Plan Year 2013 - Ok - State of Oklahoma Web Site by pengxiang

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									 Employee Benefit Options Guide




Plan Year 2013
January 1 through December 31, 2013




      Health, Dental, Life, and Vision
                                         #2745
     Update to Printed Version of This Guide
Update to CommunityCare’s After Hours Urgent Care benefit on page 19:

  Preauthorization is not required for this benefit.

Update to GlobalHealth’s Chiropractic and Manipulative Therapy Visit benefit on
page 21:

  $20 copay.
           – IMPORTANT – IMPORTANT – IMPORTANT –


 Before choosing a plan, it is very important that you review the list of
 network providers available in your area for that plan. Although a plan
 may be available in your area, the number of network providers may
 be limited. See the network provider listing on each plan’s website or
 contact their customer service. See Help Lines on page 28 for contact
 information.




           – IMPORTANT – IMPORTANT – IMPORTANT –



The participating carriers reviewed and approved the information in this
Guide. There is no guarantee that a provider will remain within a plan’s
network or be accepting new patients throughout the year. Please verify
your provider’s participation in your plan’s network.




           – IMPORTANT – IMPORTANT – IMPORTANT –



This publication was printed by the Office of Management and Enterprise Services as authorized by 74 O.S.,
Section 1301, et seq. 20,000 copies have been printed at a cost of $0.61 each. Copies have been deposited
with the Publications Clearinghouse of the Oklahoma Department of Libraries and submitted to Documents.
OK.gov in accordance with the Oklahoma State Government Open Documents Initiative (62 O.S. § 34.11.3).


             A fully accessible version of this guide is available on the OSEEGIB website at
                             www.sib.ok.gov or www.healthchoiceok.com.
Oklahoma State and Education Employees Group Insurance Board
              A Division of the Office of Management and Enterprise Services
                           Monthly Premiums for Current Employees
                         Plan Year January 1, 2013 - December 31, 2013
                HEALTH PLANS                            MEMBER             SPOUSE          CHILD        CHILDREN
 HealthChoice High                                          $ 463.99          $ 681.96      $ 235.57        $ 363.45
 HealthChoice High Alternative                              $ 463.99          $ 681.96      $ 235.57        $ 363.45
 HealthChoice Basic                                         $ 402.98          $ 593.52      $ 207.66        $ 319.80
 HealthChoice Basic Alternative                             $ 402.98          $ 593.52      $ 207.66        $ 319.80
 HealthChoice S-Account                                     $ 382.56          $ 515.44      $ 190.18        $ 291.90
 HealthChoice USA                                           $ 710.21          $ 710.21      $ 233.25        $ 359.70
 CommunityCare HMO                                          $ 543.82          $ 792.14      $ 276.98        $ 443.16
 GlobalHealth HMO                                           $ 398.84          $ 654.14      $ 210.18        $ 335.08
 DISABILITY (Employee only)                                               $9.10 (Limited county participation only)

                DENTAL PLANS                            MEMBER             SPOUSE          CHILD        CHILDREN
 HealthChoice Dental                                        $ 31.38           $ 31.38        $ 26.90         $ 66.96
 Assurant Freedom Preferred                                 $ 28.83           $ 28.67        $ 21.50         $ 57.80
 Assurant Heritage Plus with SBA (Prepaid)                  $ 11.74           $ 8.86         $ 7.60          $ 15.20
 Assurant Heritage Secure (Prepaid)                         $ 7.20            $ 5.98         $ 5.20          $ 10.38
 CIGNA Dental Care Plan (Prepaid)                           $ 9.26            $ 6.06         $ 7.08          $ 15.32
 Delta Dental PPO                                           $ 33.64           $ 33.62        $ 29.26         $ 74.04
 Delta Dental Premier                                       $ 40.66           $ 40.66        $ 35.40         $ 89.54
 Delta Dental PPO – Choice                                  $ 15.06           $ 34.18        $ 34.44         $ 83.60
                VISION PLANS                            MEMBER             SPOUSE          CHILD        CHILDREN
 Humana/CompBenefits VisionCare Plan                         $ 6.76            $ 5.06         $ 3.57         $ 4.46
 Primary Vision Care Services (PVCS)                         $ 9.25            $ 8.00         $ 8.50         $ 10.75
 Superior Vision Services                                    $ 7.14            $ 7.10         $ 6.72         $ 13.80
 UnitedHealthcare Vision                                     $ 8.18            $ 5.79         $ 4.59         $ 6.98
 Vision Service Plan (VSP)                                   $ 8.93            $ 5.98         $ 5.73         $ 12.88

               LIFE
 HealthChoice Basic Life ($20,000) $4.00    First $20,000 of Supplemental Life $4.00
                        Age-Rated Supplemental Life – Cost Per $20,000 unit
        < 30 ----------   $0.80              45 - 49    -------   $2.00                   65 - 69 ------- $10.40
        30 - 34 -------   $0.80              50 - 54    -------   $3.60                   70 - 74 ------- $17.60
        35 - 39 -------   $0.80              55 - 59    -------   $5.60                   75+ ----------- $27.20
        40 - 44 -------   $1.20              60 - 64    -------   $6.40

Dependent Life                    Low Option $2.60                Standard Option $4.32       Premier Option $8.64
Spouse                            $ 6,000 of coverage              $ 10,000 of coverage         $ 20,000 of coverage
Child (age 6 months to 26)        $ 3,000 of coverage              $ 5,000 of coverage          $ 10,000 of coverage
Child (live birth to 6 months)    $ 1,000 of coverage              $ 1,000 of coverage          $ 1,000 of coverage
                                                                                         TABLE Of CONTENTS


         Introduction ....................................................................................................... i
         2013 Plan Changes ............................................................................................ 1
         General Enrollment Information ....................................................................... 3
         Health Plans ...................................................................................................... 3
         Dental Plans ...................................................................................................... 3
         Vision Plans ......................................................................................................   4
         HealthChoice Life Insurance Plan .................................................................... 4
         HealthChoice Disability Insurance Plan ........................................................... 5
         American Fidelity Health Savings Account....................................................... 6
         Oklahoma Tobacco Helpline.............................................................................. 8
         Enrollment Periods ...........................................................................................        9
         Eligibility .......................................................................................................... 9
         HMO ZIP Code List .......................................................................................... 12
         Comparison of Benefits for Health Plans ......................................................... 16
         Comparison of Benefits for Dental Plans ......................................................... 24
         Comparison of Benefits for Vision Plans .......................................................... 26
         Help Lines ......................................................................................................... 28




        This information is only a brief summary of the plans. All benefits and limitations of these
    plans are governed in all cases by the relevant plan documents, insurance contracts, handbooks,
 and Rules of the Oklahoma State and Education Employees Group Insurance Board, a division of
the Office of Management and Enterprise Services. The Rules of the Oklahoma Administrative Code,
 Title 360, are controlling in all aspects of Plan benefits. No oral statement of any person shall modify or
  otherwise affect the benefits, limitations, or exclusions of any plan.
                             www.sib.ok.gov or www.healthchoiceok.com
                                          INTRODUCTION
     The Oklahoma State and Education Employees Group Insurance Board (OSEEGIB), a division of the Office of
Management and Enterprise Services, produced this Employee Benefit Options Guide to help you select your benefits. It
is a summary of the available plans. The insurance benefits explained in this Guide are:
     ♦ Health
     ♦ Dental
     ♦ Vision
     ♦ Life
     ♦ Disability
See the Monthly Premium Chart and Comparison of Benefits charts to determine your costs under each plan.


