The following updates have been made to the printed version of the Employees Benefit Options Guide. These changes are included in the searchable text version that follows.
The Oklahoma State and Education Employees Group
Insurance Board
For
Plan Year January 1, 2010 through December 31, 2010
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. 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.
http://www.sib.ok.gov and
http://www.healthchoiceok.com
FORMS ARE BEING MAILED SEPARATELY
THE DEADLINE
FOR TURNING IN YOUR OPTION PERIOD FORM IS DETERMINED BY YOUR INSURANCE
COORDINATOR.
Monthly Premiums for Current Employees
2010 Plan Changes
Introduction
Health, Dental, and Vision Plan Highlights
HealthChoice Disability
Insurance
General Enrollment
Information
Comparison of Benefits for Health Plans –
All Plans
HealthChoice High Option
Plan Benefits
HealthChoice Basic Plan
Benefits
HealthChoice S-Account Plan
Benefits
Aetna Alternative HMO Plan
Benefits
CommunityCare Alternative
HMO Plan Benefits
GlobalHealth Alternative
HMO Plan Benefits
PacifiCare Alternative HMO
Plan Benefits
Comparison of Benefits for
Dental Plans – All Plans
HealthChoice Dental Plan Benefits
Assurant Freedom Preferred
Plan Benefits
Assurant Prepaid Plans,
Heritage Plus with SBA, and Heritage Secure Plan Benefits
Cigna Dental Care Plan Benefits
Delta Dental PPO ‘Point of Service’ - PPO Network,
Premier Network, and Non-Network Plan Benefits
Delta’s Choice PPO – PPO Network
Comparison of Benefits for
Vision Plans – All Plans
Humana/CompBenefits
VisionCare Plan
If
you have any questions concerning anything in this guide, please refer to Help
Lines for contact information for each plan.
The
participating carriers reviewed and approved the information in this Guide.
There is no guarantee that a provider will remain with a plan’s network or have
open patient slots throughout the year. Please verify your provider’s
participation in your plan’s network.
A
searchable text version of the Employee Benefit Options Guide is available on
the OSEEGIB website at http://www.sib.ok.gov or http://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, and TDD 1-405-521-4672.
For
Plan Year January 1, 2010 through December 31, 2010
Member $442.80
Spouse $625.88
Child $228.32
Children $342.44
Member $384.22
Spouse $546.84
Child $200.36
Children $300.88
Member $365.80
Spouse $513.68
Child $190.32
Children $283.98
Member $678.57
Spouse $678.57
Child $226.33
Children $339.31
Member $715.40
Spouse $951.38
Child $488.78
Children $782.04
Member $502.32
Spouse $668.02
Child $343.20
Children $549.12
Member $775.08
Spouse $1,108.34
Child $387.54
Children $620.06
Member $534.54
Spouse $764.38
Child $267.28
Children $427.64
Member $344.18
Spouse $510.70
Child $184.56
Children $294.30
Member $312.90
Spouse $464.30
Child $167.82
Children $267.54
Member $605.20
Spouse $870.16
Child $302.38
Children $483.92
Member $417.38
Spouse $600.10
Child $208.52
Children $333.72
Member $9.10
Member $30.28
Spouse $30.28
Child $25.24
Children $65.50
Member $26.33
Spouse $26.18
Child $19.63
Children $52.79
Member $11.74
Spouse $8.86
Child $7.60
Children $15.20
Member $7.20
Spouse $5.98
Child $5.20
Children $10.38
Member $9.26
Spouse $6.06
Child $7.08
Children $15.32
Member $30.48
Spouse $30.50
Child $26.80
Children $68.22
Member $13.40
Spouse $30.44
Child $30.68
Children $74.46
Member $6.76
Spouse $5.06
Child $3.57
Children $4.46
Member $9.25
Spouse $8.00
Child $8.50
Children $10.75
Member $6.98
Spouse $6.90
Child $6.60
Children $6.60
Member $8.18
Spouse $5.79
Child $4.59
Children $6.98
Member $8.96
Spouse $6.00
Child $5.74
Children $12.92
HealthChoice Basic Life
($20,000) $4.56
First $20,000 of Supplemental Life $4.56
Age-rated Supplemental Life per $20,000
Under 30 $1.00
30 – 34 $1.00
35 – 39 $1.60
40 – 44 $2.40
45 – 49 $3.80
50 – 54 $6.40
55 – 59 $10.40
60 – 64 $12.00
65 - 69 $19.80
70 – 74 $33.40
75 and older $52.00
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
Copays are being increased from $25 to $50.
Preferred Medication – Pharmacy copays are
being increased. For a medication costing $100 or less, you pay up to $30 or
actual cost if less. For a medication costing more than $100, you pay 25% up to
a $60 maximum.
Non-Preferred Medication – Pharmacy copays
are being increased. For a medication costing $100 or less, you pay up to $60
or actual cost if less. For a medication costing more than $120, you pay 50% up
to a $120 maximum.
Brand-name triptans, which are used to treat
migraine headaches, are non-Preferred medications. Sumatriptan, the generic
form for Imitrex, is the Preferred medication in this category.
Several of the out-of-pocket maximums, copays, and pharmacy copays are
changing.
Some HMO service areas are changing.
GlobalHealth has new phone numbers. The new local number is 1-405-280-5600
and the new toll-free number is 1-877-280-5600.
Topical fluoride treatments will be covered only for children through
age 12.
CIGNA Dental Care Plan has a new phone number. The new toll-free number
is 1-800-244-6224. Also, their customer service hours have been extended to 24
hours a day, seven days a week.
If you are enrolled in one of the health plans offered through OSEEGIB, you may purchase one $20,000 unit of life insurance during Option Period without completing a Life Insurance Application. You cannot apply for supplemental life coverage that exceeds the Plan maximum of five times your annual salary or $300,000, whichever is less. You must complete a Life Insurance Application to apply for more than $20,000 of coverage.
Humana/CompBenefits will apply a $25 copay
for frames purchased out-of-network.
The Oklahoma State and Education Employees Group
Insurance Board (OSEEGIB) produced this Employee Benefit Options Guide to help
you select your benefits. It is only a summary of the available plans. The
insurance benefits explained in this Guide are Health, Dental, Life,
Disability, and Vision.
Review Section
B of your pre-printed Option Period Enrollment/Change Form. This is the coverage
you will have effective January 1, 2010, if you do not make changes during
Option Period.
Contact your
Insurance Coordinator immediately if you have questions about your current
coverage.
Review Plan
Changes for 2010 of this guide.
Ask your
Insurance Coordinator about the need to return your form even if you are not
making any changes.
Use the
following resources to help you decide on coverage for you and your dependents
– this guide, plan websites, customer services telephone numbers, provider
directories, OSEEGIB Member Services, and your Insurance Coordinator.
Decide on
the coverage for yourself (and your dependents) for 2010.
Complete
your Option Period Enrollment/Change Form and return it to your Insurance
Coordinator by the designated deadline.
Review your
Confirmation Statement when you receive it in the mail to verify your coverage
is correct.
Contact
your Insurance Coordinator if your Confirmation Statement is not correct. If
you do not make changes to your coverage, you will not receive a Confirmation
Statement from OSEEGIB. Keep a copy of your Option Period Enrollment/Change
Form as verification of insurance coverage.
Use the
following resources to help you decide on coverage for you and your dependents
– this guide, plan websites, customer service telephone numbers, provider
directories, OSEEGIB Member Services, and your Insurance Coordinator.
Decide on
coverage for yourself (and your dependents) for 2010.
Complete
your Insurance Enrollment Form and return it to your Insurance Coordinator by the
designated deadline.
Review your
Confirmation Statement when you receive it in the mail to verify your coverage
is correct.
Contact
your Insurance Coordinator immediately if your Confirmation Statement is not
correct.
There are 12
health plans available – HealthChoice High Option Plan, HealthChoice Basic
Plan, HealthChoice S-Account Plan, HealthChoice USA Plan*, Aetna Standard and Alternative
HMO, CommunityCare Standard and Alternative HMO, GlobalHealth Standard and Alternative
HMO, and PacifiCare Standard and Alternative HMO.
*The HealthChoice USA Plan is a plan designed for
employees who receive an assignment of more than 90 consecutive days outside of
Oklahoma and Arkansas. Call HealthChoice Member Services for more details.
All health plans
coordinate benefits with other group insurance plans you have in force. For
more information, check with each plan.
There are
no preexisting condition exclusions or limitations applied to any of the health
plans.
All plans
have toll-free numbers for customer service. Refer to Help Lines at the end of this
document.
To enroll
in the HealthChoice S-Account Plan, you must provide OSEEGIB with proof you
have set up a Health Savings Account at a bank or other financial institution.
This proof must be submitted by December 15, 2009. Without proof, your health
plan will default to the HealthChoice Basic Plan.
You must
live or work within the HMO’s ZIP Code service area to be eligible for that
HMO. Post Office Box addresses cannot be used to determine your eligibility for
an HMO. Refer to the HMO ZIP Code List
to verify your eligibility.
Check with
each health plan if you have benefit questions.
Pre-Medicare retirees who live outside of Oklahoma and Arkansas may be
eligible to enroll in HealthChoice USA which includes a national provider
network. Call HealthChoice for details. Refer to Help Lines at the end of this
document.
Verify your employer offers dental coverage through
OSEEGIB.
There are
seven dental plans available – HealthChoice Dental, Assurant Freedom Preferred,
Assurant Heritage Plus with SBA Prepaid, Assurant Heritage Secure Prepaid,
CIGNA Dental Care Plan Prepaid, Delta Dental PPO – POS, and Delta’s Choice –
PPO
All dental plans
have toll-free numbers for customer service. Refer to Help Lines at the end of this
document.
Check with
each dental plan if you have benefit questions.
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).
All vision
plans have limited coverage for services received from out-of-network
providers.
All plans
have toll-free numbers for customer service. Refer to Help Lines at the end of this
document.
Verify your
vision provider is a member of the vision plan’s network by calling the
toll-free numbers provided, or check the plan’s website for the most up-to-date
list of providers.
Check with
each 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. You
may change providers within your plan as needed.
If you are a current employee who will be retiring
before January 1, 2010, please contact OSEEGIB Member Services and request the appropriate materials. You
will select your benefits from either the Former Pre-Medicare or Medicare
Option Period Guide, not this guide. To contact Member Services, refer to Help Lines at the end of this
document.
Verify your employer offers HealthChoice Life
Insurance.
As a new employee, you may elect life coverage
within 30 days of your employment date or the date you become eligible. You can
enroll in a limited amount of coverage, Guaranteed Issue, without an approved
Life Insurance Application.
As a current employee, if you did not enroll when
first eligible, you may enroll:
During the
next annual Option Period. If you are enrolled in one of the health plans
offered through OSEEGIB, an approved Life Insurance Application is required
only if you apply for more than $20,000 in 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.
You may enroll
in Basic Life during Option Period without a Life Insurance Application if you
are enrolled in one of the health plans offered through OSEEGIB. Mark the
appropriate box on your Option Period Enrollment/Change Form.
Basic Life
pays a benefit of $20,000 to your beneficiaries in the event of your death.
Basic Life
coverage includes Accidental Death and Dismemberment (AD&D) coverage. This
coverage pays an additional $20,000 to your beneficiaries if your death is due
to an accident, or it pays you a reduced benefit if you lose your sight or limb
due to an accident.
At the
time of your 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 providing a Life
Insurance Application.
You may
purchase Supplemental Life coverage in increments of $20,000. One $20,000 unit
of life insurance may be purchased during Option Period without a Life
Insurance Application as long as you are already enrolled in Basic Life and one
of the health plans offered through OSEEGIB. You cannot apply for supplemental
life coverage that exceeds the Plan maximum of five times your annual salary or
$300,000, whichever is less. You must complete a Life Insurance Application to
apply for additional coverage above $20,000.
The first
$20,000 unit of Supplemental Life provides an additional $20,000 of AD&D
insurance.
A Life
Insurance Application is available from your Insurance Coordinator.
If you
enroll in Basic Life insurance, you may purchase Dependent Life insurance for
your spouse and dependents at the time of your initial enrollment, during the
annual Option Period, or within 30 days of loss of other group life insurance
or midyear qualifying event.
Dependent
Life does not include AD&D coverage.
There are
three options for Dependent Life coverage - Low Option, Standard Option, or
Premier Option. Regardless of your number of dependents, the monthly premium is
the same.
A Life
Insurance Application is not required for Dependent Life coverage.
