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2017 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, 2017 to Dec 31, 2017

Click here for more information on Dental Benefits

Benefit You Pay
Premium $189
Deductible $0
MOOP $6,700
Primary Care Physician $0 copay
Specialist $20 copay
Preventative Care* You pay nothing
Inpatient Hospital Care $250
Outpatient Surgery and Hospital Services $0 in Ambulatory Services Center or preferred facility
$200 in non-preferred facility
Diagnostic Tests, X-rays, Lab Services and Radiology $0 copay
MRI, PET, CT Scans $150
Ambulance Services $50
Emergency Room $50
Urgent Care $20 copay in-network
$25 copay out-of-network

Prescription Drug Coverage

Generations State of Oklahoma Retiree Plan Deductible: $0

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 $0 $10
Tier 2 - Generics† $15 $15 $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 $3,700 Your costs will be no more than 51% of the cost for generic drugs. You pay 40% of the cost of brand name drugs.
Catastrophic Coverage Stage After you have paid $4,950 out-of-pocket You pay the greater of 5% of the cost of the drug or $3.30 for generics/ $8.25 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.