Helpful Hints for Option Period
   ♦ Review Section B of your pre-printed Option Period Enrollment/Change Form. This is your most current
     coverage.
   ♦ Contact your Insurance Coordinator if you have questions about your current coverage.
   ♦ Review the plan changes for 2013 listed on page 1 of this Guide.
   ♦ Ask your Insurance Coordinator about returning your form even if you are not making changes.
   ♦ Use the following resources to help you decide on coverage for you and your dependents for 2013:

               ●   This Guide                                 ●   Provider Directories
               ●   Plan Websites                              ●   OSEEGIB Member Services
               ●   Customer Service Telephone Numbers         ●   Your Insurance Coordinator

   ♦ Complete your Option Period Enrollment/Change Form and return it to your Insurance Coordinator by the
     deadline set by your coordinator.
   ♦ Review your Confirmation Statement when you receive it in the mail to verify your coverage is correct.
   ♦ Contact your Insurance Coordinator right away if your Confirmation Statement is incorrect. If you do not make
     changes to your coverage and you are not automatically enrolled in one of the HealthChoice alternative
     plans (see page 1), you will not receive a Confirmation Statement from OSEEGIB*. Keep a copy of your
     Option Period Enrollment/Change Form as verification of your insurance coverage.

   *UnitedHealthcare is not a plan option for 2013. If you are enrolled in a UnitedHealthcare Plan, you must
   make another plan selection.


Helpful Hints for New Employees
   ♦ Use the following resources to help you decide on coverage for you and your dependents:

               ●   This Guide                                 ●   Provider Directories
               ●   Plan Websites                              ●   OSEEGIB Member Services
               ●   Customer Service Telephone Numbers         ●   Your Insurance Coordinator

   ♦ Complete your Insurance Enrollment Form and return it to your Insurance Coordinator.
   ♦ Review your Confirmation Statement when you receive it in the mail to verify your coverage is correct.
   ♦ Contact your Insurance Coordinator right away if your Confirmation Statement is incorrect.



                                                          i
                                     2013 PLAN CHANGES
Plan changes are indicated by bold text in the Comparison of Benefits charts.

Health Plan Changes
HealthChoice Health Plans
       To enroll or remain enrolled in the HealthChoice High or Basic Plan for Plan Year 2013, you must attest
   that you and your covered dependents are tobacco-free by completing the HealthChoice High and Basic
   Plans Tobacco-Free Attestation for Plan Year 2013 as part of the Option Period enrollment process. The
   Attestation is available to you:
       ♦ Online at www.sib.ok.gov or www.healthchoiceok.com
       ♦ By calling HealthChoice Member Services at 1-405-717-8780 or toll-free 1-800-752-9475. TDD users call
           1-405-949-2281 or toll-free 1-866-447-0436.
       If you cannot complete the tobacco-free Attestation because you and/or your covered dependents are not
   tobacco-free, you can still qualify for the HealthChoice High or HealthChoice Basic plan if you can provide
   one of the following reasonable alternatives:
       ♦ Show proof of an attempt to quit using tobacco by enrolling in the quit tobacco program available through
           the Oklahoma Tobacco Helpline* and Alere Wellbeing AND completing three coaching calls; or
       ♦ Provide a letter from your doctor indicating it is not medically advisable for you or your covered dependents
           to quit tobacco.
       If you do not complete the tobacco-free Attestation or complete one of the reasonable alternatives as defined
   above, you will automatically be enrolled in the HealthChoice High Alternative or Basic Alternative Plan, and your
   annual deductible and out-of-pocket limit will be $250 higher.
   *For information about the quit tobacco program available through the Oklahoma Tobacco Helpline and Alere
   Wellbeing, see page 8.

HMOs
   CommunityCare and GlobalHealth HMO Plans
   ♦ Both HMOs are offering one plan with benefits similar to their HMO Alternative Plans offered for Plan Year
      2012. See the Comparison of Benefits for Health Plans on pages 16-23.
   ♦ HMO service areas have changed. See the HMO ZIP Code List on pages 12-14 to check your eligibility.
   CommunityCare HMO Plan
   ♦ The specialist copay for mental health or substance abuse outpatient is being decreased from $50 to $35.
   UnitedHealthcare HMO Plans
   ♦ UnitedHealthcare is not offering its HMO for Plan Year 2013. If you are currently enrolled in a
      UnitedHealthcare plan, you must make another plan selection.


Dental Plan Changes
HealthChoice Dental Plan
   ♦ The plan year maximum is being increased from $2,000 to $2,500.


Vision Plan Changes
Superior Vision Plan
   ♦ There is a $25 copay for standard progressive lenses in-Network, and the Plan will pay up to $49 out-of-
     Network.
   ♦ There is a 5% to 50% discount off surgical fees for laser vision correction.

        Plan changes are indicated by bold text in the Comparison of Benefits charts.
                                                          1
  If you have questions about any of the
plans, contact each plan directly. See Help
Lines on page 28 of this Employee Benefit
  Options Guide for contact information.


                    2
                GENERAL ENROLLMENT INfORMATION
   Your employer determines which benefits are available to you and may not participate in all the benefits
explained in this Guide. Ask your Insurance Coordinator which benefits are available to you.
   The benefits you select will be in effect January 1, 2013, or for new employees, the effective date of your
coverage, through December 31, 2013.
   After enrollment, the plans you selected will provide more information about your benefits.

 Once enrolled in any of the plans, it is your responsibility to review your benefits carefully so you know
      what is covered, as well as the plan’s policies and procedures, before you use your benefits.