Amount of Coverage for Low Option
Spouse
$6,000
Child (age
6 months to 25) $3,000
Child
(live birth to 6 months) $1,000
Amount of Coverage for Standard Option
Spouse
$10,000
Child (age
6 months to 25) $5,000
Child
(live birth to 6 months) $1,000
Amount of Coverage for Premier Option
Spouse
$20,000
Child (age
6 months to 25) $10,000
Child
(live birth to 6 months) $1,000
Benefits are paid to your beneficiaries in a lump
sum. You must name your beneficiaries when you enroll. Your beneficiary
designation may be changed at any time. For a Beneficiary Designation Form or
more information, contact your Insurance Coordinator. Beneficiary Designation Forms
are 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.
Verify your employer offers HealthChoice Disability
Insurance (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.
Your enrollment in the 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 have continuously performed all of the
material duties of your regular occupation. Any claim for disability benefits
must be filed within one year of the beginning of your disability.
Your employer determines which benefits are
available to you and may not participate in all the benefits explained in this
Guide. Ask your Insurance Coordinator which benefits are available under your
employer’s Employee Benefit Plan.
The benefits you select will be in effect from
January 1, 2010, or the effective date of your coverage, through December 31,
2010. Please contact the insurance plans at the phone numbers or websites listed
in Help Lines at the end of
this document for more information on any of the plans.
After enrollment, the plans you have selected will
provide a member handbook or additional materials with 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.
This is the time when eligible employees may enroll
in plans, change plans or drop coverage, increase or decrease life insurance
coverage, add eligible family members to, or drop them from, coverage.
You may 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, limitations and/or exceptions may apply.
This is the time when new employees are eligible to enroll
in insurance plans, enroll eligible dependents, and apply for life insurance
coverage above Guaranteed Issue.
As a new employee, you have 30 days from your employment
date, or the date you become eligible, to make your benefit selections. If you
do not enroll within 30 days, you will not be able to enroll until the next
annual Option Period unless you experience a qualifying event during the plan year.
Your employer’s Section 125 Plan (if applicable) determines any exceptions to
this rule. Check with your Insurance Coordinator for more information.
If you request life insurance coverage in an amount
greater than two times your annual salary, 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.
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 and working a minimum of four hours per day or 20
hours per week, or a current State of Oklahoma or Local Government employee
regularly scheduled to work at least 1,000 hours a year and not classified as a
temporary or seasonal employee.
You
must be enrolled in a group health plan in order to enroll in dental or life
insurance.
If
one eligible dependent is covered, all eligible dependents must be covered.
Eligible dependents include:
Your legal spouse (including common-law)
Your unmarried children up to age 25,
including your natural child or stepchild, provided you are primarily
responsible for their support, and your natural child or stepchild, regardless
of residence, if ordered by the court; court documentation is required.
A dependent, regardless of age, who is
incapable of self-support due to a disability that was diagnosed prior to age
25. Subject to medical review and approval.
Other dependent children with an approved
Declaration of Dependency form. This form is required when the member has not
been granted custody, adoption, or guardianship by a court, and the member’s
most recent income tax return does not list the child as a dependent for income
tax purposes.
If
your spouse is enrolled separately in one of the OSEEGIB plans, your dependents
may be covered under one parent’s health, dental, or vision plan (but not
both); however, dependents may be covered by both parents for 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.
Dependents
may only be enrolled in the same types of coverage and in the same plans you
have as the primary member.
To
enroll your newborn, a 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 will not be able to do so until the next annual Option
Period. Direct notification to an HMO will not enroll your newborn, or any
other dependents. The newborn’s Social Security Number is not required at the
time of initial enrollment, but must be provided once it is received from the
Social Security Administration. Insurance premiums for the month the child was
born must be paid, and deductible and coinsurance may apply.
Without
enrollment, newborns will be 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.
Dependents
who lose eligibility may apply for continuation of health, dental, or vision
coverage under COBRA for a maximum of 36 months. Dropping dependents during
Option Period is not a COBRA qualifying event. Contact your Insurance
Coordinator for more information.
You
can exclude your spouse from health and/or dental coverage. Contact your
Insurance Coordinator for details. Your spouse must sign the Spouse Exclusion
Certification section of the Insurance Enrollment Form or the Option Period
Enrollment/Change Form.
You
can also exclude your spouse or other dependents if they are covered under
another group health or dental plan, 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.
Option
Period elections become effective on January 1, 2010, the beginning of the new
plan year.
New
employee coverage is effective the first day of the month following your
employment date or the date you become eligible through your employer.
Midyear
changes become effective the first of the month following a qualifying event.
Adopted children are eligible the first day of the month you obtain physical
custody of the child.
As
a new employee, you have 30 days following the date you become eligible to make
changes to your original benefit selections. These changes are effective the
first day of the month following the date the change in coverage is made.
Midyear
plan changes are allowed only if a qualifying event such as birth, marriage, or
loss of other coverage occurs. You must complete an Insurance Change Form
within 30 days of the event. Contact your Insurance Coordinator for more
information.
You
will be 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 for your coverage.
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 will be 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, 2010, if you do not make changes to your coverage during
Option Period. If you don’t make changes, you will not receive a CS from
OSEEGIB. Keep a copy of your Option Period Enrollment/Change Form as verification
of your coverage.
You
can keep your coverage continuous when moving from one participating employer
to another as long as there is no break in coverage that lasts more than 30
days. Premiums must be paid upon reporting to work.
Benefit
options may 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.
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.
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. An additional two percent
administration fee is added to COBRA insurance premiums. Contact your Insurance
Coordinator immediately upon termination of your employment, or when changes to
your family status occur, to find out more about your COBRA rights. Your
Insurance Coordinator will provide the necessary enrollment information and premiums
for COBRA. COBRA enrollment is limited to 18 months for eligible employees; 29
months for certain eligible disabilities; and 36 months for dependents.
If you do not live in the ZIP
Code area for a plan, that plan is not available to you. Post office box
addresses cannot be used to determine HMO enrollment eligibility. There is no
guarantee that all providers remain with the plans or that they have open
patient slots all year long. Please verify availability and physician status
prior to scheduling an appointment.
Use
your screen readers find command to search for a specific ZIP Code. Press the
letter H to move to the heading that begins the next section.
73001
GlobalHealth
73002
GlobalHealth, PacifiCare
73003
Aetna, CommunityCare, GlobalHealth, PacifiCare
73004
Aetna, GlobalHealth, PacifiCare
73005
GlobalHealth
73006
GlobalHealth
73007
Aetna, CommunityCare, GlobalHealth, PacifiCare
73008
Aetna, CommunityCare, GlobalHealth, PacifiCare
73009
GlobalHealth
73010
Aetna, GlobalHealth, PacifiCare
73011
GlobalHealth, PacifiCare
73012
Aetna, CommunityCare, GlobalHealth, PacifiCare
73013
Aetna, CommunityCare, GlobalHealth, PacifiCare
73014
CommunityCare, GlobalHealth, PacifiCare
73015
GlobalHealth
73016
GlobalHealth, PacifiCare
73017
GlobalHealth
73018
GlobalHealth, PacifiCare
73019
Aetna, CommunityCare, GlobalHealth, PacifiCare
73020
Aetna, CommunityCare, GlobalHealth, PacifiCare
73022
Aetna, CommunityCare, GlobalHealth, PacifiCare
73023
GlobalHealth
73025
Aetna, CommunityCare, GlobalHealth, PacifiCare
73026
Aetna, CommunityCare, GlobalHealth, PacifiCare
73027
Aetna, CommunityCare, GlobalHealth, PacifiCare
73028
Aetna, CommunityCare, GlobalHealth, PacifiCare
73029
GlobalHealth
73030
GlobalHealth
73031
Aetna, GlobalHealth, PacifiCare
73032
GlobalHealth
73033
GlobalHealth
73034
Aetna, CommunityCare, GlobalHealth, PacifiCare
73036
Aetna, CommunityCare, GlobalHealth, PacifiCare
73037
CommunityCare, PacifiCare
73038
GlobalHealth
73039
GlobalHealth
73040
GlobalHealth
73041
GlobalHealth
73042
GlobalHealth
73043
GlobalHealth
73044
Aetna, CommunityCare, GlobalHealth, PacifiCare
73045
Aetna, CommunityCare, GlobalHealth, PacifiCare
73047
GlobalHealth
73048
GlobalHealth
73049
Aetna, CommunityCare, GlobalHealth, PacifiCare
73050
Aetna, CommunityCare, GlobalHealth, PacifiCare
73051
Aetna, CommunityCare, GlobalHealth, PacifiCare
73052
GlobalHealth
73053
GlobalHealth
73054
Aetna, CommunityCare, GlobalHealth, PacifiCare
73055
GlobalHealth
73056
Aetna, CommunityCare, GlobalHealth, PacifiCare
