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

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.

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

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

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
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 $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.

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