                                        HEALTH PLANS
There are eight health plans available:
   ●  HealthChoice High and High Alternative Plans              ●   HealthChoice USA Plan
   ●  HealthChoice Basic and Basic Alternative Plans            ●   CommunityCare HMO
   ●  HealthChoice S-Account Plan                               ●   GlobalHealth HMO
      See Comparison of Benefits for Health Plans on pages 16-23 for specific benefit information.
   ♦ There are no preexisting condition exclusions or limitations applied to any of the health plans.
   ♦ During Option Period, to enroll or remain enrolled in the HealthChoice High or Basic Plan for Plan Year
     2013, you must complete the tobacco-free Attestation located on the OSEEGIB website.
   ♦ The HealthChoice USA Plan is designed for employees who receive a work assignment of more than
     90 consecutive days outside of Oklahoma and Arkansas. Call HealthChoice Member Services for more
     details.
   ♦ HealthChoice contracts with American Fidelity Health Services Administration to make establishing
     and keeping a Health Savings Account (HSA) easier and more convenient for HealthChoice S-Account
     members. For more information about HSAs, see page 6.
   ♦ You must live or work within an HMO’s ZIP Code service area to be eligible. Post Office Box
     addresses cannot be used to determine your HMO eligibility. See pages 12-14 for the HMO ZIP Code
     List.
   ♦ If you select an HMO, you must use the provider network designated by your plan for Oklahoma.
   ♦ All health plans coordinate benefits with other group insurance plans you have in force. For more
     information, check with each health plan.
   ♦ All plans have toll-free numbers for customer service. See Help Lines on page 28.
   ♦ Check with the individual health plan if you have benefit questions.


                                        DENTAL PLANS
Verify your employer offers dental coverage through OSEEGIB.
There are eight dental plans available:
   ●  HealthChoice Dental                              ●   CIGNA Dental Care Plan (Prepaid)
   ●  Assurant Freedom Preferred                       ●   Delta Dental PPO
   ●  Assurant Heritage Plus with SBA (Prepaid)        ●   Delta Dental Premier
   ●  Assurant Heritage Secure (Prepaid)               ●   Delta Dental PPO – Choice
      See Comparison of Benefits for Dental Plans on pages 24-25 for specific benefit information.
   ♦ All dental plans have toll-free numbers for customer service. See Help Lines on page 28.
   ♦ Check with the individual dental plan if you have benefit questions.

                                                        3
                                          VISION PLANS
Verify your employer offers vision coverage through OSEEGIB.
There are five vision plans available:
   ●  Humana/CompBenefits VisionCare Plan              ●   UnitedHealthcare Vision
   ●  Primary Vision Care Services (PVCS)              ●   Vision Service Plan (VSP)
   ●  Superior Vision Plan
      See Comparison of Benefits for Vision Plans on pages 26-27 for specific benefit information.
   ♦ Verify your vision provider participates in a vision plan’s network by contacting the plan, visiting the
     plan’s website, or calling your provider.
   ♦ All vision plans have limited coverage for services provided by out-of-network providers.
   ♦ All plans have toll-free numbers for customer service. See Help Lines on page 28.
   ♦ Check with the individual vision plan if you have benefit questions.

         If your provider leaves your health, dental, or vision plan, you cannot change plans
  until the next annual Option Period; however, you can change providers within your plan’s
  Network as needed.


                                     Thinking About Retirement?
     If you are a current employee who is retiring before January 1, 2013, please contact OSEEGIB
  Member Services and request the appropriate materials. You will select your benefits from either the former
  employee pre-Medicare Option Period guide or the Medicare Option Period guide. To contact Member
    Services, see Help Lines on page 28.


               HEALTHCHOICE LIfE INSURANCE PLAN
Verify your employer offers HealthChoice Life Insurance through OSEEGIB.
   ♦ As a new employee, you can elect life insurance coverage within 30 days of your employment date or
       the date you become eligible. You can enroll in a limited amount of coverage, known as Guaranteed
       Issue, without an approved Life Insurance Application. All requests for coverage above Guaranteed
       Issue require an approved Life Insurance Application.
   ♦ As a current employee, if you did not enroll when first eligible, you can enroll:
         ● During the annual Option Period. An approved Life Insurance Application is required to enroll in or
           increase life insurance coverage.
         ● Within 30 days of a midyear qualifying event. An approved Life Insurance Application is required.
         ● Within 30 days of the loss of other group life coverage. You can enroll in the amount of coverage
           you lost, rounded up to the next $20,000 unit, without a Life Insurance Application. Proof of loss is
           required.

Basic Life Insurance. . . for You
  ♦ Basic Life pays a benefit of $20,000 to your beneficiary in the event of your death.
  ♦ Basic Life includes Accidental Death and Dismemberment (AD&D) coverage. This coverage pays an
      additional $20,000 to your beneficiary if your death is due to an accident. It also pays benefits if you lose
      your sight or a limb due to an accident.

Supplemental Life Insurance . . . for You
  ♦ At the time of initial enrollment, you can enroll in Supplemental Life coverage in an amount equal to
     two times your annual salary, rounded up to the next $20,000 unit. This amount, known as Guaranteed
     Issue, is available without an approved Life Insurance Application.
                                                      4
   ♦ You can enroll in Supplemental Life in units of $20,000. The maximum amount of Supplemental Life
     coverage available is $500,000. You must complete a Life Insurance Application to apply for coverage.
   ♦ The first $20,000 unit of Supplemental Life provides an additional $20,000 of AD&D coverage.
   ♦ A Life Insurance Application is available from your Insurance Coordinator.

Dependent Life Insurance . . . for Your family
  ♦ If you enroll in Basic Life insurance, you can elect Dependent Life insurance for your spouse and
     eligible dependents during your initial enrollment, during the annual Option Period, or within 30 days of
     the loss of other group life insurance or other midyear qualifying event.
  ♦ Dependent Life does not include AD&D coverage.
  ♦ There are three options for Dependent Life coverage: Low, Standard, or Premier Option. Regardless of
     the number of dependents, the monthly premium is the same. Each eligible dependent must be enrolled
     in Dependent Life.
  ♦ A Life Insurance Application is not required for Dependent Life coverage.

DEPENDENT                           LOW OPTION              STANDARD OPTION            PREMIER OPTION
Spouse                             $6,000 of coverage        $10,000 of coverage       $20,000 of coverage
Child (age 6 months to 26)         $3,000 of coverage        $ 5,000 of coverage       $10,000 of coverage
Child (live birth to 6 months)     $1,000 of coverage        $ 1,000 of coverage       $ 1,000 of coverage

Beneficiary Designation
    Benefits are paid to your beneficiary in a lump sum. You must name your beneficiary or beneficiaries when
you enroll. Your beneficiary designation can be changed at any time. For a Beneficiary Designation Form or
more information, contact your Insurance Coordinator. This form is also available on the HealthChoice website
at www.sib.ok.gov or www.healthchoiceok.com. Life insurance benefits for covered dependents are always
paid to the member.


        HEALTHCHOICE DISABILITY INSURANCE PLAN
Verify your employer offers HealthChoice Disability Insurance through OSEEGIB (limited
county participation only).

   The HealthChoice Disability Insurance Plan provides partial replacement income if you are unable to work
due to an illness or injury. Disability coverage is not available to dependents.