73057
GlobalHealth, PacifiCare
73058
Aetna, CommunityCare, GlobalHealth, PacifiCare
73059
Aetna, GlobalHealth, PacifiCare
73061
CommunityCare, GlobalHealth
73062
GlobalHealth
73063
Aetna, CommunityCare, GlobalHealth, PacifiCare
73064
Aetna, CommunityCare, GlobalHealth, PacifiCare
73065
Aetna, GlobalHealth, PacifiCare
73066
Aetna, CommunityCare, GlobalHealth, PacifiCare
73067
GlobalHealth, PacifiCare
73068
Aetna, CommunityCare, GlobalHealth, PacifiCare
73069
Aetna, CommunityCare, GlobalHealth, PacifiCare
73070
Aetna, CommunityCare, GlobalHealth, PacifiCare
73071
Aetna, CommunityCare, GlobalHealth, PacifiCare
73072
Aetna, CommunityCare, GlobalHealth, PacifiCare
73073
Aetna, CommunityCare, GlobalHealth, PacifiCare
73074
GlobalHealth
73075
GlobalHealth
73077
CommunityCare, GlobalHealth
73078
Aetna, CommunityCare, GlobalHealth, PacifiCare
73079
GlobalHealth, PacifiCare
73080
Aetna, GlobalHealth, PacifiCare
73082
GlobalHealth
73083
Aetna, CommunityCare, GlobalHealth, PacifiCare
73084
Aetna, CommunityCare, GlobalHealth, PacifiCare
73085
Aetna, CommunityCare, GlobalHealth, PacifiCare
73086
GlobalHealth
73089
Aetna, GlobalHealth, PacifiCare
73090
Aetna, CommunityCare, GlobalHealth, PacifiCare
73091
GlobalHealth
73092
GlobalHealth, PacifiCare
73093
Aetna, GlobalHealth, PacifiCare
73094
GlobalHealth
73095
GlobalHealth, PacifiCare
73096
GlobalHealth
73097
Aetna, CommunityCare, GlobalHealth, PacifiCare
73098
GlobalHealth
73099
Aetna, CommunityCare, GlobalHealth, PacifiCare
73100
CommunityCare
73101
Aetna, CommunityCare, GlobalHealth, PacifiCare
73102
Aetna, CommunityCare, GlobalHealth, PacifiCare
73103
Aetna, CommunityCare, GlobalHealth, PacifiCare
73104
Aetna, CommunityCare, GlobalHealth, PacifiCare
73105
Aetna, CommunityCare, GlobalHealth, PacifiCare
73106
Aetna, CommunityCare, GlobalHealth, PacifiCare
73107
Aetna, CommunityCare, GlobalHealth, PacifiCare
73108
Aetna, CommunityCare, GlobalHealth, PacifiCare
73109
Aetna, CommunityCare, GlobalHealth, PacifiCare
73110
Aetna, CommunityCare, GlobalHealth, PacifiCare
73111
Aetna, CommunityCare, GlobalHealth, PacifiCare
73112
Aetna, CommunityCare, GlobalHealth, PacifiCare
73113
Aetna, CommunityCare, GlobalHealth, PacifiCare
73114
Aetna, CommunityCare, GlobalHealth, PacifiCare
73115
Aetna, CommunityCare, GlobalHealth, PacifiCare
73116
Aetna, CommunityCare, GlobalHealth, PacifiCare
73117
Aetna, CommunityCare, GlobalHealth, PacifiCare
73118
Aetna, CommunityCare, GlobalHealth, PacifiCare
73119
Aetna, CommunityCare, GlobalHealth, PacifiCare
73120
Aetna, CommunityCare, GlobalHealth, PacifiCare
73121
Aetna, CommunityCare, GlobalHealth, PacifiCare
73122
Aetna, CommunityCare, GlobalHealth, PacifiCare
73123
Aetna, CommunityCare, GlobalHealth, PacifiCare
73124
Aetna, CommunityCare, GlobalHealth, PacifiCare
73125
Aetna, CommunityCare, GlobalHealth, PacifiCare
73126
Aetna, CommunityCare, GlobalHealth, PacifiCare
73127
Aetna, CommunityCare, GlobalHealth, PacifiCare
73128
Aetna, CommunityCare, GlobalHealth, PacifiCare
73129
Aetna, CommunityCare, GlobalHealth, PacifiCare
73130
Aetna, CommunityCare, GlobalHealth, PacifiCare
73131
Aetna, CommunityCare, GlobalHealth, PacifiCare
73132
Aetna, CommunityCare, GlobalHealth, PacifiCare
73134
Aetna, CommunityCare, GlobalHealth, PacifiCare
73135
Aetna, CommunityCare, GlobalHealth, PacifiCare
73136
Aetna, CommunityCare, GlobalHealth, PacifiCare
73137
Aetna, CommunityCare, GlobalHealth, PacifiCare
73139
Aetna, CommunityCare, GlobalHealth, PacifiCare
73140
Aetna, CommunityCare, GlobalHealth, PacifiCare
73141
Aetna, CommunityCare, GlobalHealth, PacifiCare
73142
Aetna, CommunityCare, GlobalHealth, PacifiCare
73143
Aetna, CommunityCare, GlobalHealth, PacifiCare
73144
Aetna, CommunityCare, GlobalHealth, PacifiCare
73145
Aetna, CommunityCare, GlobalHealth, PacifiCare
73146
Aetna, CommunityCare, GlobalHealth, PacifiCare
73147
Aetna, CommunityCare, GlobalHealth, PacifiCare
73148
Aetna, CommunityCare, GlobalHealth, PacifiCare
73149
Aetna, CommunityCare, GlobalHealth, PacifiCare
73150
Aetna, CommunityCare, GlobalHealth, PacifiCare
73151
Aetna, CommunityCare, GlobalHealth, PacifiCare
73152
Aetna, CommunityCare, GlobalHealth, PacifiCare
73153
Aetna, CommunityCare, GlobalHealth, PacifiCare
73154
Aetna, CommunityCare, GlobalHealth, PacifiCare
73155
Aetna, CommunityCare, GlobalHealth, PacifiCare
73156
Aetna, CommunityCare, GlobalHealth, PacifiCare
73157
Aetna, CommunityCare, GlobalHealth, PacifiCare
73159
Aetna, CommunityCare, GlobalHealth, PacifiCare
73160
Aetna, CommunityCare, GlobalHealth, PacifiCare
73162
Aetna, CommunityCare, GlobalHealth, PacifiCare
73163
Aetna, CommunityCare, GlobalHealth, PacifiCare
73164
CommunityCare, GlobalHealth, PacifiCare
73165
Aetna, CommunityCare, GlobalHealth, PacifiCare
73167
Aetna, CommunityCare, GlobalHealth, PacifiCare
73169
Aetna, CommunityCare, GlobalHealth, PacifiCare
73170
Aetna, CommunityCare, GlobalHealth, PacifiCare
73172
Aetna, CommunityCare, GlobalHealth, PacifiCare
73173
Aetna, CommunityCare, GlobalHealth, PacifiCare
73177
CommunityCare, PacifiCare
73178
Aetna, CommunityCare, GlobalHealth, PacifiCare
73179
Aetna, CommunityCare, GlobalHealth, PacifiCare
73180
CommunityCare, PacifiCare
73184
Aetna, CommunityCare, GlobalHealth, PacifiCare
73185
Aetna, CommunityCare, GlobalHealth, PacifiCare
73189
Aetna, CommunityCare, GlobalHealth, PacifiCare
73190
Aetna, CommunityCare, GlobalHealth, PacifiCare
73193
CommunityCare, PacifiCare
73194
Aetna, CommunityCare, GlobalHealth, PacifiCare
73195
Aetna, CommunityCare, GlobalHealth, PacifiCare
73196
Aetna, CommunityCare, GlobalHealth, PacifiCare
73197
Aetna, CommunityCare, PacifiCare
73198
Aetna, CommunityCare, GlobalHealth, PacifiCare
73199
Aetna, CommunityCare, PacifiCare
73401
GlobalHealth
73402
GlobalHealth
73403
GlobalHealth
73425
GlobalHealth
73430
GlobalHealth
73432
GlobalHealth
73433
GlobalHealth
73434
GlobalHealth
73435
GlobalHealth
73436
GlobalHealth
73437
GlobalHealth
73438
GlobalHealth
73441
GlobalHealth
73442
GlobalHealth
73443
GlobalHealth
73444
GlobalHealth
73446
GlobalHealth
73447
GlobalHealth
73448
GlobalHealth
73450
GlobalHealth
73453
GlobalHealth
73455
GlobalHealth
73458
GlobalHealth
73459
GlobalHealth
73460
GlobalHealth
73461
GlobalHealth
73463
GlobalHealth
73481
GlobalHealth
73487
GlobalHealth
73488
GlobalHealth
73491
GlobalHealth
73521
GlobalHealth
73522
GlobalHealth
73523
GlobalHealth
73526
GlobalHealth
73529
GlobalHealth
73532
GlobalHealth
73533
GlobalHealth
73534
GlobalHealth
73536
GlobalHealth
73537
GlobalHealth
73539
GlobalHealth
73544
GlobalHealth
73549
GlobalHealth
73550
GlobalHealth
73554
GlobalHealth
73556
GlobalHealth
73559
GlobalHealth
73560
GlobalHealth
73564
GlobalHealth
73566
GlobalHealth
73571
GlobalHealth
73601
GlobalHealth
73620
GlobalHealth
73625
GlobalHealth
73639
GlobalHealth
73646
GlobalHealth
73651
GlobalHealth
73655
GlobalHealth
73658
GlobalHealth
73669
GlobalHealth
73701
GlobalHealth
73702
GlobalHealth
73703
GlobalHealth
73705
GlobalHealth
73706
GlobalHealth
73716
GlobalHealth
73718
GlobalHealth
73720
GlobalHealth
73724
GlobalHealth
73727
GlobalHealth
73729
GlobalHealth
73730
GlobalHealth
73733
GlobalHealth
73734
GlobalHealth
73735
GlobalHealth
73736
GlobalHealth
73737
GlobalHealth
73738
GlobalHealth
73742
GlobalHealth
73743
GlobalHealth
73744
GlobalHealth
73747
GlobalHealth
73750
GlobalHealth
73753
GlobalHealth
73754
GlobalHealth
73755
GlobalHealth
73756
GlobalHealth
73757
CommunityCare, GlobalHealth
73760
GlobalHealth
73762
GlobalHealth, PacifiCare
73763
GlobalHealth
73764
GlobalHealth
73768
GlobalHealth
73770
GlobalHealth
73772
GlobalHealth
73773
GlobalHealth
73838
GlobalHealth
73860
GlobalHealth
74001
CommunityCare, GlobalHealth
74002
CommunityCare, GlobalHealth, PacifiCare
74003
CommunityCare, GlobalHealth
74004
CommunityCare
74005
CommunityCare
74006
CommunityCare
74008
Aetna, CommunityCare, GlobalHealth, PacifiCare
74009
CommunityCare
74010
CommunityCare, GlobalHealth, PacifiCare
74011
Aetna, CommunityCare, GlobalHealth, PacifiCare
74012
Aetna, CommunityCare, GlobalHealth, PacifiCare
74013
Aetna, CommunityCare, GlobalHealth, PacifiCare
74014
Aetna, CommunityCare, GlobalHealth, PacifiCare
74015
Aetna, CommunityCare, GlobalHealth, PacifiCare
74016
Aetna, CommunityCare, GlobalHealth, PacifiCare
74017
Aetna, CommunityCare, GlobalHealth, PacifiCare
74018
Aetna, CommunityCare, GlobalHealth, PacifiCare
74019
Aetna, CommunityCare, GlobalHealth, PacifiCare
74020
CommunityCare, GlobalHealth, PacifiCare
74021
Aetna, CommunityCare, GlobalHealth, PacifiCare
74022
CommunityCare, GlobalHealth
74023
CommunityCare, GlobalHealth, PacifiCare
74026
GlobalHealth, PacifiCare
74027
CommunityCare, GlobalHealth
74028
CommunityCare, GlobalHealth, PacifiCare
74029
CommunityCare
74030
CommunityCare, GlobalHealth, PacifiCare
74031
Aetna, CommunityCare, GlobalHealth, PacifiCare
74032
CommunityCare, GlobalHealth, PacifiCare
74033
Aetna, CommunityCare, GlobalHealth, PacifiCare
74034
CommunityCare, GlobalHealth
74035
CommunityCare, GlobalHealth, PacifiCare
74036
Aetna, CommunityCare, GlobalHealth, PacifiCare
74037
Aetna, CommunityCare, GlobalHealth, PacifiCare
74038
CommunityCare, GlobalHealth, PacifiCare
74039
Aetna, CommunityCare, GlobalHealth, PacifiCare
74041
CommunityCare, GlobalHealth, PacifiCare
74042
CommunityCare, GlobalHealth
74043
Aetna, CommunityCare, GlobalHealth, PacifiCare
74044
CommunityCare, GlobalHealth, PacifiCare
74045
CommunityCare, GlobalHealth
74046
CommunityCare, GlobalHealth, PacifiCare
74047
Aetna, CommunityCare, GlobalHealth, PacifiCare
74048
CommunityCare, GlobalHealth
74050
Aetna, CommunityCare, GlobalHealth, PacifiCare
74051
CommunityCare, GlobalHealth
74052
CommunityCare, GlobalHealth, PacifiCare
74053
Aetna, CommunityCare, GlobalHealth, PacifiCare
74054
Aetna, CommunityCare, GlobalHealth, PacifiCare
74055
Aetna, CommunityCare, GlobalHealth, PacifiCare
74056
CommunityCare, GlobalHealth
74058
CommunityCare, GlobalHealth
74059
CommunityCare, GlobalHealth, PacifiCare
74060
Aetna, CommunityCare, GlobalHealth, PacifiCare
74061
CommunityCare, GlobalHealth, PacifiCare
74062
CommunityCare, GlobalHealth, PacifiCare
74063
Aetna, CommunityCare, GlobalHealth, PacifiCare
74066
Aetna, CommunityCare, GlobalHealth, PacifiCare
74067
Aetna, CommunityCare, GlobalHealth, PacifiCare
74068
CommunityCare, GlobalHealth, PacifiCare
74070
Aetna, CommunityCare, GlobalHealth, PacifiCare
74071
CommunityCare, GlobalHealth, PacifiCare
