacy Benefits
Be aware than only costs for Preferred medications purchased at Network Pharmacies count toward the out-of-pocket limit. The following copays apply to Network Pharmacy benefits until the out-of-pocket limit is met. Once the out-of-pocket limit is met, the plan pays 100% for generic and Preferred medications purchased at Network Pharmacies for the remainder of the calendar year.
Up to a 30-Day Retail Network Benefit
Generic
You pay cost of medication up to a maximum copay of $10
Preferred brand-name
If cost of medication is $60 or less, you pay maximum copay of $15 or cost of medication, if less
If cost of medication is more than $60, you pay 25% of cost up to a maximum copay of $30
Non-Preferred brand name
If cost of medication is $60 or less, you pay maximum copay of $30 or cost of medication, if less
If cost of medication is more than $60, you pay 50% of cost up to a maximum copay of $60
A 31 to 90-Day Retail Network Benefit and Mail Service
Generic
You pay cost of medication up to a maximum copay of $25
Preferred brand-name
If cost of medication is $120 or less, you pay maximum copay of $30 or cost of medication, if less
If cost of medication is more than $120, you pay 25% of cost up to a maximum copay of $60
Non-Preferred brand name
If cost of medication is $120 or less, you pay maximum copay of $60 or cost of medication, if less
If cost of medication is more than $120, you pay 50% of cost up to a maximum copay of $120
Specialty Medications
Specialty medications are covered for up to a 30-day supply and only when ordered through Accredo Health. Copays are:
Preferred medication - $60 copay
Non-Preferred medication - $120 copay
All Plan provisions apply. Some medications are subject to prior authorization and/or quantity limitations. If you choose a brand-name medication when a generic is available, you are responsible for the difference in the cost in addition to the copay.
Network Preventive Benefits for Members Age 20 and Older
As an enhanced benefit for HealthChoice members, preventive procedures and many other services are 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 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
For more information about preventive services, please refer to the HealthChoice High, High Alternative, Basic, and Basic Alternative Plans handbook or go to the HealthChoice website at www.sib.ok.gov or www.healthchoiceok.com.
Non-Network Benefits
After the combined medical and pharmacy deductible is met, you are responsible for the following costs:
50% coinsurance for covered medical services
Amounts above the HealthChoice Allowed Charges
$100 emergency room copay
$300 non-Network inpatient copay
Amounts above the Plan’s maximum benefit limitations
Non-covered services or charges
Pharmacy copays
Cost differences between brand-name and generic medications
Out-of-Pocket Limit for Network Services
The out-of-pocket limit amount includes the deductible amounts listed previously. Only Network medical and pharmacy expenses count toward meeting the out-of-pocket limit. Non-Network expenses do not count toward the out-of-pocket limit.
Individual is $3,000
Family of two or more is $6,000
The entire individual or family out-of-pocket limit must be met before Network benefits are paid at 100% of Allowed Charges. The family out-of-pocket limit can be met by one or more family members.
Charges That Do Not Count Toward the Out-of-Pocket Limit
The following charges to do not count toward the out-of-pocket limit and do not qualify for 100% payment even after the out-of-pocket limit is met:
Amounts above the HealthChoice Allowed Charges
Non-Network services or charges
Non-covered services or charges
Non-Network hospital confinement copays
Non-Network emergency room copays
Non-Network pharmacy purchases
Non-Preferred and non-covered medication purchases
Cost differences between brand-name and generic medications
Lifetime Maximums
The HealthChoice plans do not have lifetime maximums for medical or pharmacy costs.
Disclaimer
Although OSEEGIB and the Health Savings Account (HSA) trustee/custodian together provide health insurance benefits, each are independent entities with separate responsibilities. OSEEGIB expressly disclaims any fiduciary obligation to manage the member’s HSA funds or accounts. HSA account information concerning contributions, IRS determinations, withdrawals, or any matters regarding the HSA is the sole responsibility of the HSA trustee/custodian chosen by the member.