Eligibility
    Enrollment in the disability plan begins the first day of the month following your employment date or the
date you become eligible. You become eligible for disability benefits after 31 consecutive days of employment.
During that time, you must continuously perform all of the material duties of your regular occupation. Any
claim for disability benefits must be filed within one year of the date your disability began.




                                                        5
                             HEALTH SAVINGS ACCOUNTS
   A Health Savings Account (HSA) is an individually owned savings account that allows you to set aside money for
health care tax-free whenever you select an HSA qualified High Deductible Health Plan (HDHP). Money left in the
account can accumulate interest tax-free and money used to pay for qualified medical expenses can be made tax-free.
Through your employer’s Section 125 plan, you can contribute pre-tax amounts up to the yearly maximum allowed.
SOME HIGHLIGHTS Of HSAs
   ♦ HSA contributions are tax-free.
   ♦ Interest may be tax-free.
   ♦ Interest earned is applied to your account starting with first dollar contribution.
   ♦ Withdrawals are not taxed when funds are used for qualified medical expenses.
   ♦ You decide when and how to use your money.
   ♦ No “use it or lose it” requirement meaning whatever deposits you make each year can be left on deposit to earn
     interest and to be available to pay for future medical expenses.
   ♦ You can pay for qualified medical expenses on yourself and your spouse or your tax dependents regardless of
     whether or not they are on your health plan.
   ♦ No matter where you go, your account follows you. Even if you change jobs, change medical coverage, become
     unemployed, move to another state, or change your marital status, your HSA goes with you. You own it!
   ♦ If you do not remain a qualified individual, you can continue to earn interest and pay for qualified medical
     expenses as long as there are funds in your account.
CONTRIBUTIONS
    You can contribute up to the annual maximum amount allowed by law in any given tax-year. The IRS establishes
the maximum amounts on an annual basis. The 2013 maximum allowable is $3,250 for an individual or $6,450 for a
family. If your HDHP is effective other than January 1 and you wish to make the maximum contribution, you must
meet certain requirements. Visit www.afhsa.com for more information.
    If you are age 55 and older, you are eligible to make an additional catch-up contribution of $1,000 per year. HSAs
are owned by one individual, so if you and your spouse are covered under the family HDHP and both of you are age 55
or older, only you as the owner of the account can make the catch up contribution. Your spouse would be required to
establish his or her own HSA to make catch-up contributions.
QUALIfIED MEDICAL EXPENSES
    There are many expenses that qualify for tax-free distributions. For a listing, you can refer to the HSA Eligible
Expenses listed on www.afhsa.com. If you use funds for any expenses that are not eligible, then the funds withdrawn
are subject to income taxes and a 20% additional tax penalty. The non-qualified distributions must be reported on your
annual income tax return.
    Additional information on eligible expenses can be found in IRS Publication 502 at www.irs.gov. Even though
Publication 502 is a valuable resource on what qualifies as a medical expense, it addresses only what expenses are
deductible. It does not describe the different rules for reimbursing medical expenses under an HSA.
MAKING WITHDRAWALS fROM YOUR HSA
You can withdraw funds from your account in three ways: 1. HSA Debit Card; 2. On-Line Distribution Request; 3.
Distribution Form.
You can use the money from your HSA as follows:
       1. You can only use the funds that have been deposited.
       2. You can withdraw funds for qualified medical expenses incurred after the date your account is established.



SB-22136 0512                                              6
        3. You may elect to make withdrawals from your HSA when the expenses are incurred, or you may make
           withdrawals for these expenses anytime in the future. There is no time limit.
    The IRS requires that you keep receipts to prove that your HSA funds were used to pay for qualified medical
expenses in order to receive the tax benefit. Although you are not required to send your receipts with your tax returns,
keeping your receipts with your tax information is an excellent way to ensure proper documentation. You will receive
two forms each year as a result of having an HSA: 1) a 1099-SA which shows the total distributions from your account
will be mailed by January 31, and 2) a 5498-SA which shows total contributions to your account will be mailed by May
31. Each of these forms will be sent to the IRS.
ELIGIBILITY REQUIREMENTS
   To be eligible to establish and contribute to an HSA, you must meet the following requirements:
      1. You must have an HSA-qualified HDHP.
      2. You cannot be claimed as a dependent on anyone else’s tax return.
      3. You cannot be covered under a non-HDHP coverage other than “permitted coverage” or “permitted
         insurance” and/or preventative care. Products such as Cancer, Accident, Long Term Care, and Disability
         Income are usually considered permitted coverage/insurance. Check with your employer or the insurance
         provider to be sure.
      4. You cannot have a general purpose Health FSA-Medical Reimbursement Account or a general purpose
         Health Reimbursement Account (HRA). However, you can have a Limited Purpose Health FSA or HRA
         which allows for dental and vision reimbursement only should your employer offer this benefit. Note: If you
         are covered under your spouse’s general purpose Health FSA or HRA, then you are not eligible to establish
         and contribute to an HSA. In addition, your eligibility may be affected if you have access to the following:
         Employer’s on-site clinic, VA benefits, Tri-Care, or an Indian Clinic.
      5. You cannot be enrolled in Medicare.
INTEREST & ACCOUNT fEES
   HSA deposits are deposited into an interest bearing FDIC insured account. The more you save the more you earn.
Monthly maintenance and transaction fees may apply and will be deducted from your account. Check with your
employer for the interest/fee schedule.
   If you seek higher returns or value security, we do not charge transaction fees or broker commissions when we give
you access to investment fund options that cover the spectrum of investment risks. (Fees associated with certain mutual
funds may be incurred. Review the mutual funds prospectus for additional information when you are ready to invest.)
SUMMARY
    HSAs give you the savings potential, flexibility, portability, and tax savings unlike any other savings account.
By enrolling in a qualified HDHP, you save on premiums. By investing those savings into an HSA, you can save for
medical expenses in the future.
    Individuals who elect an HSA with us will receive a welcome packet outlining all the information associated with
the account. This flyer is meant to provide you high level information on HSAs. For more information on HSAs visit
our website at www.afhsa.com. There you will find an overview specific to employees/individuals along with other
helpful information.
CONTACT INfORMATION
American Fidelity Health Services Administration                                           Toll-Free - 1-866-326-3600
2000 N. Classen Blvd, Suite 7E                                                             Fax - (405) 523-5072
Oklahoma City, OK 73106                                                                    Web site - www.afhsa.com
(405) 523-5699 – Local Number                                                              email - HSA-Support@af-group.com


 American Fidelity Health Services Administration and its affiliates do not provide legal or tax advice and the information provided is general in nature and
           should not be considered legal or tax advice. You should consult with an attorney or tax professional regarding legal or tax advice.