74072
CommunityCare, GlobalHealth
74073
Aetna, CommunityCare, GlobalHealth, PacifiCare
74074
CommunityCare, GlobalHealth, PacifiCare
74075
CommunityCare, GlobalHealth, PacifiCare
74076
CommunityCare, GlobalHealth, PacifiCare
74077
CommunityCare, GlobalHealth
74078
CommunityCare, GlobalHealth
74079
GlobalHealth, PacifiCare
74080
Aetna, CommunityCare, GlobalHealth, PacifiCare
74081
CommunityCare, GlobalHealth, PacifiCare
74082
CommunityCare, PacifiCare
74083
CommunityCare, GlobalHealth
74084
CommunityCare, GlobalHealth
74085
CommunityCare, GlobalHealth, PacifiCare
74100
CommunityCare
74101
Aetna, CommunityCare, GlobalHealth, PacifiCare
74102
Aetna, CommunityCare, GlobalHealth, PacifiCare
74103
Aetna, CommunityCare, GlobalHealth, PacifiCare
74104
Aetna, CommunityCare, GlobalHealth, PacifiCare
74105
Aetna, CommunityCare, GlobalHealth, PacifiCare
74106
Aetna, CommunityCare, GlobalHealth, PacifiCare
74107
Aetna, CommunityCare, GlobalHealth, PacifiCare
74108
Aetna, CommunityCare, GlobalHealth, PacifiCare
74110
Aetna, CommunityCare, GlobalHealth, PacifiCare
74112
Aetna, CommunityCare, GlobalHealth, PacifiCare
74114
Aetna, CommunityCare, GlobalHealth, PacifiCare
74115
Aetna, CommunityCare, GlobalHealth, PacifiCare
74116
Aetna, CommunityCare, GlobalHealth, PacifiCare
74117
Aetna, CommunityCare, GlobalHealth, PacifiCare
74119
Aetna, CommunityCare, GlobalHealth, PacifiCare
74120
Aetna, CommunityCare, GlobalHealth, PacifiCare
74121
Aetna, CommunityCare, GlobalHealth, PacifiCare
74126
Aetna, CommunityCare, GlobalHealth, PacifiCare
74127
Aetna, CommunityCare, GlobalHealth, PacifiCare
74128
Aetna, CommunityCare, GlobalHealth, PacifiCare
74129
Aetna, CommunityCare, GlobalHealth, PacifiCare
74130
Aetna, CommunityCare, GlobalHealth, PacifiCare
74131
Aetna, CommunityCare, GlobalHealth, PacifiCare
74132
Aetna, CommunityCare, GlobalHealth, PacifiCare
74133
Aetna, CommunityCare, GlobalHealth, PacifiCare
74134
Aetna, CommunityCare, GlobalHealth, PacifiCare
74135
Aetna, CommunityCare, GlobalHealth, PacifiCare
74136
Aetna, CommunityCare, GlobalHealth, PacifiCare
74137
Aetna, CommunityCare, GlobalHealth, PacifiCare
74141
Aetna, CommunityCare, GlobalHealth, PacifiCare
74145
Aetna, CommunityCare, GlobalHealth, PacifiCare
74146
Aetna, CommunityCare, GlobalHealth, PacifiCare
74147
Aetna, CommunityCare, GlobalHealth, PacifiCare
74148
Aetna, CommunityCare, GlobalHealth, PacifiCare
74149
Aetna, CommunityCare, GlobalHealth, PacifiCare
74150
Aetna, CommunityCare, GlobalHealth, PacifiCare
74152
Aetna, CommunityCare, GlobalHealth, PacifiCare
74153
Aetna, CommunityCare, GlobalHealth, PacifiCare
74155
Aetna, CommunityCare, GlobalHealth, PacifiCare
74156
Aetna, CommunityCare, GlobalHealth, PacifiCare
74157
Aetna, CommunityCare, GlobalHealth, PacifiCare
74158
Aetna, CommunityCare, GlobalHealth, PacifiCare
74159
Aetna, CommunityCare, GlobalHealth, PacifiCare
74169
Aetna, CommunityCare, GlobalHealth, PacifiCare
74170
Aetna, CommunityCare, GlobalHealth, PacifiCare
74171
Aetna, CommunityCare, GlobalHealth, PacifiCare
74172
Aetna, CommunityCare, GlobalHealth, PacifiCare
74182
Aetna, CommunityCare, GlobalHealth, PacifiCare
74183
Aetna, CommunityCare, PacifiCare
74184
Aetna, CommunityCare
74186
Aetna, CommunityCare, GlobalHealth, PacifiCare
74187
Aetna, CommunityCare, GlobalHealth, PacifiCare
74189
Aetna, CommunityCare, PacifiCare
74192
Aetna, CommunityCare, GlobalHealth, PacifiCare
74193
Aetna, CommunityCare, GlobalHealth, PacifiCare
74194
Aetna, CommunityCare, PacifiCare
74301
CommunityCare, PacifiCare
74330
Aetna, CommunityCare, GlobalHealth, PacifiCare
74331
CommunityCare
74332
CommunityCare, GlobalHealth
74333
CommunityCare
74335
CommunityCare
74337
Aetna, CommunityCare, GlobalHealth, PacifiCare
74338
CommunityCare
74339
CommunityCare
74340
Aetna, CommunityCare, GlobalHealth, PacifiCare
74342
CommunityCare
74343
CommunityCare
74344
CommunityCare
74345
CommunityCare
74346
CommunityCare
74347
CommunityCare
74349
Aetna, CommunityCare, GlobalHealth, PacifiCare
74350
Aetna, CommunityCare, GlobalHealth, PacifiCare
74352
Aetna, CommunityCare, GlobalHealth, PacifiCare
74353
CommunityCare, PacifiCare
74354
CommunityCare
74355
CommunityCare
74358
CommunityCare
74359
CommunityCare
74360
CommunityCare
74361
Aetna, CommunityCare, GlobalHealth, PacifiCare
74362
Aetna, CommunityCare, GlobalHealth, PacifiCare
74363
CommunityCare
74364
Aetna, CommunityCare, GlobalHealth, PacifiCare
74365
Aetna, CommunityCare, GlobalHealth, PacifiCare
74366
Aetna, CommunityCare, GlobalHealth, PacifiCare
74367
Aetna, CommunityCare, GlobalHealth, PacifiCare
74368
CommunityCare
74369
CommunityCare
74370
CommunityCare
74401
CommunityCare, GlobalHealth
74402
CommunityCare, GlobalHealth
74403
CommunityCare, GlobalHealth
74421
CommunityCare, GlobalHealth, PacifiCare
74422
CommunityCare, GlobalHealth, PacifiCare
74423
CommunityCare, GlobalHealth
74425
CommunityCare
74426
CommunityCare, GlobalHealth
74427
CommunityCare, GlobalHealth
74428
CommunityCare, GlobalHealth
74429
Aetna, CommunityCare, GlobalHealth, PacifiCare
74430
CommunityCare
74431
CommunityCare, GlobalHealth, PacifiCare
74432
CommunityCare, GlobalHealth
74434
CommunityCare, GlobalHealth
74435
CommunityCare, GlobalHealth
74436
CommunityCare, GlobalHealth, PacifiCare
74437
CommunityCare, GlobalHealth, PacifiCare
74438
CommunityCare, GlobalHealth
74439
CommunityCare, GlobalHealth
74440
CommunityCare
74441
CommunityCare, GlobalHealth
74442
CommunityCare
74444
CommunityCare, GlobalHealth
74445
CommunityCare, GlobalHealth, PacifiCare
74446
CommunityCare, GlobalHealth, PacifiCare
74447
CommunityCare, GlobalHealth, PacifiCare
74450
CommunityCare, GlobalHealth
74451
CommunityCare, GlobalHealth
74452
CommunityCare, GlobalHealth
74454
CommunityCare, GlobalHealth, PacifiCare
74455
CommunityCare, GlobalHealth
74456
CommunityCare, GlobalHealth, PacifiCare
74457
CommunityCare
74458
CommunityCare, GlobalHealth, PacifiCare
74459
CommunityCare, GlobalHealth
74460
CommunityCare, GlobalHealth, PacifiCare
74461
CommunityCare, GlobalHealth
74462
CommunityCare
74463
CommunityCare, GlobalHealth
74464
CommunityCare, GlobalHealth
74465
CommunityCare, GlobalHealth
74466
CommunityCare, PacifiCare
74467
CommunityCare, GlobalHealth, PacifiCare
74468
CommunityCare, GlobalHealth
74469
CommunityCare, GlobalHealth
74470
CommunityCare, GlobalHealth
74471
CommunityCare, GlobalHealth
74472
CommunityCare
74477
CommunityCare, GlobalHealth, PacifiCare
74501
CommunityCare
74502
CommunityCare
74521
CommunityCare
74522
CommunityCare
74523
CommunityCare
74526
CommunityCare
74528
CommunityCare
74529
CommunityCare
74530
GlobalHealth
74531
GlobalHealth
74536
CommunityCare
74543
CommunityCare
74545
CommunityCare
74546
CommunityCare
74547
CommunityCare
74548
CommunityCare
74549
CommunityCare
74552
CommunityCare
74553
CommunityCare
74554
CommunityCare
74557
CommunityCare
74558
CommunityCare
74559
CommunityCare
74560
CommunityCare
74561
CommunityCare
74562
CommunityCare
74563
CommunityCare
74565
CommunityCare
74567
CommunityCare
74570
GlobalHealth
74571
CommunityCare
74574
CommunityCare
74577
CommunityCare
74578
CommunityCare
74604
CommunityCare, GlobalHealth
74630
CommunityCare, GlobalHealth
74633
CommunityCare, GlobalHealth
74637
CommunityCare, GlobalHealth
74640
GlobalHealth
74644
CommunityCare, GlobalHealth
74650
CommunityCare, GlobalHealth
74651
CommunityCare, GlobalHealth
74652
CommunityCare, GlobalHealth
74727
CommunityCare
74735
CommunityCare
74738
CommunityCare
74743
CommunityCare
73748
GlobalHealth
74756
CommunityCare
74759
CommunityCare
74760
CommunityCare
74761
CommunityCare
74801
Aetna, CommunityCare, GlobalHealth, PacifiCare
74802
Aetna, CommunityCare, GlobalHealth, PacifiCare
74804
Aetna, CommunityCare, GlobalHealth, PacifiCare
74818
CommunityCare, GlobalHealth, PacifiCare
74820
GlobalHealth
74821
GlobalHealth
74824
GlobalHealth, PacifiCare
74825
GlobalHealth
74826
Aetna, CommunityCare, GlobalHealth, PacifiCare
74827
GlobalHealth
74829
GlobalHealth, PacifiCare
74830
CommunityCare, GlobalHealth, PacifiCare
74831
Aetna, GlobalHealth, PacifiCare
74832
GlobalHealth, PacifiCare
74833
GlobalHealth, PacifiCare
74834
GlobalHealth, PacifiCare
74835
PacifiCare
74836
GlobalHealth
74837
CommunityCare, GlobalHealth, PacifiCare
74838
PacifiCare
74839
GlobalHealth
74840
Aetna, CommunityCare, GlobalHealth, PacifiCare
74842
GlobalHealth
74843
GlobalHealth
74844
GlobalHealth
74845
CommunityCare, GlobalHealth
74848
GlobalHealth
74849
CommunityCare, GlobalHealth, PacifiCare
74850
GlobalHealth
74851
Aetna, CommunityCare, GlobalHealth, PacifiCare
74852
Aetna, CommunityCare, GlobalHealth, PacifiCare
74854
Aetna, CommunityCare, GlobalHealth, PacifiCare
74855
Aetna, GlobalHealth, PacifiCare
74856
GlobalHealth
74857
Aetna, CommunityCare, GlobalHealth, PacifiCare
74859
GlobalHealth, PacifiCare
74860
GlobalHealth, PacifiCare
74862
PacifiCare
74864
GlobalHealth, PacifiCare
74865
GlobalHealth
74866
Aetna, CommunityCare, GlobalHealth, PacifiCare
74867
CommunityCare, GlobalHealth, PacifiCare
74868
CommunityCare, GlobalHealth, PacifiCare
74869
Aetna, GlobalHealth, PacifiCare
74871
GlobalHealth
74872
GlobalHealth
74873
Aetna, CommunityCare, GlobalHealth, PacifiCare
74875
GlobalHealth, PacifiCare
74878
Aetna, CommunityCare, GlobalHealth, PacifiCare
74880
GlobalHealth, PacifiCare
74881
Aetna, GlobalHealth, PacifiCare
74882
PacifiCare
74883
GlobalHealth
74884
CommunityCare, GlobalHealth, PacifiCare
74901
CommunityCare
74902
CommunityCare
74930
CommunityCare
74931
CommunityCare
74932
CommunityCare
74935
CommunityCare
74936
CommunityCare, GlobalHealth
74937
CommunityCare
74939
CommunityCare
74940
CommunityCare
74941
CommunityCare
74942
CommunityCare
74943
CommunityCare
74944
CommunityCare
74945
CommunityCare, GlobalHealth
74946
CommunityCare, GlobalHealth
74947
CommunityCare
74948
CommunityCare, GlobalHealth
74949
CommunityCare
74951
CommunityCare
74953
CommunityCare
74954
CommunityCare, GlobalHealth
74955
CommunityCare, GlobalHealth
74956
CommunityCare
74959
CommunityCare
74960
CommunityCare
74962
CommunityCare, GlobalHealth
74964
CommunityCare
74965
CommunityCare
74966
CommunityCare
This
is only a sample of the services covered by each plan. For services that are
not listed in this comparison chart, contact each plan. Refer to the Help
Lines at
the end of this document for contact information.
This
chart reflects your cost for the listed Network services.
