State of Oklahoma Group Retirees Benefits at a Glance
2022 GENERATIONS STATE OF OKLAHOMA GROUP RETIREES (HMO) MEDICARE ADVANTAGE PLAN
Benefits at a Glance
The following is intended to be only a summary of benefits for the Generations State of Oklahoma Group Retirees (HMO) Plan. For a complete list, including any limitations, exclusions, and plan restrictions, please review the GlobalHealth Evidence of Coverage for Generations State of Oklahoma Group Retirees (HMO) Plan.
Coverage effective Jan 1, 2022 to Dec 31, 2022
BENEFIT |
YOU PAY |
Premium |
$205 |
Deductible |
$0 |
MOOP |
$3,450 |
Primary Care Physician |
$0 |
Specialist |
$20 copay |
Preventive Care |
You pay nothing |
Inpatient Hospital Care |
$50 copay/day - days 1-5 $0 - unlimited days after |
Outpatient Surgery and Hospital Services |
You pay nothing – Ambulatory Surgery Center $200 – Hospital |
Diagnostic Tests, X-rays, Lab Services and Radiology |
You pay nothing for labs and x-rays; $40 copay for therapeutic radiology; $100 copay for sleep studies in outpatient facility |
MRI, PET, CT Scans |
$150 copay per visit |
Ambulance Services |
$50 copay |
Emergency Room |
$75 copay |
Urgent Care |
$15 copay |
Chiropractic |
$20 copay |
Home Health |
You pay nothing |
Standard Diabetic Testing Supplies |
You pay nothing |
Prescription Drug Coverage
Effective January 1, 2022 - December 31, 2022
Deductible: $0
30-DAY PREFERRED RETAIL AND MAIL ORDER |
|
DRUG TYPE |
STATE OF OKLAHOMA GROUP RETIREES |
Tier 1 – Preferred Generics |
$0 |
Tier 2 – Generics |
$15 |
Tier 3 – Preferred Brand Name |
$42 |
Tier 4 – Non-Preferred Drugs |
$95 |
Tier 5 – Specialty |
33% |
90-DAY PREFERRED RETAIL AND MAIL ORDER |
|
DRUG TYPE |
STATE OF OKLAHOMA GROUP RETIREES |
Tier 1 – Preferred Generics |
$0 |
Tier 2 – Generics |
$0 |
Tier 3 – Preferred Brand Name |
$84 |
Tier 4 – Non-Preferred Drugs |
$190 |
Coverage Gap Stage After your prescription costs reach $4,430 |
Your costs will be no more than 25% of the cost for generic drugs. You pay 25% of the cost of brand name drugs plus a portion of the dispensing fee. |
Catastrophic Coverage Stage After you have paid $7,050 out-of-pocket |
You pay the greater of 5% of the cost of the drug or $3.95 for generics/$9.85 for brand names. |
Gap Coverage |
You have additional gap coverage for Tier 1 drugs, Tier 2 drugs, and Tier 3 oral anti-diabetic drugs, insulin and syringes. See the Evidence of Coverage for benefits and limitations. |
PLEASE NOTE: Please visit our website for the most up-to-date drug formulary. The formulary and/or pharmacy network may change at any time. You will receive notice when necessary.
Costs are higher at a Standard Pharmacy.
Additional Benefits Not Covered Under Original Medicare
Effective January 1, 2022 - December 31, 2022
BENEFIT |
YOU PAY |
Routine Vision Exam |
You pay nothing for up to 1 visit per year |
Routine Supplemental Eyewear Benefit |
Plan pays up to a $200 calendar year maximum |
Over-the-Counter Benefit |
$50 quarterly benefit for over-the-counter (OTC) health and wellness products available through our mail order service If $50 is not used in a quarter, the balance does not carry over Catalog prices include shipping, handling, and sales tax |
Fitness Benefit |
You pay nothing at an in-network fitness facility plus 1 home fitness kit per year |
Routine Hearing |
You pay nothing for up to 1 routine hearing exam visit plus 1 hearing aid evaluation per year |
Hearing Aids |
Plan pays up to a $500 calendar year maximum for hearing aids and fitting |
* Our plan covers many preventive services, including:
- Abdominal aortic aneurysm screening
- Alcohol misuse counseling
- Bone mass measurement
- Breast cancer screening (mammogram)
- Cardiovascular disease (behavioral therapy)
- Cardiovascular screenings
- Cervical and vaginal cancer screening
- Colonoscopy
- Colorectal cancer screenings
- Depression screening
- Diabetes screenings
- Fecal occult blood test
- Flexible sigmoidoscopy
- HIV screening
- Medical nutrition therapy services
- Obesity screening and counseling
- Prostate cancer screenings (PSA)
- Sexually transmitted infections screening and counseling
- Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease)
- Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots
- "Welcome to Medicare" preventive visit (one-time)
- Yearly "Wellness" visit
Any additional preventive services approved by Medicare during the contract year will be covered.