SB-22136 0512                                                                 7
What is the Oklahoma Tobacco Helpline?
    The Helpline is a highly effective service that provides a series of one-on-one tobacco cessation
coaching sessions over the telephone. Once enrolled in the program, most participants also receive nicotine
replacement products such as patches, gum, or lozenges. The Helpline has been proven to work for
Oklahomans, and similar Helplines have been proven to work for people all over the country.

How does telephone coaching work?
    When you call the Helpline at 1-800-QUIT-NOW, you’ll speak with a helpful registration assistant who
will ask a few questions to gather your phone number and other contact information, insurance provider,
and basic information about your reason for calling. Then, a Helpline Quit Coach™ will work with you
to determine your readiness to quit, discuss your options for using nicotine replacement products or other
cessation aids, and assist you in developing a quit plan that is right for you. The Quit Coach will also
schedule up to four follow-up sessions throughout your quitting process, and you may call in to speak with a
coach as needed between scheduled calls.

    Once enrolled, you may also participate in Web Coach, an online resource with helpful quitting tips and
tools and an online community for additional support. Your Quit Coach will discuss this feature with you.

Who is eligible to receive Helpline services?
    Anyone living in Oklahoma ages 13 and older may call the Helpline and receive services at no charge up
to twice per year. Helpline specialists assist tobacco users, health care professionals, and concerned family
members and friends.

What are the Oklahoma Tobacco Helpline hours?
   The Helpline is available 24 hours a day, 7 days a week.

Additional HealthChoice Insurance Helpline Benefits
    HealthChoice members enrolled in the Helpline program may receive up to 12 weeks of nicotine
replacement products up to twice per year with no copay or deductible. The products are mailed directly to
your home.




                                                     8
                                 ENROLLMENT PERIODS
Option Period Enrollment – Coverage effective January 1, 2013
  This is the time when eligible employees can:
     ●    Enroll in plans
     ●    Change plans or drop coverage
     ●    Increase or decrease life insurance coverage
     ●    Add or drop eligible family members from coverage
  ♦ You can enroll in health, dental, life, and/or vision coverage for yourself and/or your dependent(s) during the
     annual Option Period, as long as you have not dropped that coverage within the past 12 months. If you have
     dropped coverage within the past 12 months, limitations and/or exceptions may apply.

Initial Enrollment – Coverage effective the first of the month following your employment
date or the date set by your employer
  This is the time when new employees are eligible to:
     ●    Enroll in plans
     ●    Enroll eligible dependents
     ●    Apply for life insurance coverage above Guaranteed Issue
  ♦ As a new employee, you have 30 days from your employment date, or the date you become eligible, to enroll in
     coverage. If you do not enroll within 30 days, you cannot enroll until the next annual Option Period, unless you
     experience a qualifying event. Check with your Insurance Coordinator for more information.
  ♦ You have 30 days following your eligibility date to make changes to your original enrollment.
  ♦ If you request life insurance coverage in an amount greater than two times your annual salary, known as
     Guaranteed Issue, you must complete and submit a Life Insurance Application for approval. See your Insurance
     Coordinator for an application.
  ♦ Keep a copy of your Insurance Enrollment Form for your records.

Midyear Changes – Coverage generally effective the first of the month following a
qualifying event
  ♦ Midyear plan changes are allowed only when a qualifying event such as birth, marriage, or loss of other
    group coverage occurs. You must complete an Insurance Change Form within 30 days of the event. See your
    Insurance Coordinator for more information.


                                              ELIGIBILITY
Members
  ♦ Your employer must participate in the plans offered through OSEEGIB.
  ♦ You must be a current Education employee eligible to participate in the Oklahoma Teachers’ Retirement System
    working a minimum of four hours per day or 20 hours per week, or a current State of Oklahoma or Local
    Government employee regularly scheduled to work at least 1,000 hours a year and not classified as a temporary
    or seasonal employee.
  ♦ You must be enrolled in a group health plan to enroll in dental and/or life insurance.


Dependents
  ♦ If one eligible dependent is covered, all eligible dependents must be covered. You can choose not to cover


                                                         9
      dependents who do not reside with you, are married, are not financially dependent on you for support, or have
      other group coverage. Eligible dependents include:
      ●    Your legal spouse (including common-law).
      ●    Your daughter, son, stepdaughter, stepson, eligible foster child, adopted child, or child legally placed with
           you for adoption up to age 26, whether married or unmarried.
      ●    A dependent, regardless of age, who is incapable of self-support due to a disability that was diagnosed prior
           to age 26. Subject to medical review and approval.
      ●    Other unmarried dependent children up to age 26, upon completion of an Application for Coverage for
           Other Dependent Children. Guardianship papers or a tax return showing dependency can be provided in lieu
           of the application.
  ♦   If your spouse is enrolled separately in one of the OSEEGIB plans, your dependents can be covered under one
      parent’s health, dental, and/or vision plan (but not both); however, both parents can cover dependents under
      Dependent Life insurance.
  ♦   Dependents who are not enrolled within 30 days of your eligibility date cannot be enrolled until the next annual
      Option Period, unless a qualifying event such as birth, marriage, or loss of other group coverage occurs. If
      eligible dependents are dropped from coverage, you cannot re-enroll them for a minimum of 12 months. The
      12-month requirement does not apply when dependents lose other group health, dental, vision, and/or life
      insurance coverage and are seeking reinstatement of coverage through OSEEGIB.
  ♦   Dependents can only be enrolled in the same types of coverage and in the same plans you enroll in.
  ♦   To enroll your newborn, an Insurance Change Form must be provided to your Insurance Coordinator within 30
      days of the birth. If you do not enroll your newborn during this 30-day period, you cannot do so until the next
      annual Option Period. Direct notification to a plan will not enroll your newborn or any other dependents. The
      newborn’s Social Security number is not required at the time of initial enrollment, but must be provided once it
      is received from the Social Security Administration. Insurance premiums for the month the child was born must
      be paid. Under the HealthChoice plans, a separate deductible and coinsurance may apply.
  ♦   Without enrollment, newborns are covered only for the first 48 hours following a vaginal birth or the first 96
      hours following a cesarean section birth. Deductible and coinsurance may apply.

Excluding Dependents from Coverage
  ♦ You can exclude your spouse from health and/or dental coverage while covering other dependents on these
     benefits. Your spouse must sign the Spouse Exclusion Certification section of the enrollment or change form.
  ♦ You can exclude dependents who do not reside with you, are married, are not financially dependent on you for
     support, have other group coverage, or are eligible for Indian or military health benefits.
  Note: Your spouse cannot be excluded from vision coverage if your other dependents are covered unless your
        spouse has proof of other group vision coverage.

