The Employees Group Insurance Division, a division of the Office of Management and Enterprise Services

HEALTHCHOICE S-ACCOUNT PLAN

For Plan Year January 1 through December 31, 2013

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.