$500 individual and
$1,500 family
$500 individual and
$1,000 family; deductible applies after Plan pays first $500 of Allowed Charges
$1,500 individual and $3,000
family; the combined medical and pharmacy deductible must be met before
benefits are paid
No deductible
No deductible
No deductible
No deductible
No deductible
$2,800 Network,
individual and $3,300 non-Network individual, plus amounts over Allowed Charges
$5,500 individual and
$11,000 family
$4,000 individual and
$8,000 family; non-Network charges do not apply
$2,500 individual and $5,000
family
$3,000 individual and
$6,000 family
$3,000 individual and $6,000
family
$3,000 individual and
$5,000 family
$2,500 individual and $5,000
family
$50 copay
Copays do not apply;
refer to the HealthChoice Basic Plan Benefits section for more specific plan
information
Member pays 100% of
Allowed Charges until deductible is met; $50 copay applies after deductible
$30 copay/PCP and $40
copay/specialist
$55 copay/PCP and $65
copay/specialist
$35 copay/PCP and $50
copay/specialist
$25 copay/PCP and $50
copay/specialist
$35 copay/PCP and $50
copay/specialist
20% of Allowed Charges
after deductible
Refer to the
HealthChoice Basic Plan Benefits section for more specific plan information
20% of Allowed Charges
after deductible
No copay/laboratory
services or outpatient radiology; $150 copay per MRI, CAT, MRA, or PET scan
$65 copay per visit; per
scan for MRI, CT, MRA, and PET scan
No additional
copay/laboratory services or outpatient radiology; $200 copay per MRI, CAT,
MRA, or PET scan
$0 copay; $250 copay per
MRI, MRA, PET, or CAT
$0 copay/standard lab
and radiology; $200 copay per MRI, MRA, PET, or CAT
20% of Allowed Charges
after deductible; $300 deductible per non-Network admission
Refer to the
HealthChoice Basic Plan Benefits section for more specific plan information
20% of Allowed Charges
after deductible; $300 deductible per non-Network admission
$350 copay;
preauthorization required
$1,000 copay;
preauthorization required
$500 copay
$250 copay per day; $750
maximum per admission
$1,000 copay/admission
20% of Allowed Charges after
deductible
Refer to the
HealthChoice Basic Plan Benefits section for more specific plan information
20% of Allowed Charges
after deductible
$250 copay;
preauthorization required
$500 per visit copay;
must be preauthorized
$300 copay
$250 copay
$500 copay
$50 copay; no deductible
applies
Refer to the HealthChoice
Basic Plan Benefits section for more specific plan information
$50 copay; no deductible
applies
$0 copay
$0 copay up to age 2
$0 copay up to age 2
$0 copay/PCP; $25 copay PCP
over age 2
$0 copay
No charge for well baby
and adult immunizations; $50 office visit copay and/or administration fee may
apply
Refer to the
HealthChoice Basic Plan Benefits section for more specific plan information
No charge for well baby
and adult immunizations; $50 office visit copay and/or administration fee may
apply
$0 copay/birth through
age 18; $10 copay/ages 19 and over
$0 copay/ages birth
through age 18; $10 copay/ages 19 and over
$0 copay/ages birth
through 18 years; $25 copay/ages 19 and over
$0 copay/ages birth to
age 18; $25 copay/PCP office visit for adults; standard copays may apply in
conjunction with office visit
$0 copay/birth through
age 18 (if no other service is rendered); $10 copay ages 19 and over
$50 copay per exam, one
mammogram per year at no charge for women age 40 and over
One mammogram at no charge
for women age 40 and over; refer to the HealthChoice Basic Plan Benefits
section for more specific plan information
$50 copay per exam, one
mammogram at no charge for women age 40 and over
$10 copay per visit for
routine physicals
$10 copay for ages 19
and over
$25 copay
$25 copay/PCP; Limit: one
per year
$35 copay/PCP; $50
copay/specialist
20% of Allowed Charges
after deductible; Limit: 60 tests every 24 months
Refer to the
HealthChoice Basic Plan Benefits section for more specific plan information
20% of Allowed Charges
after deductible; Limit: 60 tests every 24 months
$30 copay/PCP; $40
copay/specialist; $30 for 6 week supply of antigen (including shots)
$20 copay per visit; $20
copay for 6 week supply of antigen (includes shots)
$35 copay/PCP visit; $50
copay/specialist visit; $30 copay for 6 week supply of antigen (including
shots)
$25 copay/PCP visit; $50
copay/specialist; $30 copay for 6 week supply of antigen (including shots)
$35 copay/PCP; $50
copay/specialist; $35 serum and shots including a 6 week supply of antigen
20% of Allowed Charges
after deductible; Additional $100 ER deductible, waived if admitted
Refer to the
HealthChoice Basic Plan Benefits section for more specific plan information
20% of Allowed Charges
after deductible; Additional $100 ER deductible, waived if admitted
$150 copay; waived if
admitted
$200 per visit copay;
waived if admitted
$200 copay; waived if
admitted
$150 copay; waived if
admitted
$200 copay; waived if
admitted
20% of Allowed Charges
after deductible
Refer to the
HealthChoice Basic Plan Benefits section for more specific plan information
20% of Allowed Charges
after deductible
$40 copay
$75 per visit copay
$50 copay per visit
$25 copay/PCP; $50
copay/all others
$50 copay per visit
*Mental Health Parity
provides that certain biological conditions for severe mental illness are not
limited as other mental health conditions. This does not apply to substance
abuse.
20% of Allowed Charges
after deductible; Limit: 30 days per year*
Refer to the
HealthChoice Basic Plan Benefits section for more specific plan information
20% of Allowed Charges
after deductible; Limit: 30 days per year*
$350 copay
$1,000 copay; Must be
preauthorized
$500 copay; Must be
preauthorized and approved through CCOK Behavioral Health Services
$250 copay; $750 maximum
per admission
$1,000 copay
*Mental Health Parity
provides that certain biological conditions for severe mental illness are not
limited as other mental health conditions. This does not apply to substance
abuse.
20% of Allowed Charges
after deductible; Limit: 26 visits per year*
Refer to the
HealthChoice Basic Plan Benefits section for more specific plan information
20% of Allowed Charges
after deductible; Limit: 26 visits per year*
$30 copay/PCP; $40
copay/specialist
$55 copay/PCP; $65 copay/specialist;
Single or group therapy except for the biologically-based diagnoses treated as
other illnesses
$35 copay/PCP; $50
copay/specialist; Must be preauthorized and approved through CCOK Behavioral
Health Services
$50 copay; Must be
preauthorized
$35 copay/PCP; $50
copay/specialist
20% of Allowed Charges
after deductible for purchase, rental, repair, or replacement
Refer to the
HealthChoice Basic Plan Benefits section for more specific plan information
20% of Allowed Charges
after deductible for purchase, rental, repair, or replacement
20% coinsurance initial
device; 20% coinsurance repair and replacement
20% of contracted rate
20% coinsurance initial
device; 20% coinsurance repair and replacement
20% coinsurance; $5,000
annual maximum
20% coinsurance; $10,000
annual maximum
20% of Allowed Charges
after deductible; For each service – Limit: 20 visits per year without prior
authorization; Maximum of 60 visits per year
Refer to the
HealthChoice Basic Plan Benefits section for more specific plan information
20% of Allowed Charges
after deductible; For each service – Limit: 20 visits per year without prior
authorization; Maximum of 60 visits per year
No copay inpatient; $30
copay/PCP; $40 copay/specialist; Limit: 60 treatment days per illness
No copay inpatient; $65
copay/outpatient therapy; Limit: 60 consecutive days per illness
No copay inpatient; $50
copay outpatient therapy; Limit: 60 days per illness
No copay inpatient; $50
copay per outpatient visit; Limit: 60 consecutive days per illness
$1,000 copay inpatient;
Outpatient - $35 copay/PCP; $50 copay/specialist; Limit: 60 days per illness
20% of Allowed Charges
after deductible; Limit: 20 visits per year without prior authorization; Maximum
of 60 visits
Refer to the
HealthChoice Basic Plan Benefits section for more specific plan information
20% of Allowed Charges
after deductible; Limit: 20 visits per year without prior authorization;
Maximum of 60 visits
No copay inpatient; $30
copay/PCP; $40 copay/specialist; Limit: 60 treatment days per illness
$65 copay outpatient
therapy; Limit: 60 consecutive days per illness
No copay inpatient; $50
copay outpatient therapy; Limit: 60 days per illness
No copay inpatient; $50
copay per outpatient visit; Limit: 60 consecutive days per illness
$1,000 copay inpatient;
Outpatient - $35 copay/PCP; $50 copay/specialist; Limit: 60 days per illness
Chiropractic services -
20% of Allowed Charges after deductible; Limit: 20 visits per year without
prior authorization; Maximum of 60 visits per year
Manipulative therapy - Refer
to Physical Therapy/Physical Medicine
Refer to the
HealthChoice Basic Plan Benefits section for more specific plan information
Chiropractic services -
20% of Allowed Charges after deductible; Limit: 20 visits per year without
prior authorization; Maximum of 60 visits per year
Manipulative therapy -
Refer to Physical Therapy/Physical Medicine
$40 copay; Limit: 15
visits per year; PCP referral required
$65 copay; Limit: 15
visits per calendar year
$50 copay; Limit: 15
visits per year
$50 copay; Limit: 15
visits per year – referral required
$50 copay; Limit: 15
visits per year – referral required; Limited to treatment of neurological and
orthopedic conditions
20% of Allowed Charges
after deductible; Includes one postpartum home visit – criteria must be met
Refer to the
HealthChoice Basic Plan Benefits section for more specific plan information
20% of Allowed Charges
after deductible; Includes one postpartum home visit – criteria must be met
$30 copay for initial
visit; $350 copay per hospital admission
$65 copay for initial
visit; thereafter covered at 100%; $1,000 copay per hospital admission
$35 copay for initial
visit; $500 copay per hospital admission
$25 copay initial visit
only; $250 copay per hospital admission per day; $750 maximum per admission
$35 copay/PCP; $50
copay/specialist for initial visit once diagnosis of pregnancy is confirmed; $1,000
copay hospital admission
$50 copay/basic hearing
screening; Limit: one per year; Hearing aids are covered as durable medical
equipment for children up to age 18
Refer to the
HealthChoice Basic Plan Benefits section for more specific plan information
$50 copay/basic hearing
screening; Limit: one per year; Hearing aids are covered as durable medical
equipment for children up to age 18
$30 copay; Limit: one
per year; Hearing aids – 20% coinsurance for children up to age 18
$10 copay; Limit: one
per ear every 48 months; Hearing aids covered for children up to age 18
$35 copay; Limit: one
per year; Hearing aids – 20% coinsurance for children up to age 18
$25 copay per visit;
Limit: one visit per year; Hearing aids – 20% coinsurance; Covered for children
up to age 18; Limit: $5,000 combined DME, orthotics, and prosthetics
$35 copay/PCP; Hearing aids –
covered for children up to age 18
NETWORK:
Generic Mandate
PREFERRED MEDICATION:
The cost of medication is $100 or less – you
pay up to $30 or actual cost if less
The cost of medication is more than $100 –
you pay 25% up to a $60 maximum
Out-of-pocket maximum - $2,500 per person
using Preferred products at Network pharmacies, then you pay $0
NON-PREFERRED
MEDICATION:
The cost of medication is $100 or less – you
pay up to $60 or actual cost if less
The cost of medication is more than $100 –
you pay 50% up to a $120 maximum
Out-of-pocket maximums do not apply to
non-Preferred medications
NOTE:
Pharmacy benefits may cover up to a 34-day
supply or 100 units, whichever is greater
Some medications may have a limit on
quantity and/or duration of therapy
Some medications require prior authorization
Specialty medications are covered when
ordered through Accredo Health Group
HealthChoice Health
Plans offer each covered individual a lifetime pharmacy benefit of $2 million
If you choose a
brand-name medication when a generic is available, you will be responsible for
the difference in cost, plus the copay
NON-NETWORK:
PREFERRED MEDICATION:
You pay the cost of medication up to $75
maximum plus a dispensing fee
NON-PREFERRED
MEDICATION:
You pay the cost of medication up to $125
maximum plus a dispensing fee
After the combined
medical and pharmacy $1,500 individual or $3,000 family deductible has been
met, the pharmacy benefits are:
NETWORK:
Generic Mandate
PREFERRED MEDICATION:
The cost of medication is $100 or less – you
pay up to $30 or actual cost if less
The cost of medication is more than $100 –
you pay 25% up to a $60 maximum
NON-PREFERRED
MEDICATION:
The cost of medication is $100 or less – you
pay up to $60 or actual cost if less
The cost of medication is more than $100 –
you pay 50% up to a $120 maximum
NOTE:
Pharmacy benefits may cover up to a 34-day
supply or 100 units, whichever is greater
Some medications may have a limit on
quantity and/or duration of therapy
Some medications require prior authorization
Specialty medications are covered when
ordered through Accredo Health Group
HealthChoice Health
Plans offer each covered individual a lifetime pharmacy benefit of $2 million
If you choose a
brand-name medication when a generic is available, you will be responsible for
the difference in cost, plus the copay
NON-NETWORK:
PREFERRED MEDICATION:
You pay the cost of medication up to $75
maximum plus a dispensing fee
NON-PREFERRED
MEDICATION:
You pay the cost of medication up to $125
maximum plus a dispensing fee
Up to $5 generic
formulary
Up to $30 brand
formulary (when no generic is available)
Up to $60 brand
formulary (when generic is available)
The lesser of 30-day
supply or 100 units
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 own formulary design
Tier 1: $20
Tier 2: $40
Tier 3: $70
MAIL ORDER 90-DAY SUPPLY
$40 copay for formulary
generic drugs
$80 copay for formulary
drugs
$140 copay for
non-formulary brand-name and non-formulary generic drugs
Greater of 30-day supply
or 100 units
Certain medications have
restricted quantities
Tier 1: $10
Tier 2: $40
Tier 3: $65
Up to $65 non-formulary
The lesser of 30-day
supply or 100 units
Selected medications may
have restricted quantities
Tier 1: $10
Tier 2: $50
Tier 3: $75
The lesser of 30-day
supply or 100 units
Certain medications may
have restricted quantities
These copays do not
apply to the maximum out-of-pocket
$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
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 the Help
Lines at
the end of this document for contact information.