Confirmation Statement
  ♦ You are mailed a Confirmation Statement (CS) when you enroll or make changes to your coverage. Your CS
    lists the coverage you are enrolled in, the effective date of your coverage, and the premium amounts.
  ♦ Always review your CS to verify your coverage is correct. Corrections to your coverage must be submitted to
    your Insurance Coordinator within 60 days of your election. Corrections reported after 60 days are effective the
    first of the month following notification.
  ♦ Section B of your Option Period Enrollment/Change Form lists your most current coverage. If you don’t make
    changes and you are not automatically enrolled in one of the HealthChoice alternative plans (see page 1),
    you will not receive a CS from OSEEGIB. Keep a copy of your Option Period Enrollment/Change Form as
    verification of your coverage.




                                                         10
Transfer Employee
  ♦ You can keep your coverage continuous when you move from one participating employer to another as long as
    there is no break in coverage that lasts longer than 30 days. Premiums must be paid upon reporting to work.
  ♦ Benefit options vary from employer to employer. Changes to your coverage must be made within the first 30
    days of your transfer. See your Insurance Coordinator for more information.

Termination of Coverage
  ♦ Coverage will end the last day of the month in which a termination event occurs. Examples of termination
    events include:
    ●  Loss of employment
    ●  Loss of dependent eligibility
    ●  Non-payment of premiums
    ●  Death

COBRA – Temporary Continuation of Coverage
  ♦ The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) allows you and/or your dependents
    to continue health, dental, and/or vision insurance coverage after your employment terminates or after your
    dependent loses eligibility. Certain time limits apply to enrollment. Contact your Insurance Coordinator
    immediately upon termination of your employment, or when changes to your family status occur, to find out
    more about your COBRA rights. Be aware, dropping dependent coverage during Option Period is not a
    COBRA qualifying event.




                                                      11
                                 HMO ZIP Code List
                         C = CommunityCare         G = GlobalHealth

    72761    C   73038    G   73078   CG   73121   CG   73162   CG   73440   G    73531    G
    73001    G   73039    G   73079    G   73122   CG   73163   CG   73441   G    73532    G
    73002    G   73040    G   73080    G   73123   CG   73164   CG   73442   G    73533    G
    73003   CG   73041    G   73082    G   73124   CG   73165   CG   73443   G    73534    G
    73004    G   73042    G   73083   CG   73125   CG   73167   CG   73444   G    73536    G

H   73005
    73006
             G
             G
                 73043
                 73044
                          G
                         CG
                              73084
                              73085
                                      CG
                                      CG
                                           73126
                                           73127
                                                   CG
                                                   CG
                                                        73169
                                                        73170
                                                                CG
                                                                CG
                                                                     73446
                                                                     73447
                                                                             G
                                                                             G
                                                                                  73537
                                                                                  73538
                                                                                           G
                                                                                           G

M   73007
    73008
            CG
            CG
                 73045
                 73047
                         CG
                          G
                              73086
                              73089
                                       G
                                       G
                                           73128
                                           73129
                                                   CG
                                                   CG
                                                        73172
                                                        73173
                                                                CG
                                                                CG
                                                                     73448
                                                                     73449
                                                                             G
                                                                             G
                                                                                  73539
                                                                                  73540
                                                                                           G
                                                                                           G
O   73009
    73010
             G
             G
                 73048
                 73049
                          G
                         CG
                              73090
                              73092
                                      CG
                                       G
                                           73130
                                           73131
                                                   CG
                                                   CG
                                                        73177
                                                        73178
                                                                 G
                                                                CG
                                                                     73450
                                                                     73453
                                                                             G
                                                                             G
                                                                                  73541
                                                                                  73542
                                                                                           G
                                                                                           G
    73011    G   73050   CG   73093    G   73132   CG   73179   CG   73455   G    73543    G
    73012    G   73051   CG   73095    G   73134   CG   73180    C   73456   G    73544    G
Z   73013   CG   73052    G   73096    G   73135   CG   73184   CG   73458   G    73546    G
    73014   CG   73053    G   73097   CG   73136   CG   73185   CG   73459   G    73547    G
I   73015    G   73054   CG   73098    G   73137   CG   73189   CG   73460   G    73548    G

P   73016
    73017
             G
             G
                 73055
                 73056
                          G
                         CG
                              73099
                              73101
                                      CG
                                      CG
                                           73139
                                           73140
                                                   CG
                                                   CG
                                                        73190
                                                        73193
                                                                CG
                                                                 C
                                                                     73461
                                                                     73463
                                                                             G
                                                                             G
                                                                                  73549
                                                                                  73550
                                                                                           G
                                                                                           G
    73018    G   73057    G   73102   CG   73141   CG   73194   CG   73481   G    73551    G
    73019   CG   73058   CG   73103   CG   73142   CG   73195   CG   73487   G    73552    G
C   73020
    73021
            CG
             G
                 73059
                 73061
                          G
                         CG
                              73104
                              73105
                                      CG
                                      CG
                                           73143
                                           73144
                                                   CG
                                                   CG
                                                        73196
                                                        73197
                                                                CG
                                                                 C
                                                                     73488
                                                                     73491
                                                                             G
                                                                             G
                                                                                  73553
                                                                                  73554
                                                                                           G
                                                                                           G
O   73022   CG   73062    G   73106   CG   73145   CG   73198    C   73501   G    73555    G
    73023    G   73063   CG   73107   CG   73146   CG   73199    C   73502   G    73556    G
D   73024    G   73064   CG   73108   CG   73147   CG   73401   G    73503   G    73557    G
    73025    G   73065    G   73109   CG   73148   CG   73402   G    73505   G    73558    G
E   73026   CG   73066   CG   73110   CG   73149   CG   73403   G    73506   G    73559    G
    73027   CG   73067    G   73111   CG   73150   CG   73425   G    73507   G    73560    G
    73028   CG   73068   CG   73112   CG   73151   CG   73430    G   73520   G    73561    G

L   73029
    73030
             G
             G
                 73069
                 73070
                         CG
                         CG
                              73113
                              73114
                                      CG
                                      CG
                                           73152
                                           73153
                                                   CG
                                                   CG
                                                        73432
                                                        73433
                                                                 G
                                                                 G
                                                                     73521
                                                                     73522
                                                                             G
                                                                             G
                                                                                  73562
                                                                                  73564
                                                                                           G
                                                                                           G

I   73031
    73032
             G
             G
                 73071
                 73072
                         CG
                         CG
                              73115
                              73116
                                      CG
                                      CG
                                           73154
                                           73155
                                                   CG
                                                   CG
                                                        73434
                                                        73435
                                                                 G
                                                                 G
                                                                     73523
                                                                     73526
                                                                             G
                                                                             G
                                                                                  73565
                                                                                  73566
                                                                                           G
                                                                                           G
S   73033
    73034
             G
            CG
                 73073
                 73074
                         CG
                          G
                              73117
                              73118
                                      CG
                                      CG
                                           73156
                                           73157
                                                   CG
                                                   CG
                                                        73436
                                                        73437
                                                                 G
                                                                 G
                                                                     73527
                                                                     73528
                                                                             G
                                                                             G
                                                                                  73567
                                                                                  73568
                                                                                           G
                                                                                           G
T   73036   CG   73075    G   73119   CG   73159   CG   73438    G   73529   G    73569    G
    73037   CG   73077   CG   73120   CG   73160   CG   73439    G   73530   G    73570    G




