Employee Benefit Guide 2012 - City of Oklahoma City

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Health Plan Benefits Comparison Common Medical Event Services You May Need Group Indemnity Health Plan Network Group Indemnity Health Plan Non-Network HMO Plan Primary care visit to treat an injury or illness $15 copayment + deductible + 10% of eligible charges $15 copayment + deductible + 30% of eligible charges $15 copayment per visit If you visit a health care provider’s office or clinic... Specialist visit Preventative Care/ Screening/Immunization Chiropractic Care $15 copayment + deductible + 10% of eligible charges $15 copayment + deductible + 30% of eligible charges $15 copayment per visit Plan pays 100% Plan pays 100% Plan pays 100% $15 copayment + deductible + 10% of eligible charges $15 copayment + deductible + 30% of eligible charges $15 copayment If you have a test... Diagnostic Test (x-ray, blood work) Imaging (CT/PET Scans, MRIs) Deductible + 10% of eligible charges Deductible + 10% of eligible charges Deductible + 30% of eligible charges Deductible + 30% of eligible charges $0 $0 If you need drugs to treat your illness or condition... Generic Drugs $15 No Benefit $15 Brand $30 No Benefit $25 90-day Mail Order Website for more information Prenatal and postnatal care 2 copayments for a 90-day No Benefit supply www.express-scripts.com $15 copayment + deductible + 10% of eligible charges $15 copayment + deductible + 30% of eligible charges 2 copayments for a 90-day supply www.uhcwest.com $15 copayment first visit If you become pregnant... If you need immediate medical attention... Delivery and all inpatient services Emergency medical transportation Emergency Room $50 copayment + deductible + 10% of eligible charges Plan pays 100% for birthing centers and related physician expenses EMSA paid at 100%, deductible waived. Non-EMSA providers: Deductible + 10% of eligible charges $50 copayment + deductible + 10% of eligible charges $50 copayment + deductible + 30% of eligible charges Plan pays 100% for birthing centers and related physician expenses EMSA paid at 100%, deductible waived. Non-EMSA providers: Deductible + 30% of eligible charges $50 copayment + deductible + 30% of eligible charges $100 copayment per admission $0 copayment (prior authorization required except for emergencies) $50 copayment, waived if admitted Urgent Care $15 copayment + deductible + 10% of eligible charges $15 copayment + deductible + 30% of eligible charges $15 copayment If you have outpatient surgery... Facility fee (e.g. ambulatory surgery center) Physician/Surgeon fee $50 copayment + deductible + 10% of eligible charges Deductible + 10% of eligible charges $50 copayment + deductible + 30% of eligible charges Deductible + 30% of eligible charges $50 copayment $0 copayment per visit 18
Health Plan Benefits Comparison Common Medical Event Services You May Need Group Indemnity Health Plan Network Group Indemnity Health Plan Non-Network HMO Plan If you have a hospital stay... Facility Fee (e.g. hospital room) Physician/Surgeon Fee $50 copayment + deductible + 10% of eligible charges Deductible + 10% of eligible charges $50 copayment + deductible + 30% of eligible charges Deductible + 30% of eligible charges $100 copayment per admission $0 Mental/Behavioral Health Outpatient Services $15 copayment + deductible + 10% of eligible charges $15 copayment + deductible + 30% of eligible charges $15 copayment per visit If you have mental health, behavioral health, or substance abuse needs... Mental/Behavioral Health Inpatient Services Substance Use Disorder Outpatient Services $50 copayment + deductible + 10% of eligible charges $15 copayment + deductible + 10% of eligible charges $50 copayment + deductible + 30% of eligible charges $15 copayment + deductible + 30% of eligible charges $100 copayment per admission $15 copayment per visit Substance Use Disorder Inpatient Services $50 copayment + deductible + 10% of eligible charges $50 copayment + deductible + 30% of eligible charges $100 copayment per admission Home Health Care Rehabilitation Services Deductible + 10% of eligible charges (Maximum of 120 days) Deductible + 10% of eligible charges Deductible + 30% of eligible charges (Maximum of 120 days) Deductible + 30% of eligible charges $0 $100 copayment per admission If you have recovery or other special health needs... If your child needs dental, eye care, or hearing services... Skilled Nursing Care Durable Medical Equipment Hearing Services (Adult) Deductible + 10% of eligible charges (Limited to 120 days) Deductible + 10% of eligible charges $500 Benefit for Hearing Aid every 24 months Deductible + 30% of eligible charges (Limited to 120 days) Deductible + 30% of eligible charges $500 Benefit for Hearing Aid every 24 months $0 (Limited to 100 consecutive Inpatient days per disability) $0 ($5,000 maximum benefit per Calendar Year) $0 copayment (Limited to one hearing aid every 3 years) Eye Exam No benefit No benefit $15 copayment (One visit per year) Glasses No benefit No benefit Preferred pricing from network provider Dental Check-up No benefit No benefit No benefit Hearing Services Deductible + 10% of eligible charges on hearing aids for children age 17 and under Deductible + 30% of eligible charges on hearing aids for children age 17 and under No copayment on hearing aids for children age 17 and under 19
Page 1 and 2: Employee Benefit Guide 2012
Page 3: Table of Contents 2012 Benefits Enr
Page 6 and 7: City Benefits Program Eligibility &
Page 8 and 9: Enrollment Schedule for Plan Year 2
Page 10 and 11: Three Easy Ways to Enroll Enroll O
Page 12 and 13: Your Benefit Design Structuring You
Page 15 and 16: INSURANCE PLANS Health Plan Benefit
Page 17: Health Plan Benefits Comparison Pla
Page 21 and 22: HMO Plan UnitedHealthcare All servi
Page 23 and 24: Dental Plan BlueCross BlueShield of
Page 25 and 26: Vision Care Plan VSP Your VSP Visio
Page 27 and 28: Group Term Life Insurance and AD&D
Page 29 and 30: Individual Term Life Insurance Amer
Page 31: Cancer Insurance Limited Benefit Ca
Page 34 and 35: Flexible Spending Accounts American
Page 36 and 37: Flexible Spending Accounts American
Page 38 and 39: Flexible Spending Accounts FSA Work
Page 41 and 42: SPECIAL CITY BENEFITS Employee Assi
Page 43 and 44: Employee Assistance Program Allianc
Page 45: IRC 457 Deferred Compensation IRC 4
Page 48 and 49: Dependent Eligibility Requirements
Page 50 and 51: Important Benefit Plan Information
Page 52 and 53: Important Benefit Plan Information
Page 54 and 55: Continuation of Coverage (COBRA) CO
Page 56 and 57: Guide to Qualifying Changes in Stat
Page 58 and 59: Definitions Allowed Amount: Maximum
Page 60 and 61: Definitions Pre-existing Condition:
Page 63 and 64: IMPORTANT NOTIFICATIONS Medicare Di
Page 65 and 66: Medicare Disclosure For More Inform
Page 67 and 68: American Fidelity Privacy Notice PR

Employee Benefit Guide 2012 - City of Oklahoma City

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