This
chart reflects your cost for the listed Network services.
$500 individual and
$1,500 family
$2,800 Network,
individual and $3,300 non-Network individual, plus amounts over Allowed Charges
$50 copay
20% of Allowed Charges
after deductible
20% of Allowed Charges
after deductible; $300 deductible per non-Network admission
20% of Allowed Charges
after deductible
$50 copay; no deductible
applies
No charge for well baby
and adult immunizations; $50 office visit copay and/or administration fee may
apply
$50 copay per exam, one
mammogram per year at no charge for women age 40 and over
20% of Allowed Charges
after deductible; Limit: 60 tests every 24 months
20% of Allowed Charges
after deductible; Additional $100 ER deductible, waived if admitted
20% of Allowed Charges
after deductible
*Mental Health Parity
provides that certain biological conditions for severe mental illness are not
limited as other mental health conditions. This does not apply to substance
abuse.
20% of Allowed Charges
after deductible; Limit: 30 days per year*
*Mental Health Parity
provides that certain biological conditions for severe mental illness are not
limited as other mental health conditions. This does not apply to substance
abuse.
20% of Allowed Charges
after deductible; Limit: 26 visits per year*
20% of Allowed Charges
after deductible for purchase, rental, repair, or replacement
20% of Allowed Charges
after deductible; For each service – Limit: 20 visits per year without prior
authorization; Maximum of 60 visits per year
20% of Allowed Charges
after deductible; Limit: 20 visits per year without prior authorization;
Maximum of 60 visits
Chiropractic services -
20% of Allowed Charges after deductible; Limit: 20 visits per year without
prior authorization; Maximum of 60 visits per year
Manipulative therapy -
Refer to Physical Therapy/Physical Medicine
20% of Allowed Charges
after deductible; Includes one postpartum home visit – criteria must be met
$50 copay/basic hearing
screening; Limit: one per year; Hearing aids are covered as durable medical
equipment for children up to age 18
NETWORK:
Generic Mandate
PREFERRED MEDICATION:
The cost of medication is $100 or less – you
pay up to $30 or actual cost if less
The cost of medication is more than $100 –
you pay 25% up to a $60 maximum
Out-of-pocket maximum - $2,500 per person
using Preferred products at Network pharmacies, then you pay $0
NON-PREFERRED
MEDICATION:
The cost of medication is $100 or less – you
pay up to $60 or actual cost if less
The cost of medication is more than $100 –
you pay 50% up to a $120 maximum
Out-of-pocket maximums do not apply to
non-Preferred medications
NOTE:
Pharmacy benefits may cover up to a 34-day
supply or 100 units, whichever is greater
Some medications may have a limit on
quantity and/or duration of therapy
Some medications require prior authorization
Specialty medications are covered when
ordered through Accredo Health Group
HealthChoice Health
Plans offer each covered individual a lifetime pharmacy benefit of $2 million
If you choose a
brand-name medication when a generic is available, you will be responsible for
the difference in cost, plus the copay
NON-NETWORK:
PREFERRED MEDICATION:
You pay the cost of medication up to $75
maximum plus a dispensing fee
NON-PREFERRED MEDICATION:
You pay the cost of medication up to $125
maximum plus a dispensing fee
This
is only a sample of the services covered by each plan. For services that are
not listed in this comparison chart, contact each plan. Refer to the Help
Lines at
the end of this document for contact information.
This
chart reflects your cost for the listed Network services.
$500 individual and
$1,000 family; deductible applied after Plan pays first $500 of Allowed Charges
$5,500 individual and
$11,000 family
*Mental Health Parity
provides that certain biological conditions for severe mental illness are not
limited as other mental health conditions. This does not apply to substance
abuse.
Copays do not apply
All services, benefits, exceptions,
limitations, and conditions are identical between the HealthChoice High Option
Plan and the HealthChoice Basic Plan
For Network Services, you pay:
$0 of Allowed Charges
through the first $500
100% through the next
$500 of deductible (only Allowed Charges apply to the deductible)
50% of the next $10,000
of Allowed Charges
$0 of Allowed Charges
over $11,000
You may use non-Network
providers, but it will be more costly
NETWORK:
Generic Mandate
PREFERRED MEDICATION:
The cost of medication is $100 or less – you
pay up to $30 or actual cost if less
The cost of medication is more than $100 –
you pay 25% up to a $60 maximum
Out-of-pocket maximum - $2,500 per person
using Preferred products at Network pharmacies, then you pay $0
NON-PREFERRED
MEDICATION:
The cost of medication is $100 or less – you
pay up to $60 or actual cost if less
The cost of medication is more than $100 –
you pay 50% up to a $120 maximum
Out-of-pocket maximums do not apply to
non-Preferred medications
NOTE:
Pharmacy benefits may cover up to a 34-day
supply or 100 units, whichever is greater
Some medications may have a limit on
quantity and/or duration of therapy
Some medications require prior authorization
Specialty medications are covered when
ordered through Accredo Health Group
HealthChoice Health
Plans offer each covered individual a lifetime pharmacy benefit of $2 million
If you choose a
brand-name medication when a generic is available, you will be responsible for
the difference in cost, plus the copay
NON-NETWORK:
PREFERRED MEDICATION:
You
pay the cost of medication up to $75 maximum plus a dispensing fee
NON-PREFERRED
MEDICATION:
You pay the cost of medication up to $125
maximum plus a dispensing fee
This is
only a sample of the services covered by each plan. For services that are not
listed in this comparison chart, contact each plan. Refer to the Help
Lines at
the end of this document for contact information.
This
chart reflects your cost for the listed Network services.
$1,500 individual and
$3,000 family; the combined medical and pharmacy deductible must be met before
benefits are paid
$4,000 individual and
$8,000 family; non-Network charges do not apply
Member pays 100% of
Allowed Charges until deductible is met; $50 copay applies after deductible
20% of Allowed Charges
after deductible
20% of Allowed Charges
after deductible; $300 deductible per non-Network admission
20% of Allowed Charges
after deductible
$50 copay; no deductible
applies
No charge for well baby
and adult immunizations; $50 office visit copay and/or administration fee may
apply
$50 copay per exam, one
mammogram at no charge for women age 40 and over
20% of Allowed Charges
after deductible; Limit: 60 tests every 24 months
20% of Allowed Charges
after deductible; Additional $100 ER deductible, waived if admitted
20% of Allowed Charges
after deductible
*Mental Health Parity
provides that certain biological conditions for severe mental illness are not
limited as other mental health conditions. This does not apply to substance
abuse.
20% of Allowed Charges
after deductible; Limit: 30 days per year*
*Mental Health Parity
provides that certain biological conditions for severe mental illness are not
limited as other mental health conditions. This does not apply to substance
abuse.
20% of Allowed Charges
after deductible; Limit: 26 visits per year*
20% of Allowed Charges
after deductible for purchase, rental, repair, or replacement
20% of Allowed Charges
after deductible; For each service – Limit: 20 visits per year without prior
authorization; Maximum of 60 visits per year
20% of Allowed Charges
after deductible; Limit: 20 visits per year without prior authorization;
Maximum of 60 visits
Chiropractic services -
20% of Allowed Charges after deductible; Limit: 20 visits per year without
prior authorization; Maximum of 60 visits per year
Manipulative therapy -
Refer to Physical Therapy/Physical Medicine
20% of Allowed Charges
after deductible; Includes one postpartum home visit – criteria must be met
$50 copay/basic hearing
screening; Limit: one per year; Hearing aids are covered as durable medical
equipment for children up to age 18
After the combined
medical and pharmacy $1,500 individual or $3,000 family deductible has been
met, the pharmacy benefits are:
NETWORK:
Generic Mandate
PREFERRED MEDICATION:
The cost of medication is $100 or less – you
pay up to $30 or actual cost if less
The cost of medication is more than $100 –
you pay 25% up to a $60 maximum
NON-PREFERRED
MEDICATION:
The cost of medication is $100 or less – you
pay up to $60 or actual cost if less
The cost of medication is more than $100 –
you pay 50% up to a $120 maximum
NOTE:
Pharmacy benefits may cover up to a 34-day
supply or 100 units, whichever is greater
Some medications may have a limit on
quantity and/or duration of therapy
Some medications require prior authorization
Specialty medications are covered when
ordered through Accredo Health Group
HealthChoice Health
Plans offer each covered individual a lifetime pharmacy benefit of $2 million
If you choose a
brand-name medication when a generic is available, you will be responsible for
the difference in cost, plus the copay
NON-NETWORK:
PREFERRED MEDICATION:
You pay the cost of medication up to $75
maximum plus a dispensing fee
NON-PREFERRED MEDICATION:
You pay the cost of medication up to $125
maximum plus a dispensing fee
This
is only a sample of the services covered by each plan. For services that are
not listed in this comparison chart, contact each plan. Refer to the Help
Lines at
the end of this document for contact information.
This
chart reflects your cost for the listed Network services.
No deductible
$2,500 individual and
$5,000 family
$30 copay/PCP and $40
copay/specialist
No copay/laboratory
services or outpatient radiology; $150 copay per MRI, CAT, MRA, or PET scan
$350 copay;
preauthorization required
$250 copay;
preauthorization required
$0 copay
$0 copay/birth through
age 18; $10 copay/ages 19 and over
$10 copay per visit for
routine physicals
$30 copay/PCP; $40
copay/specialist; $30 for 6 week supply of antigen (including shots)
$150 copay; waived if
admitted
$40 copay
$350 copay
$30 copay/PCP; $40 copay/specialist
20% coinsurance initial
device; 20% coinsurance repair and replacement
No copay inpatient; $30
copay/PCP; $40 copay/specialist; Limit: 60 treatment days per illness
No copay inpatient; $30
copay/PCP; $40 copay/specialist; Limit: 60 treatment days per illness
$40 copay; Limit: 15
visits per year; PCP referral required
$30 copay for initial
visit; $350 copay per hospital admission
$30 copay; Limit: one
per year; Hearing aids – 20% coinsurance for children up to age 18
Up to $5 generic
formulary
Up to $30 brand
formulary (when no generic is available)
Up to $60 brand
formulary (when generic is available)
The lesser of 30-day
supply or 100 units
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 own formulary design
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 the Help
Lines at
the end of this document for contact information.
This
chart reflects your cost for the listed Network services.
No deductible
$3,000 individual and
$6,000 family
$55 copay/PCP and $65
copay/specialist
$65 copay per visit; per
scan for MRI, CT, MRA, and PET scan
$1,000 copay;
preauthorization required
$500 per visit copay;
must be preauthorized
$0 copay up to age 2
$0 copay/ages birth
through age 18; $10 copay/ages 19 and over
$10 copay for ages 19
and over
$20 copay per visit; $20
copay for 6 week supply of antigen (includes shots)
$200 per visit copay;
waived if admitted
$75 per visit copay
$1,000 copay; Must be
preauthorized
$55 copay/PCP; $65 copay/specialist;
Single or group therapy except for the biologically-based diagnoses treated as
other illnesses
20% of contracted rate
No copay inpatient; $65
copay/outpatient therapy; Limit: 60 consecutive days per illness
$65 copay outpatient
therapy; Limit: 60 consecutive days per illness
$65 copay; Limit: 15
visits per calendar year
$65 copay for initial
visit; thereafter covered at 100%; $1,000 copay per hospital admission
$10 copay; Limit: one
per ear every 48 months; Hearing aids covered for children up to age 18
Tier 1: $20
Tier 2: $40
Tier 3: $70
MAIL ORDER 90-DAY SUPPLY
$40 copay for formulary
generic drugs
$80 copay for formulary
drugs
$140 copay for
non-formulary brand-name and non-formulary generic drugs
Greater of 30-day supply
or 100 units
Certain medications have
restricted quantities
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 the Help
Lines at
the end of this document for contact information.
This
chart reflects your cost for the listed Network services.
No deductible
$3,000 individual and
$6,000 family
$35 copay/PCP and $50
copay/specialist
No additional
copay/laboratory services or outpatient radiology; $200 copay per MRI, CAT,
MRA, or PET scan
$500 copay
$300 copay
$0 copay up to age 2
$0 copay/ages birth
through 18 years; $25 copay/ages 19 and over
$25 copay
$35 copay/PCP visit; $50
copay/specialist visit; $30 copay for 6 week supply of antigen (including
shots)
$200 copay; waived if
admitted
$50 copay per visit
$500 copay; Must be
preauthorized and approved through CCOK Behavioral Health Services
$35 copay/PCP; $50
copay/specialist; Must be preauthorized and approved through CCOK Behavioral
Health Services
20% coinsurance initial
device; 20% coinsurance repair and replacement
No copay inpatient; $50
copay outpatient therapy; Limit: 60 days per illness
No copay inpatient; $50
copay outpatient therapy; Limit: 60 days per illness
$50 copay; Limit: 15
visits per year
$35 copay for initial visit;
$500 copay per hospital admission
$35 copay; Limit: one
per year; Hearing aids – 20% coinsurance for children up to age 18
Tier 1: $10
Tier 2: $40
Tier 3: $65
Up to $65 non-formulary
The lesser of 30-day
supply or 100 units
Selected medications may
have restricted quantities
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 the Help
Lines at
the end of this document for contact information.