                                              12
                                                                       continued on next page
 continued from previous page           HMO ZIP Code List
                           C = CommunityCare              G = GlobalHealth

73571   G     73701    G    73757        G   73933    G     74029   CG   74072    CG     74132   CG
73572   G     73702    G    73758        G   73937    G     74030   CG   74073    CG     74133   CG
73573   G     73703    G    73759        G   73938    G     74031   CG   74074    CG     74134   CG
73601   G     73705    G    73760        G   73939    G     74032   CG   74075    CG     74135   CG
73620   G     73706    G    73761        G   73942    G     74033   CG   74076    CG     74136   CG
73622   G     73716    G    73762        G   73944    G     74034   CG   74077    CG     74137   CG       H
73624   G     73717    G    73763        G   73945    G     74035   CG   74078    CG     74141   CG
73625   G     73718    G    73764        G   73946    G     74036   CG   74079     G     74145   CG       M
                                                                                                          O
73626   G     73719    G        73766    G   73947    G     74037   CG   74080    CG     74146   CG
73627   G     73720    G        73768    G   73949    G     74038   CG   74081    CG     74147   CG
73628   G     73722    G        73770    G   73950    G     74039   CG   74082    CG     74148   CG
73632    G    73724    G        73771    G   73951    G     74041   CG   74083    CG     74149   CG
73638
73639
         G
         G
              73726
              73727
                       G
                       G
                                73772
                                73773
                                         G
                                         G
                                             74001
                                             74002
                                                     CG
                                                     CG
                                                            74042
                                                            74043
                                                                    CG
                                                                    CG
                                                                         74084
                                                                         74085
                                                                                  CG
                                                                                  CG
                                                                                         74150
                                                                                         74152
                                                                                                 CG
                                                                                                 CG
                                                                                                          Z
73641    G    73728    G        73801    G   74003   CG     74044   CG   74101    CG     74153   CG       I
                                                                                                          P
73642    G    73729    G        73802    G   74004   CG     74045   CG   74102    CG     74155   CG
73644    G    73730    G        73832    G   74005   CG     74046   CG   74103    CG     74156   CG
73645    G    73731    G        73834    G   74006   CG     74047   CG   74104    CG     74157   CG
73646    G    73733    G        73835    G   74008   CG     74048   CG   74105    CG     74158   CG
73647
73648
         G
         G
              73734
              73735
                       G
                       G
                                73838
                                73840
                                         G
                                         G
                                             74009
                                             74010
                                                      C
                                                     CG
                                                            74050
                                                            74051
                                                                    CG
                                                                    CG
                                                                         74106
                                                                         74107
                                                                                  CG
                                                                                  CG
                                                                                         74159
                                                                                         74169
                                                                                                 CG
                                                                                                 CG
                                                                                                          C
73650    G    73736    G        73841    G   74011   CG     74052   CG   74108    CG     74170   CG       O
73651    G    73737    G        73842    G   74012   CG     74053   CG   74110    CG     74171   CG
73654    G    73738    G        73843    G   74013   CG     74054   CG   74112    CG     74172   CG       D
73655
73658
         G
         G
              73739
              73741
                       G
                       G
                                73844
                                73848
                                         G
                                         G
                                             74014
                                             74015
                                                     CG
                                                     CG
                                                            74055
                                                            74056
                                                                    CG
                                                                    CG
                                                                         74114
                                                                         74115
                                                                                  CG
                                                                                  CG
                                                                                         74182
                                                                                         74183
                                                                                                 CG
                                                                                                  C
                                                                                                          E
73659    G    73742    G        73851    G   74016   CG     74058   CG   74116    CG     74184    C
73660    G    73743    G        73852    G   74017   CG     74059   CG   74117    CG     74186   CG
73661    G    73744    G        73853    G   74018   CG     74060   CG   74119    CG     74187   CG       L
73662   G     73746    G    73855        G   74019   CG     74061   CG   74120    CG     74189    C
73663   G     73747    G    73857        G   74020   CG     74062   CG   74121    CG     74192   CG       I
73664
73666
        G
        G
              73749
              73750
                       G
                       G
                            73858
                            73859
                                         G
                                         G
                                             74021
                                             74022
                                                     CG
                                                     CG
                                                            74063
                                                            74066
                                                                    CG
                                                                    CG
                                                                         74126
                                                                         74127
                                                                                  CG
                                                                                  CG
                                                                                         74193
                                                                                         74194
                                                                                                 CG
                                                                                                  C
                                                                                                          S
73667
73668
        G
        G
              73753
              73754
                       G
                       G
                            73860
                            73901
                                         G
                                         G
                                             74023
                                             74026
                                                     CG
                                                      G
                                                            74067
                                                            74068
                                                                    CG
                                                                    CG
                                                                         74128
                                                                         74129
                                                                                  CG
                                                                                  CG
                                                                                         74301
                                                                                         74330
                                                                                                 CG
                                                                                                 CG
                                                                                                          T
73669   G     73755    G    73931        G   74027   CG     74070   CG   74130    CG     74331   CG
73673   G     73756    G    73932        G   74028   CG     74071   CG   74131    CG     74332   CG




                                                     13                          continued on next page
    continued from previous page      HMO ZIP Code List
                            C = CommunityCare           G = GlobalHealth

     74333   CG    74425   CG      74468   CG   74561   CG   74724   G    74826   CG   74877   C
     74335   CG    74426   CG      74469   CG   74562   CG   74726   G    74827   G    74878   CG
     74336   C     74427   CG      74470   CG   74563   CG   74727   CG   74829   G    74880   CG
     74337   CG    74428   CG      74471   CG   74565   CG   74728   G    74830   CG   74881   G
     74338   CG    74429   CG      74472   CG   74567   CG   74729   G    74831   G    74883   G

H    74339
     74340
             CG
             CG
                   74430
                   74431
                           CG
                           CG
                                   74477
                                   74501
                                           CG
                                           CG
                                                74569
                                                74570
                                                        G
                                                        CG
                                                             74730
                                                             74731
                                                                     G
                                                                     G
                                                                          74832
                                                                          74833
                                                                                  G
                                                                                  G
                                                                                       74884
                                                                                       74901
                                                                                               CG
                                                                                               CG

