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2020 STATE OF OKLAHOMA RETIREE MEDICARE ADVANTAGE PLAN

Benefits at a Glance

The following is intended to be only a summary of benefits for the Generations State of Oklahoma Retiree Plan. For a complete list, including any limitations, exclusions, and plan restrictions, please review the GlobalHealth Evidence of Coverage for Generations State of Oklahoma Retiree Plan.

Coverage effective Jan 1, 2020 to Dec 31, 2020

BENEFIT

YOU PAY

Premium

$216

Deductible

$0

MOOP

$3,400

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

$320 – 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

Diabetes Supplies

You pay nothing

Prescription Drug Coverage

Effective January 1, 2020 - December 31, 2020

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 $4,020

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 $6,350 out-of-pocket

You pay the greater of 5% of the cost of the drug or $3.60 for generics/$8.95 for brand names.

Gap Coverage

 

You pay the same cost sharing for Tier 1 drugs or for oral anti-diabetic drugs in Tier 3 that you paid in the Initial Coverage Stage, whichever is less, and the plan pays the rest.

 

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, 2020 - December 31, 2020

DRUG TYPE

STATE OF OKLAHOMA GROUP RETIREES

BENEFIT

YOU PAY

Routine Vision Exam

You pay nothing for up to 1 visit per year

Routine 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

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.

2019 STATE OF OKLAHOMA RETIREE MEDICARE ADVANTAGE PLAN

Benefits at a Glance

The following is intended to be only a summary of benefits for the Generations State of Oklahoma Retiree Plan. For a complete list, including any limitations, exclusions, and plan restrictions, please review the GlobalHealth Summary of Benefits for the Generations State of Oklahoma Retiree Plan.

Coverage effective Jan 1, 2019 to Dec 31, 2019

Benefit You Pay
Premium $192
Deductible $0
MOOP $3,400
Primary Care Physician $0 copay
Specialist $20 copay
Preventative Care* You pay nothing
Inpatient Hospital Care $250
Outpatient Surgery and Hospital Services

$150 copay for observation services
$200 copay for surgery

Diagnostic Tests, X-rays, Lab Services and Radiology You pay $150 copay per visit for diagnostic radiology service
You pay nothing for lab services
You pay $100 for sleep studies in an outpatient facility; all other
diagnostic tests and procedures, you pay nothing
• You pay $40 copay per visit for therapeutic radiology 
• You pay nothing for outpatient x-rays
MRI, PET, CT Scans $150
Ambulance Services $50
Emergency Room $75
Urgent Care $20 copay 

Prescription Drug Coverage

Generations State of Oklahoma Retiree Plan Deductible: $0

  GENERATIONS STATE OF OKLAHOMA RETIREE PLAN
Drug Type 30-Day Supply at Preferred Retail Pharmacy 90-Day Supply from Mail Order Pharmacy† 30-Day Supply from Standard Retail Pharmacy
Tier 1 - Preferred Generics† $5 $15 $10
Tier 2 - Generics† $15 $45 $20
Tier 3 - Preferred Brand Name‡ $42 $126 $47
Tier 4 - Non-Preferred 40% 40% 50%
Tier 5 - Specialty 33% N/A 33%
Tier 6 - Select Care Drugs $5 $0 $10
Coverage Gap Stage After your prescription costs reach $3,820 For generic drugs in Tiers 1
and 6, you pay either the same
copayment as in the Initial
Coverage Stage or 37% of the
costs, whichever is lower. For
brand name drugs, you pay
25% of the price (plus a portion
of the dispensing fee). For
insulin in Tier 3, you pay either
the same copayment as in the
Initial Coverage Stage or 25%
of the costs, whichever is lower.
Catastrophic Coverage Stage After you have paid $5,100 out-of-pocket You pay the greater of 5% of the cost of the drug or $3.40 for generics/ $8.50 for brand names.

* 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.

† You pay the same amount in the Coverage Gap Phase as you do in the Initial Coverage Phase for Tier 1 & 2.

‡ You pay the same amount in the Coverage Gap Phase as you do in the Initial Coverage Phase for Tier 3, for insulin only.

2018 STATE OF OKLAHOMA RETIREE MEDICARE ADVANTAGE PLAN

Benefits at a Glance

The following is intended to be only a summary of benefits for the Generations State of Oklahoma Retiree Plan. For a complete list, including any limitations, exclusions, and plan restrictions, please review the GlobalHealth Summary of Benefits for the Generations State of Oklahoma Retiree Plan.

Coverage effective Jan 1, 2018 to Dec 31, 2018

Benefit You Pay
Premium $192
Deductible $0
MOOP $3,400
Primary Care Physician $0 copay
Specialist $20 copay
Preventative Care* You pay nothing
Inpatient Hospital Care $250
Outpatient Surgery and Hospital Services

$150 copay for observation services
$200 copay for surgery

Diagnostic Tests, X-rays, Lab Services and Radiology You pay $150 copay per visit for diagnostic radiology service
You pay nothing for lab services
You pay $100 for sleep studies in an outpatient facility; all other
diagnostic tests and procedures, you pay nothing
• You pay $40 copay per visit for therapeutic radiology 
• You pay nothing for outpatient x-rays
MRI, PET, CT Scans $150
Ambulance Services $50
Emergency Room $75
Urgent Care $20 copay 

Prescription Drug Coverage

Generations State of Oklahoma Retiree Plan Deductible: $0

  GENERATIONS STATE OF OKLAHOMA RETIREE PLAN
Drug Type 30-Day Supply at Preferred Retail Pharmacy 90-Day Supply from Mail Order Pharmacy† 30-Day Supply from Standard Retail Pharmacy
Tier 1 - Preferred Generics† $5 $10 $10
Tier 2 - Generics† $15 $30 $20
Tier 3 - Preferred Brand Name‡ $42 $84 $47
Tier 4 - Non-Preferred 40% 30% 50%
Tier 5 - Specialty 33% N/A 33%
Coverage Gap Stage After your prescription costs reach $3,750 Your costs will be no more than 44% of the cost for generic drugs. You pay 35% of the cost of brand name drugs.
Catastrophic Coverage Stage After you have paid $5,000 out-of-pocket You pay the greater of 5% of the cost of the drug or $3.35 for generics/ $8.35 for brand names.

* 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.

† You pay the same amount in the Coverage Gap Phase as you do in the Initial Coverage Phase for Tier 1 & 2.

‡ You pay the same amount in the Coverage Gap Phase as you do in the Initial Coverage Phase for Tier 3, for insulin only.