This
chart reflects your cost for the listed Network services.
No deductible
$3,000 individual and
$5,000 family
$25 copay/PCP and $50
copay/specialist
$0 copay; $250 copay per
MRI, MRA, PET, or CAT
$250 copay per day; $750
maximum per admission
$250 copay
$0 copay/PCP; $25 copay
PCP over age 2
$0 copay/ages birth to
age 18; $25 copay/PCP office visit for adults; standard copays may apply in
conjunction with office visit
$25 copay/PCP; Limit:
one per year
$25 copay/PCP visit; $50
copay/specialist; $30 copay for 6 week supply of antigen (including shots)
$150 copay; waived if
admitted
$25 copay/PCP; $50
copay/all others
$250 copay; $750 maximum
per admission
$50 copay; Must be
preauthorized
20% coinsurance; $5,000
annual maximum
No copay inpatient; $50
copay per outpatient visit; Limit: 60 consecutive days per illness
No copay inpatient; $50
copay per outpatient visit; Limit: 60 consecutive days per illness
$50 copay; Limit: 15
visits per year – referral required
$25 copay initial visit
only; $250 copay per hospital admission per day; $750 maximum per admission
$25 copay per visit;
Limit: one visit per year; Hearing aids – 20% coinsurance; Covered for children
up to age 18; Limit: $5,000 combined DME, orthotics, and prosthetics
Tier 1: $10
Tier 2: $50
Tier 3: $75
The lesser of 30-day
supply or 100 units
Certain medications may
have restricted quantities
These copays do not
apply to the maximum out-of-pocket
This
is only a sample of the services covered by each plan. For services that are
not listed in this comparison chart, contact each plan. Refer to the Help
Lines at
the end of this document for contact information.
This
chart reflects your cost for the listed Network services.
No deductible
$2,500 individual and
$5,000 family
$35 copay/PCP and $50
copay/specialist
$0 copay/standard lab
and radiology; $200 copay per MRI, MRA, PET, or CAT
$1,000 copay/admission
$500 copay
$0 copay
$0 copay/birth through
age 18 (if no other service is rendered); $10 copay ages 19 and over
$35 copay/PCP; $50
copay/specialist
$35 copay/PCP; $50
copay/specialist; $35 serum and shots including a 6 week supply of antigen
$200 copay; waived if
admitted
$50 copay per visit
$1,000 copay
$35 copay/PCP; $50
copay/specialist
20% coinsurance; $10,000
annual maximum
$1,000 copay inpatient;
Outpatient - $35 copay/PCP; $50 copay/specialist; Limit: 60 days per illness
$1,000 copay inpatient;
Outpatient - $35 copay/PCP; $50 copay/specialist; Limit: 60 days per illness
$50 copay; Limit: 15
visits per year – referral required; Limited to treatment of neurological and
orthopedic conditions
$35 copay/PCP; $50
copay/specialist for initial visit once diagnosis of pregnancy is confirmed;
$1,000 copay hospital admission
$35 copay/PCP; Hearing aids –
covered for children up to age 18
$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
For
services that are not listed in this comparison chart, contact each plan. Refer
to the Help Lines at the end of this document for contact information.
This
chart reflects your cost for the listed services.
Network: $25 Basic and Major;
Non-Network: $25 Preventive, Basic, and Major
$25 per person, per
calendar year; Waived for preventive services in-network
No deductible
No deductible or plan
maximum; $5 office copay applies
PPO Network: $25 per
person, per year applies to Basic and Major Care only
Premier Network and
Non-Network: $100 per person, per year
PPO Network: $100 per
person, per year applies to Major Care only (Level 4)
Allowed Charges apply
Network: $0; Non-Network: $0
of Allowed Charges after deductible
$0 with no deductible
when in-network
No charge for routine
cleaning (once every six months); No charge for topical fluoride application
(up to age 18); No charge for periodic oral evaluations
Sealant: $15 per tooth;
No charge for routine cleaning once every six months; No charge for topical
fluoride application (through age 18); No charge for periodic oral evaluations
PPO Network: $0 of
allowable amounts; No deductible applies
Premier Network and
Non-Network: $0 of allowable amounts after deductible
PPO Network: Schedule of
covered services and copays. Copay examples: Routine cleaning $5; Periodic oral
evaluations $5; Topical fluoride application (up to age 19) $5
Allowed Charges apply
Network: 15%; Non-Network: 30%;
Deductible applies
Network: 15%;
Non-Network 30%; Plan pays 85% of usual and customary when in-network: Deductible
applies
Fillings; Minor oral
surgery; Refer to the copay schedule for each plan
Amalgam: One surface,
permanent teeth $20
PPO Network: 15% of
allowable amounts after deductible
Premier Network and
Non-Network: 30% of allowable amounts after deductible
PPO Network: Schedule of
covered services and copays. Copay example: Amalgam, one surface, primary or permanent
tooth $12
Allowed Charges apply
Network: 40%; Non-Network:
50%; Deductible applies
Network: 40%;
Non-Network: 50%; Plan pays 60% of usual and customary when in-network; Deductible
applies
Root canal; Periodontal;
Crowns; Refer to the copay schedule for each plan
Root canal, anterior:
$325; Periodontal/scaling/root planing one to three teeth (per quadrant): $65
PPO Network: 40% of
allowable amounts after deductible
Premier Network and
Non-Network: 50% of allowable amounts after deductible
PPO Network: Schedule of
covered services and copays. Copay examples: Crown, porcelain/ceramic substrate
$241; Complete denture, maxillary $320
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 over age
19 with TMD
Network: 40%;
Non-Network: 50%; Up to $1,800 lifetime maximum for members under age 19; 24 month
waiting period may apply
25% discount; Adults and
children
$2,100 out-of-pocket for
children through age 18; $2,900 out-of-pocket for adults; 24 month treatment
excludes orthodontic treatment plan and banding
PPO Network: 40% of
allowable amounts, up to lifetime maximum of $1,800; No deductible applies; No
waiting period
Premier Network and
Non-Network: 40% of allowable amounts, up to lifetime maximum of $1,800; No
deductible applies; No waiting period
PPO Network: You pay
amounts in excess of $50 per month; Lifetime maximum up to $1,800; No
deductible applies; No waiting period
Network and non-Network:
$2,000 per person, per year
$2,000
No annual maximum for
general dentist
No maximum
PPO Network: $2,000 per
person, per year
Premier Network and
Non-Network: $2,000 per person, per year
PPO Network: $2,000 per
person, per year
Network: No claims to file; Non-Network:
You file claims
Member/provider must
file claims
No claims to file
No claims to file
PPO Network: Claims are
filed by participating dentists
Premier Network and
Non-Network: Claims are filed by participating dentists
PPO Network: Claims are
filed by participating dentists
For
services that are not listed in this comparison chart, contact each plan. Refer
to the Help Lines at the end of this document for contact information.
This
chart reflects your cost for the listed services.
Network: $25 Basic and Major;
Non-Network: $25 Preventive, Basic, and Major
Allowed Charges apply
Network: $0; Non-Network: $0
of Allowed Charges after deductible
Allowed Charges apply
Network: 15%; Non-Network:
30%; Deductible applies
Allowed Charges apply
Network: 40%; Non-Network:
50%; Deductible applies
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 over age
19 with TMD
Network and non-Network:
$2,000 per person, per year
Network: No claims to file;
Non-Network: You file claims
For
services that are not listed in this comparison chart, contact each plan. Refer
to the Help Lines at the end of this document for contact information.
This
chart reflects your cost for the listed services.
$25 per person, per
calendar year; Waived for preventive services in-network
Allowed Charges apply
$0 with no deductible
when in-network
Allowed Charges apply
Network: 15%;
Non-Network 30%; Plan pays 85% of usual and customary when in-network:
Deductible applies
Allowed Charges apply
Network: 40%;
Non-Network: 50%; Plan pays 60% of usual and customary when in-network;
Deductible applies
Allowed Charges apply
Network: 40%;
Non-Network: 50%; Up to $1,800 lifetime maximum for members under age 19; 24
month waiting period may apply
$2,000
Member/provider must
file claims
For
services that are not listed in this comparison chart, contact each plan. Refer
to the Help Lines at the end of this document for contact information.
This
chart reflects your cost for the listed services.
No deductible
Allowed Charges apply
No charge for routine
cleaning (once every six months); No charge for topical fluoride application (up
to age 18); No charge for periodic oral evaluations
Allowed Charges apply
Fillings; Minor oral
surgery; Refer to the copay schedule for each plan
Allowed Charges apply
Root canal; Periodontal;
Crowns; Refer to the copay schedule for each plan
Allowed Charges apply
25% discount; Adults and
children
No annual maximum for
general dentist
No claims to file
For
services that are not listed in this comparison chart, contact each plan. Refer
to the Help Lines at the end of this document for contact information.
This
chart reflects your cost for the listed services.
No deductible
Allowed Charges apply
No charge for routine
cleaning (once every six months); No charge for topical fluoride application
(up to age 18); No charge for periodic oral evaluations
Allowed Charges apply
Fillings; Minor oral
surgery; Refer to the copay schedule for each plan
Allowed Charges apply
Root canal; Periodontal;
Crowns; Refer to the copay schedule for each plan
Allowed Charges apply
25% discount; Adults and
children
No annual maximum for
general dentist
No claims to file
For
services that are not listed in this comparison chart, contact each plan. Refer
to the Help Lines at the end of this document for contact information.
This
chart reflects your cost for the listed services.
No deductible or plan
maximum; $5 office copay applies
Allowed Charges apply
Sealant: $15 per tooth;
No charge for routine cleaning once every six months; No charge for topical
fluoride application (through age 18); No charge for periodic oral evaluations
Allowed Charges apply
Amalgam: One surface,
permanent teeth $20
Allowed Charges apply
Root canal, anterior:
$325; Periodontal/scaling/root planing one to three teeth (per quadrant): $65
Allowed Charges apply
$2,100 out-of-pocket for
children through age 18; $2,900 out-of-pocket for adults; 24 month treatment
excludes orthodontic treatment plan and banding
No maximum
No claims to file
For
services that are not listed in this comparison chart, contact each plan. Refer
to the Help Lines at the end of this document for contact information.
This
chart reflects your cost for the listed services.
PPO Network: $25 per
person, per year applies to Basic and Major Care only
Premier Network and
Non-Network: $100 per person, per year
Allowed Charges apply
PPO Network: $0 of
allowable amounts; No deductible applies
Premier Network and
Non-Network: $0 of allowable amounts after deductible
Allowed Charges apply
PPO Network: 15% of
allowable amounts after deductible
Premier Network and
Non-Network: 30% of allowable amounts after deductible
Allowed Charges apply
PPO Network: 40% of
allowable amounts after deductible
Premier Network and
Non-Network: 50% of allowable amounts after deductible
Allowed Charges apply
PPO Network: 40% of
allowable amounts, up to lifetime maximum of $1,800; No deductible applies; No
waiting period
Premier Network and
Non-Network: 40% of allowable amounts, up to lifetime maximum of $1,800; No
deductible applies; No waiting period
PPO Network: $2,000 per
person, per year
Premier Network and
Non-Network: $2,000 per person, per year
PPO Network: Claims are
filed by participating dentists
Premier Network and
Non-Network: Claims are filed by participating dentists
For
services that are not listed in this comparison chart, contact each plan. Refer
to the Help Lines at the end of this document for contact information.
This
chart reflects your cost for the listed services.
PPO Network: $100 per
person, per year applies to Major Care only (Level 4)
Allowed Charges apply
PPO Network: Schedule of
covered services and copays. Copay examples: Routine cleaning $5; Periodic oral
evaluations $5; Topical fluoride application (up to age 19) $5
Allowed Charges apply
PPO Network: Schedule of
covered services and copays. Copay example: Amalgam, one surface, primary or
permanent tooth $12
Allowed Charges apply
PPO Network: Schedule of
covered services and copays. Copay examples: Crown, porcelain/ceramic substrate
$241; Complete denture, maxillary $320
Allowed Charges apply
PPO Network: You pay
amounts in excess of $50 per month; Lifetime maximum up to $1,800; No
deductible applies; No waiting period
PPO Network: $2,000 per
person, per year
PPO Network: Claims are
filed by participating dentists
Vision
benefits apply from January 1 through December 31, 2010.
