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HEALTH PLAN & SERVICES FOR STATE, EDUCATION AND LOCAL GOVERNMENT EMPLOYEES

Give yourself and your family the security that comes with knowing somebody is watching over you, ready to help in times of medical need. Whether you need a simple doctor’s visit so you can get back to your daily routine, or more complex treatment to restore your health, GlobalHealth has your solution.

Benefits at a Glance

The following is intended to be only a summary of benefits offered by GlobalHealth, plan MSTSB17, for State, Education, and Local Government Employees. For a complete list, including any limitations, exclusions, and plan restrictions, please review the GlobalHealth State of Oklahoma Schedule of Benefits and Member Handbook by clicking here.

BENEFIT State of Okahoma 2017 Benefit Plan
Annual Deductible This plan doesn’t have an annual deductible.
Annual out-of-pocket maximum Member: $3,500
Family: $10,500
Primary Care Physician Visits $0 copay per visit
Specialist Physician Visits $50 copay per visit
Preventive Care/Well Child Visits $0 copay per visit
X-Rays & Labs $0 copay per visit
Specialized Scans, Imaging & Diagnostic Exams $250 copay per scan in preferred facility; $750 copay per scan in non-preferred facility
Inpatient Hospital Stay $250 copay per day with $750 maximum per admission
Outpatient Surgery $250 copay in preferred facility;
$750 copay in non-preferred facility
Emergency Room Service $300 copay, waived if admitted to hospital inpatient
Urgent Care $25 copay in urgent care facility
Prescription Drugs (Chickasaw Nation Refill Center is a home delivery option for Native American members. Click here for more information.)

Retail Pharmacy $5/$10/$50/$75/$100/$200

Home Delivery or Extended Supply Retail $10/$20/$100/$150

Maternity Care $0 copay for prenatal care;
$25 one-time copay for delivery and all post-natal care;
$500 copay per admission for delivery
Family Planning No copay for women on FDA-approved services;
$50 copay for men if services performed in an office setting
Allergy Care $0 copay per PCP visit;
$50 copay per specialist visit;
$30 copay/6-week supply of antigen and administration
Physical, Occupational, Speech Therapy (Limited to 60 combined visits per course of therapy.) No copay for inpatient; Outpatient: $50 copay per visit; Rehabilitation Facility: $250 copay/day with $750 copay/admission
Chiropractic Care (15 visits per year) $25 copay per visit
Mental Health Services, Chemical Dependency & Substance Abuse $0 copay per outpatient office visit
$250 copay/day up to $750/admission

* All medications included in the $5 copayment (low-cost generic) program are denoted with [LCG] in the Drug Formulary, also available here.

NCQA

EXCLUSIONS AND LIMITATIONS

All benefits described below are excluded or limited under this Plan for all types of services.

General Limitations

We cover certain benefits only as follows:

Ancillary services and supplies

  • Hearing aids are limited to coverage for:
    • Children through the month in which he or she turns eighteen (18) years of age, one (1) aid per ear every forty-eight (48) months unless Medically Necessary for replace more often.
    • Children less than two (2) years of age, four (4) additional ear molds per year.
  • Corrective lenses and fittings limited to first set of basic frames and lenses (up to $100.00) following cataract surgery.
  • Routine foot care, shoes, shoe inserts, arch supports, and supportive devices limited to foot care for Members diagnosed with diabetes or peripheral vascular disease.
  • Orthopedic or corrective shoes limited to those permanently attached to a Denis Browne splint for children.
  • Wigs and scalp prostheses limited to $150 reimbursement per Plan Year when required due to loss of hair resulting from chemotherapy or radiation therapy.
  • Breast pumps limited to one (1) per Plan Year for women who are pregnant or nursing.
  • Orthotic devices limited to:
    • Members with diagnoses pertaining to peripheral vascular disease or diabetes.

Behavioral health services

  • Autism Screening is limited to children at ages eighteen (18) months and twenty-four (24) months.
  • Developmental Screening is limited to children up to the age of three (3) years.
  • Compulsive disorders treatment is limited to programs for feeding and eating disorders.
  • Residential treatment center care limited to 100 days per Plan Year.
  • Medical detoxification limited to 100 days per Plan Year.
  • Behavioral health case management limited to eight (8) hours per month and twenty-four (24) hours per Plan Year.
  • Psychosocial rehabilitation limited to eight (8) hours per month and twenty-four (24) hours per Plan Year.
  • Psychological testing limited to eight (8) hours per Plan Year.
  • Psychiatric or psychological treatment for developmental disorders limited to mental retardation, pervasive developmental disorder and other specific disorders, such as autism, Rett’s, or Asperger’s.
  • Applied behavioral analysis limited to:
    • Members under age nine (9) or if not diagnosed or treated until after age three (3) for at least six (6) years;
    • A maximum of twenty-five (25) hours per week; and
    • A maximum of $25,000 per Plan Year

Chiropractic care

  • Limited for fifteen (15) visits per Plan Year.