2021 STATE OF OKLAHOMA GROUP RETIREES (HMO) MEDICARE ADVANTAGE PLAN
Benefits at a Glance
The following is intended to be only a summary of benefits for the Generations State of Oklahoma Group Retirees (HMO) Plan. For a complete list, including any limitations, exclusions, and plan restrictions, please review the GlobalHealth Evidence of Coverage for Generations State of Oklahoma Group Retirees (HMO) Plan.
Coverage effective Jan 1, 2021 to Dec 31, 2021
BENEFIT |
YOU PAY |
Premium |
$206 |
Deductible |
$0 |
MOOP |
$3,450 |
Primary Care Physician |
$0 |
Specialist |
$20 copay |
Preventive Care |
You pay nothing |
Inpatient Hospital Care |
$250 copay |
Outpatient Surgery and Hospital Services |
You pay nothing – Ambulatory Surgery Center $200 – Hospital |
Diagnostic Tests, X-rays, Lab Services and Radiology |
You pay nothing for labs and x-rays; $40 copay for therapeutic radiology; $100 copay for sleep studies in outpatient facility |
MRI, PET, CT Scans |
$150 copay per visit |
Ambulance Services |
$50 copay |
Emergency Room |
$75 copay |
Urgent Care |
$15 copay |
Chiropractic |
$20 copay |
Home Health |
You pay nothing |
Standard Diabetic Testing Supplies |
You pay nothing |
All cost shares for treatment of COVID-19 are waived even if the public health emergency is lifted. Those services include: Emergency services, inpatient hospital care, Medicare Part B prescription drugs, observation services, specialist visits, skilled nursing facility, and urgently needed services.
Prescription Drug Coverage
Effective January 1, 2021 - December 31, 2021
Deductible: $0
30-DAY PREFERRED RETAIL AND MAIL ORDER |
|
DRUG TYPE |
STATE OF OKLAHOMA GROUP RETIREES |
Tier 1 – Preferred Generics |
$5 |
Tier 2 – Generics |
$15 |
Tier 3 – Preferred Brand Name |
$42 |
Tier 4 – Non-Preferred Drugs |
40% |
Tier 5 – Specialty |
33% |
90-DAY PREFERRED RETAIL AND MAIL ORDER |
|
DRUG TYPE |
STATE OF OKLAHOMA GROUP RETIREES |
Tier 1 – Preferred Generics |
$0 |
Tier 2 – Generics |
$0 |
Tier 3 – Preferred Brand Name |
$84 |
Tier 4 – Non-Preferred Drugs |
40% |
Coverage Gap Stage After your prescription costs reach $4,130 |
Your costs will be no more than 25% of the cost for generic |
Catastrophic Coverage Stage After you have paid $6,550 out-of-pocket |
You pay the greater of 5% of the cost of the drug or $3.70 for generics/$9.20 for brand names. |
Gap Coverage |
You have additional gap coverage for Tier 1 drugs, Tier 2 drugs, and Tier 3 oral anti-diabetic drugs, insulin and syringes. See the Evidence of Coverage for benefits and limitations. |
PLEASE NOTE: Please visit our website for the most up-to-date drug formulary. The formulary and/or pharmacy network may change at any time. You will receive notice when necessary.
Costs are higher at a Standard Pharmacy.
Additional Benefits Not Covered Under Original Medicare
Effective January 1, 2021 - December 31, 2021
DRUG TYPE |
STATE OF OKLAHOMA GROUP RETIREES |
BENEFIT |
YOU PAY |
Routine Vision Exam |
You pay nothing for up to 1 visit per year |
Routine Supplemental Eyewear Benefit |
Plan pays up to a $200 calendar year maximum |
Over-the-Counter Benefit |
$50 quarterly benefit for over-the-counter (OTC) health and wellness products available through our mail order service If $50 is not used in a quarter, the balance does not carry over Prices include shipping, handling, and sales tax |
Fitness Benefit |
You pay nothing at an in-network fitness facility or for up to 2 home fitness kits per year |
Routine Hearing Exam - for hearing aid evaluation |
You pay nothing for up to 1 visit per year |
Hearing Aids |
Plan pays up to a $500 calendar year maximum for hearing aids and fitting |
* Our plan covers many preventive services, including:
- Abdominal aortic aneurysm screening
- Alcohol misuse counseling
- Bone mass measurement
- Breast cancer screening (mammogram)
- Cardiovascular disease (behavioral therapy)
- Cardiovascular screenings
- Cervical and vaginal cancer screening
- Colonoscopy
- Colorectal cancer screenings
- Depression screening
- Diabetes screenings
- Fecal occult blood test
- Flexible sigmoidoscopy
- HIV screening
- Medical nutrition therapy services
- Obesity screening and counseling
- Prostate cancer screenings (PSA)
- Sexually transmitted infections screening and counseling
- Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease)
- Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots
- "Welcome to Medicare" preventive visit (one-time)
- Yearly "Wellness" visit
Any additional preventive services approved by Medicare during the contract year will be covered.