For
services that are not listed in this comparison chart, contact your plan. Refer
to the Help Lines at the end of this document for contact information.
In-Network: $10 copay; One
exam for eyeglasses or contacts per year
Out-of-Network: Copays do not
apply; Plan pays up to $35; One exam per year
In-Network: $0 copay; No
limit on exams per year
Out-of-Network*: Exam
fee reimbursed up to $40; One exam per year
*Out-of-Network limited
to one eye exam and one set of eyeglasses or contact lenses annually. Cannot be
used with In-Network services
In-Network: $10 copay; One
exam per year
Out-of-Network: OD - $26 max;
MD - $34 max
In-Network: $10 copay; One
exam per year
Out-of-Network: Plan pays up
to $40
In-Network: $10 copay; One
exam per year
Out-of-Network: $10 copay;
Plan pays up to $35
In-Network: $25 material
copay applies to lenses and/or frames (single, lined bifocal, trifocal,
lenticular 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
In-Network: You pay
wholesale cost with no limit on number of pairs
Out-of-Network*: Fees
reimbursed up to $40-$60 for one set of lenses and frames
*Out-of-Network limited
to one eye exam and one set of eyeglasses or contact lenses annually. Cannot be
used with In-Network services
In-Network: $25 copay; One
pair of lenses per year
Out-of-Network: Plan pays up
to $26 single, $39 bifocals, $49 trifocals, $78 lenticular
In-Network: $25 copay; One
pair of lenses per year
Out-of-Network: Plan pays up
to $40 single, $60 bifocals, $80 trifocals, $80 lenticular
In-Network: $25 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 copay*;
Plan pays up to $25 single, $40 bifocals, $55 trifocals, $80 lenticular
*Benefit includes an annual
$25 materials copay for lenses or frames, but not both. Contact VSP for additional
information regarding in-network added value discounts.
In-Network: $25 material
copay applies to lenses and/or frames; $45 wholesale frame allowance; One set
of frames per year
Out-of-Network: $25 copay;
Plan pays up to $45; One set of frames per year
In-Network: You pay
wholesale cost with no limit on number of pairs
Out-of-Network*: Fees
reimbursed up to $40-$60 for one set of lenses and frames
*Out-of-Network limited
to one eye exam and one set of eyeglasses or contact lenses annually. Cannot be
used with In-Network services
In-Network: $25 copay; Plan
pays up to $125; One set of frames per year
Out-of-Network: Plan pays up
to $68
In-Network: $25 copay; One
set of frames per year
Out-of-Network: Plan pays up
to $45
In-Network: $25 copay*; One
frame per year $120 allowance; 20% off any out-of-pocket costs above the
allowance
Out-of-Network: $25 copay*;
Plan pays up to $45
*Benefit includes an annual
$25 materials copay for lenses or frames, but not both. Contact VSP for
additional information regarding in-network added value discounts.
In-Network: $130 allowance
for conventional or disposable lenses and fitting fee in lieu of all other
benefits; Medically necessary, plan pays 100%; One set of contacts 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
In-Network: You pay wholesale
cost for an annual supply of contacts; For first time fittings, $50 copay on
soft lenses and $75 copay on all rigid gas permeable lenses
Out-of-Network*: Fees
reimbursed up to $60; One set annually (in lieu of glasses)
*Out-of-Network limited
to one eye exam and one set of eyeglasses or contact lenses annually. Cannot be
used with In-Network services
In-Network: $0 copay; Plan
pays up to $120; Medically necessary contacts are covered in full (in lieu of
glasses)
Out-of-Network: $0 copay;
Plan pays up to $100; Medically necessary contacts, plan pays up to $210 (in
lieu of glasses)
In-Network: $25 copay covers
fitting/evaluation fees, contacts (including disposables), and up to two
follow-up visits (in lieu of glasses)
Out-of-Network: Plan pays up
to $150; For medically necessary contacts, plan pays up to $210 (in lieu of
glasses)
In-Network: $0 copay; $120
allowance applied to the cost of your contact lens exam and the contact lenses;
15% discount on contact lens exam (in lieu of glasses)
Out-of-Network: $0 copay;
Plan pays up to $105 for disposable or conventional contact lenses (in lieu of
glasses)
In-Network: $895 copay
conventional; $1,295 copay custom; $1,895 copay custom plus bladeless when
services are rendered by a TLC Network Provider
Out-of-Network: No benefit
In-Network: Discounted
laser refractive surgery at multiple state locations
Out-of-Network*: No
benefit
*Out-of-Network limited
to one eye exam and one set of eyeglasses or contact lenses annually. Cannot be
used with In-Network services
In-Network: 20% off retail
price
Out-of-Network: No benefit
In-Network: Members have
access to discounted refractive eye surgery from numerous provider locations
throughout the U.S.
Out-of-Network: No benefit
In-Network: Laser vision
correction services (PRK, LASIK, and Custom LASIK) are provided at a reduced
cost through VSP’s contracted laser surgery centers
Out-of-Network: No benefit
Vision
benefits apply from January 1 through December 31, 2010.
For
services that are not listed in this comparison chart, contact your plan. Refer
to the Help Lines at the end of this document for contact information.
In-Network: $10 copay; One
exam for eyeglasses or contacts per year
Out-of-Network: Copays do not
apply; Plan pays up to $35; One exam per year
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
In-Network: $25 material
copay applies to lenses and/or frames; $45 wholesale frame allowance; One set
of frames per year
Out-of-Network: $25 copay;
Plan pays up to $45; One set of frames per year
In-Network: $130 allowance
for conventional or disposable lenses and fitting fee in lieu of all other
benefits; Medically necessary, plan pays 100%; One set of contacts 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
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
Vision
benefits apply from January 1 through December 31, 2010.
For
services that are not listed in this comparison chart, contact your plan. Refer
to the Help Lines at the end of this document for contact information.
In-Network: $0 copay; No
limit on exams per year
Out-of-Network*: Exam
fee reimbursed up to $40; One exam per year
*Out-of-Network limited
to one eye exam and one set of eyeglasses or contact lenses annually. Cannot be
used with In-Network services
In-Network: You pay
wholesale cost with no limit on number of pairs
Out-of-Network*: Fees
reimbursed up to $40-$60 for one set of lenses and frames
*Out-of-Network limited
to one eye exam and one set of eyeglasses or contact lenses annually. Cannot be
used with In-Network services
In-Network: You pay
wholesale cost with no limit on number of pairs
Out-of-Network*: Fees
reimbursed up to $40-$60 for one set of lenses and frames
*Out-of-Network limited
to one eye exam and one set of eyeglasses or contact lenses annually. Cannot be
used with In-Network services
In-Network: You pay
wholesale cost for an annual supply of contacts; For first time fittings, $50
copay on soft lenses and $75 copay on all rigid gas permeable lenses
Out-of-Network*: Fees
reimbursed up to $60; One set annually (in lieu of glasses)
*Out-of-Network limited
to one eye exam and one set of eyeglasses or contact lenses annually. Cannot be
used with In-Network services
In-Network: Discounted
laser refractive surgery at multiple state locations
Out-of-Network*: No
benefit
*Out-of-Network limited
to one eye exam and one set of eyeglasses or contact lenses annually. Cannot be
used with In-Network services
Vision
benefits apply from January 1 through December 31, 2010.
For
services that are not listed in this comparison chart, contact your plan. Refer
to the Help Lines at the end of this document for contact information.
In-Network: $10 copay; One
exam per year
Out-of-Network: OD - $26 max;
MD - $34 max
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
In-Network: $25 copay; Plan
pays up to $125; One set of frames per year
Out-of-Network: Plan pays up
to $68
In-Network: $0 copay; Plan
pays up to $120; Medically necessary contacts are covered in full (in lieu of
glasses)
Out-of-Network: $0 copay;
Plan pays up to $100; Medically necessary contacts, plan pays up to $210 (in
lieu of glasses)
In-Network: 20% off retail
price
Out-of-Network: No benefit
Vision
benefits apply from January 1 through December 31, 2010.
For
services that are not listed in this comparison chart, contact your plan. Refer
to the Help Lines at the end of this document for contact information.
In-Network: $10 copay; One
exam per year
Out-of-Network: Plan pays up
to $40
In-Network: $25 copay; One
pair of lenses per year
Out-of-Network: Plan pays up
to $40 single, $60 bifocals, $80 trifocals, $80 lenticular
In-Network: $25 copay; One
set of frames per year
Out-of-Network: Plan pays up
to $45
In-Network: $25 copay covers
fitting/evaluation fees, contacts (including disposables), and up to two
follow-up visits (in lieu of glasses)
Out-of-Network: Plan pays up
to $150; For medically necessary contacts, plan pays up to $210 (in lieu of
glasses)
In-Network: Members have
access to discounted refractive eye surgery from numerous provider locations
throughout the U.S.
Out-of-Network: No benefit
Vision
benefits apply from January 1 through December 31, 2010.
For
services that are not listed in this comparison chart, contact your plan. Refer
to the Help Lines at the end of this document for contact information.
In-Network: $10 copay; One
exam per year
Out-of-Network: $10 copay;
Plan pays up to $35
In-Network: $25 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 copay*;
Plan pays up to $25 single, $40 bifocals, $55 trifocals, $80 lenticular
*Benefit includes an annual
$25 materials copay for lenses or frames, but not both. Contact VSP for
additional information regarding in-network added value discounts.
In-Network: $25 copay*; One
frame per year $120 allowance; 20% off any out-of-pocket costs above the
allowance
Out-of-Network: $25 copay*;
Plan pays up to $45
*Benefit includes an annual
$25 materials copay for lenses or frames, but not both. Contact VSP for
additional information regarding in-network added value discounts.
In-Network: $0 copay; $120
allowance applied to the cost of your contact lens exam and the contact lenses;
15% discount on contact lens exam (in lieu of glasses)
Out-of-Network: $0 copay;
Plan pays up to $105 for disposable or conventional contact lenses (in lieu of
glasses)
In-Network: Laser vision
correction services (PRK, LASIK, and Custom LASIK) are provided at a reduced
cost through VSP’s contracted laser surgery centers
Out-of-Network: No benefit
Oklahoma City Area 1-405-416-1800
All Other Areas 1-800-782-5218
TDD Oklahoma City Area 1-405-416-1525
TDD All Other Areas 1-800-941-2160
Website http://www.sib.ok.gov
or http://www.healthchoiceok.com
All Areas 1-800-903-8113
TDD All Areas 1-800-825-1230
All Areas 1-800-848-8121
TDD All Areas 1-877-267-6367
Oklahoma City Area 1-405-717-8780
All Other Areas 1-800-752-9475
TDD Oklahoma City Area 1-405-949-2281
TDD All Other Areas 1-866-447-0436
Oklahoma City Area 1-405-841-9686
All Areas 1-800-722-2567
TDD All Areas 1-800-863-5488
Customer Service and Claims 1-800-782-5218
Provider Information 1-877-877-0715 ext. 4059
TDD All Areas 1-800-941-2160
Website http://www.choicecarenetwork.com
All Areas 1-800-949-3104
TDD All Areas
1-800-628-3323
Website
http://www.aetnaokstateemployees.com
All Areas 1-800-777-4890
TDD All Areas 1-800-722-0353
Website http://www.ccok.com
Oklahoma
City Area 1-405-280-5600
All Other Areas 1-877-280-5600
TDD All Areas 1-800-522-8506
Website http://www.globalhealth.cc
All Areas 1-800-825-9355
TDD All Areas
1-800-557-7595
Website
http://www.pacificare.com
Prepaid
Plan 1-800-443-2995
Indemnity Plan 1-800-442-7742
Website http://www.assurantemployeebenefits.com
All Areas 1-800-244-6224
Hearing
Impaired Relay Service 1-405-948-3303
Website http://www.cigna.com
Oklahoma
City Area 1-405-607-2100
All Other Areas 1-800-522-0188
Website http://www.deltadentalok.org/state_employees/
All Areas 1-800-865-3676
TDD
All Areas 1-877-553-4327
Website http://www.compbenefits.com/custom/stateofoklahoma
All Areas 1-888-357-6912
TDD
All Areas 1-800-722-0353
Website http://www.pvcs-usa.com
All Areas 1-800-507-3800
TDD
All Areas 1-916-852-2382
Website http://www.superiorvision.com
All Areas 1-800-638-3120
TDD
All Areas 1-800-524-3157
Website http://www.myuhcvision.com
All Areas 1-800-877-7195
TDD All Areas 1-800-428-4833
Website http://www.vsp.com