Cosmetic services

  • Treatment, item, supply, drug, procedure, or any portion of a procedure performed primarily to improve physical appearance limited to:
    • Repairing conditions resulting from an accidental injury;
    • Improvement of the physiological functioning of a malformed body member not related to dentistry or dental processes to the teeth and surrounding tissue; and
    • Breast reconstruction following a mastectomy.

Dental services - medical coverage

  • Dentistry or dental processes to the teeth and surrounding tissue limited to:
    • Emergency room services to treat accidental injury to the jaw, sound natural teeth, mouth, or face.
    • Improvement of the physiological functioning of a malformed body member resulting from a congenital defect.
  • General anesthesia/IV sedation for dental services limited to Members who are:
    • Under the age of nine (9) when he or she has a medical or emotional condition that requires Hospitalization or general anesthesia for dental care;
    • Severely disabled;
    • A minor four (4) years of age or under who, in the judgment of the Practitioner treating the child, is not of sufficient emotional development to undergo a Medically Necessary dental procedure without the use of anesthesia; and
    • Require Inpatient or Outpatient services because of an underlying medical condition and clinical status or because of the severity of the dental procedure.

Experimental or Investigational therapies

  • Drugs, items, devices, and procedures limited to:
    • Off-label uses of certain drugs used in the treatment of cancer or the study of oncology; and
    • Certain investigational uses of drugs, including chemotherapy for cancer treatment, if administered as part of an Approved Clinical Trial.

General care or Hospital services

  • Hospital private room limited to when the Member is required under the infection control policy of the Hospital to be in isolation to prevent contagion.
  • Treatment of injuries or illnesses sustained or contracted as the result of being under the influence of any narcotic, unless prescribed by a physician, limited to injury as a result of a medical condition (including both physical and mental health conditions).

Genetic analysis, services, or testing

  • Genetic counseling and testing is limited to women whose family history is associated with an increased risk for deleterious mutations in BRCA 1 and BRCA 2 genes.

Home Healthcare

  • Limited to 100 visits per Plan Year.

Physical, occupational, and speech therapy

  • Physical, occupational, and/or speech therapy services limited to sixty (60) combined visits per Plan Year for you to regain, maintain, or prevent deterioration of a skill or function that has been acquired, but then lost or impaired due to illness, injury, or disabling condition.

Prescription Drugs

  • Inhaler extender devices, peak flow meters, Ana-Kits, and EpiPens are limited to three (3) per Plan Year.
  • Prescription diaphragms are limited to two (2) per Plan Year.
  • The Pharmacy and Therapeutics Committee’s standard quantity limits, prior authorization criteria, and step therapies apply.
  • Specialty Drugs are limited to a one-month supply.
  • Smoking cessation products are limited to two (2) full 90-day courses of any FDA-approved tobacco cessation product per Plan Year, if prescribed by your PCP. Limited to Members who are at least eighteen (18) years old.
  • Drugs prescribed or administered by Out-of-network physicians in non-emergencies is limited to those prescribed by dentists.
  • Non-prescription contraceptive jellies, ointments, foams, or devices limited to those that are FDA-approved and prescribed by a Network physician for a woman.
  • Biological sera, medication prescribed for parenteral use or administration, allergy sera, immunizing agents, and immunizing injectable drugs limited to immunizations covered under Preventive Care guidelines and administered at a Network pharmacy.
  • Prescription drugs for the treatment of sexual dysfunction, including erectile dysfunction, impotence, and anorgasmy, hyporgasmy, or decreased libido limited to post-prostate surgery indications.

Sexual dysfunction

  • Services related to sexual dysfunction limited to drugs and supplies for post-prostate surgery indications.

Skilled Nursing Facility care

  • Limited to 100 days per Plan Year.

Transgender services

  • Limited to individually appropriate Preventative Care services.

Vision

  • Routine services limited to one (1) check-up, including eye refraction, per Plan Year.
  • Treatment for orthoptics or visual training limted to a diagnosis of mild strabismus.

General Excluded Services

  • The following benefits are not covered:

Ancillary services and supplies

  • Mattresses and other bedding or bed-wetting alarms.
  • Equipment or devices not medical in nature such as braces worn for athletic or recreational use, ear plugs, elastic stockings or supports, or garter belts.
  • Jacuzzi/whirlpools.
  • Power-operated vehicles that may be used as wheelchairs.
  • Purchase or rental of equipment or supplies for common household use including, but not limited to: Physical fitness equipment, traction tables, air conditioners, water purifiers, air-cleaning machines or filtration devices, cervical or lumbar pillows, grab bars, raised toilet seats, shower benches, beds, or chairs.
  • Bandages, pads, or diapers.

Behavioral health services

  • Education, tutoring, and services for the purpose of diagnosing or treating a learning disability, disruptive, impulse-control, or conduct disorder.
  • Marital counseling.

Dental services – medical coverage

  • General dental services.
  • Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and the alveolar bones).
  • Correction of occlusive jaw defects, dental implants, or grafting of alveolar ridges.
  • Treatment of soft tissue for the purpose of facilitating dental procedures or dentures.

Experimental or Investigational therapies

  • Drugs, therapies, and technologies whose long-term efficacy or effect is undetermined or unproven or whose efficacy is no greater than that of traditionally accepted standard treatment.
  • New procedures, services, supplies, and drugs until they are reviewed for safety, efficacy, and cost-effectiveness and approved by GlobalHealth.

General care or Hospital services

  • Treatment of any kind which is excessive or not Medically Necessary.
  • Services received without an authorization, when one is required, and complications arising from those services.
  • Treatment of any kind received before your start date of coverage or after the time coverage ends, even if authorized.
  • Care or services provided outside the GlobalHealth Service Area if the need for such care or services could have been foreseen before leaving the Service Area.
  • Services, other than Hospital services for behavioral health, for which you do not allow the release of information to GlobalHealth.
  • Services for travel, insurance, licensing, employment, school, camp, sports, premarital, or pre-adoption purposes.
  • Personal or comfort items.
  • Services received while outside of the United States (50 states and District of Columbia).
  • Charges for injuries resulting from war or act of war (whether declared or undeclared) while serving in the military or an auxiliary unit attached to the military or working in an area of war whether voluntarily or as required by an employer.
  • Treatment of injuries or illnesses resulting from an attempt or commission of a felony, or as a result of being engaged in an illegal occupation.
  • Services as a result of recreational drug or alcohol use.
  • Elective or voluntary enhancement procedures, services, supplies, or medications, including but not limited to:
    • Hair growth
    • Sexual performance
    • Athletic performance
    • Cosmetic purposes
    • Anti-aging
  • Separate charges for missed or canceled appointments, penalty or finance charges, maintenance and/or record-keeping, record copying, or Case Management services.
  • Treatment, supplies, drugs, and devices for which no charge was made. Treatment, supplies, drugs, and devices for which no payment would be requested if you did not have this coverage.
  • Custodial care, respite care, homemaker services, or domiciliary care.
  • Treatment for injury resulting from extreme activities including, but not limited to:
    • Base jumping
    • Bungee jumping
    • Bull riding
    • Car racing
    • Skydiving
    • Motorcycle stunts
  • Alternative drugs and/or treatments used in the place of standard therapy, to treat any condition or illness.
  • Screening services requested solely by you, such as commercially advertised heart scans.

Obstetrical and Infertility services

  • Elective abortions.
  • Home uterine monitoring.
  • Expenses related to surrogate parenthood.
  • Alternative programs for delivery such as home delivery and use of midwives and birthing centers.
  • In vitro fertilization, artificial insemination, embryo transfers, reversal of voluntary sterilization, ovum transplant, gamete intrafallopian transfer (“GIFT”), zygote intrafallopian transfer (“ZIFT”), surrogate parenting, and donor semen expenses.

Other coverage

  • Treatment for disabilities connected to military service for which you are legally entitled and to which you have reasonable accessibility (i.e., services through a federal governmental agency).
  • Services that are provided as a result of Workers’ Compensation laws or similar laws.
  • Treatment for which the cost is recoverable under any other coverage, including Workers’ Compensation, Occupational Disease law, or any state or government agency.

Other Excluded Services

  • Services resulting in whole or in part from an excluded condition, item, or service.

Physical, occupational, and speech therapy

  • Kinesiology, movement therapy, or biofeedback.
  • Rolf technique.
  • Massage therapy.
  • Acupuncture/acupressure.
  • Recreational therapy including, but not limited to:
    • Animal-facilitated therapy
    • Music therapy

Prescription Drugs

  • Drugs and dietary supplements available without a prescription (over-the-counter) or for which there is a non-prescription therapeutic equivalent available, even if ordered by a physician.
  • Saline and medications for irrigation.
  • Topical testosterone products (e.g., AndroGel®, Fortesta®, etc.).
  • Drugs prescribed for a non-FDA approved indication, dosage, or length of therapy.

Repair and replacement

  • Drugs, eyewear, devices, appliances, equipment, dental work, or other items that are lost, missing, sold, or stolen.
  • Items that have been damaged or destroyed due to improper use or abuse.

Transplants

  • Artificial or non-human organ transplants or transplants considered experimental, investigative, or unproven.
  • Donor Screening tests and donor search expenses.

Transportation/lodging

  • Routine, non-emergent ambulance transport unless preauthorized by GlobalHealth.
  • Lodging, meals, and transportation costs.

Vision

  • Non-prescription lenses.
  • LASIK, INTACS, radial keratotomy, and other refractive surgery.
  • Computer programs of any type, including, but not limited to, those to assist with vision therapy.
  • Special multifocal ocular implant lenses.

Weight Reduction Programs

  • Gastric stapling, gastric balloon services, or any surgical treatment for obesity or weight-loss purposes.