M    74342
     74343
             CG
             CG
                   74432
                   74434
                           CG
                           CG
                                   74502
                                   74521
                                           CG
                                           CG
                                                74571
                                                74572
                                                        CG
                                                        G
                                                             74733
                                                             74734
                                                                     G
                                                                     G
                                                                          74834
                                                                          74836
                                                                                  G
                                                                                  G
                                                                                       74902
                                                                                       74930
                                                                                               CG
                                                                                               CG
O    74344
     74345
             CG
             G
                   74435
                   74436
                           CG
                           CG
                                   74522
                                   74523
                                           CG
                                           CG
                                                74574
                                                74576
                                                        CG
                                                        G
                                                             74735
                                                             74736
                                                                     CG
                                                                     G
                                                                          74837
                                                                          74838
                                                                                  CG
                                                                                  C
                                                                                       74931
                                                                                       74932
                                                                                               CG
                                                                                               CG
     74346   CG    74437   CG      74525   G    74577   CG   74737   G    74839   G    74935   CG
     74347   CG    74438   CG      74526   C    74578   CG   74738   CG   74840   CG   74936   CG
Z    74349   CG    74439   G       74528   CG   74601   G    74740   G    74842   G    74937   CG
     74350   CG    74440   CG      74529   CG   74602   G    74741   G    74843   G    74939   CG
I    74352   CG    74441   CG      74530   G    74604   G    74743   CG   74844   G    74940   CG
     74353   C     74442   CG      74531   G    74630   CG   74745   G    74845   CG   74941   CG
P    74354   CG    74444   CG      74533   G    74631   G    74747   G    74848   G    74942   CG
     74355   CG    74445   CG      74534   G    74632   G    74748   G    74849   CG   74943   CG
     74358   CG    74446   CG      74535   G    74633   CG   74750   G    74850   G    74944   CG

C    74359
     74360
             CG
             CG
                   74447
                   74450
                           CG
                           CG
                                   74536
                                   74538
                                           CG
                                           G
                                                74636
                                                74637
                                                        G
                                                        CG
                                                             74752
                                                             74753
                                                                     G
                                                                     G
                                                                          74851
                                                                          74852
                                                                                  CG
                                                                                  CG
                                                                                       74945
                                                                                       74946
                                                                                               CG
                                                                                               CG

O    74361
     74362
             CG
             CG
                   74451
                   74452
                           CG
                           CG
                                   74540
                                   74543
                                           G
                                           CG
                                                74640
                                                74641
                                                        G
                                                        G
                                                             74754
                                                             74755
                                                                     G
                                                                     G
                                                                          74854
                                                                          74855
                                                                                  CG
                                                                                  G
                                                                                       74947
                                                                                       74948
                                                                                               CG
                                                                                               CG
D    74363
     74364
             CG
             CG
                   74454
                   74455
                           CG
                           CG
                                   74545
                                   74546
                                           CG
                                           CG
                                                74643
                                                74644
                                                        G
                                                        CG
                                                             74756
                                                             74759
                                                                     CG
                                                                     CG
                                                                          74856
                                                                          74857
                                                                                  G
                                                                                  CG
                                                                                       74949
                                                                                       74951
                                                                                               CG
                                                                                               CG
E    74365   CG    74456   CG      74547   CG   74646   G    74760   CG   74859   G    74953   CG
     74366   CG    74457   CG      74548   C    74647   G    74761   CG   74860   G    74954   CG
     74367   CG    74458   CG      74549   CG   74650   CG   74764   G    74864   G    74955   CG
     74368   CG    74459   CG      74552   CG   74651   CG   74766   G    74865   G    74956   CG
L    74369   CG    74460   CG      74553   CG   74652   CG   74801   CG   74866   CG   74957   CG

I    74370
     74401
             CG
             CG
                   74461
                   74462
                           CG
                           CG
                                   74554
                                   74555
                                           CG
                                           G
                                                74653
                                                74701
                                                        CG
                                                        G
                                                             74802
                                                             74804
                                                                     CG
                                                                     CG
                                                                          74867
                                                                          74868
                                                                                  CG
                                                                                  CG
                                                                                       74959
                                                                                       74960
                                                                                               CG
                                                                                               CG

S    74402
     74403
             CG
             CG
                   74463
                   74464
                           CG
                           CG
                                   74556
                                   74557
                                           G
                                           CG
                                                74702
                                                74720
                                                        G
                                                        G
                                                             74818
                                                             74820
                                                                     CG
                                                                     G
                                                                          74869
                                                                          74871
                                                                                  G
                                                                                  G
                                                                                       74962
                                                                                       74963
                                                                                               CG
                                                                                               G

T    74421
     74422
             CG
             CG
                   74465
                   74466
                           CG
                           C
                                   74558
                                   74559
                                           CG
                                           CG
                                                74721
                                                74722
                                                        G
                                                        G
                                                             74821
                                                             74824
                                                                     G
                                                                     G
                                                                          74872
                                                                          74873
                                                                                  G
                                                                                  CG
                                                                                       74964
                                                                                       74965
                                                                                               CG
                                                                                               CG
     74423   CG    74467   CG      74560   CG   74723   G    74825   G    74875   G    74966   CG




                                                   14
  Plan changes are indicated by bold text in the
         Comparison of Benefits charts.

If you have questions about any of the plans,
  contact each plan directly. See Help Lines
on page 28 of this Employee Benefit Options
        Guide for contact information.
This information is only a brief summary of the plans. All benefits and limitations of these plans are
governed in all cases by the relevant plan documents, insurance contracts, handbooks, and Rules
of the Oklahoma State and Education Employees Group Insurance Board, a division of the Office
of Management and Enterprise Services. The Rules of the Oklahoma Administrative Code, Title
360, are controlling in all aspects of Plan benefits. No oral statement of any person shall modify or
 otherwise affect the benefits, limitations, or exclusions of any plan.
                     www.sib.ok.gov or www.healthchoiceok.com




                                                 15
                   COMPARISON Of BENEfITS fOR HEALTH PLANS
       Your Costs
H     for network
                                  healthChoiCe
                              high, high alternative,
                                                                        healthChoiCe
                                                                        BasiC and BasiC
                                                                                                             healthChoiCe
                                                                                                            s-aCCount Plan
E       serviCes                  and usa Plans

                            High and USA Plans
                                                                       alternative Plans
                                                                  Basic Plan                           $1,500 individual
A                           $500 individual
                            $1,500 family
                                                                  $500 individual
                                                                  $1,000 family
                                                                                                       $3,000 family
                                                                                                       The individual deductible
                                                                  Applies after Plan pays first $500
L     Calendar Year                                               of Allowed Charges                   does not apply if two or more
                                                                                                       family members are covered
       deduCtiBles          High Alternative Plan                 Basic Alternative Plan
T                           $750 individual
                            $2,250 family
                                                                  $750 individual
                                                                  $1,500 family
                                                                                                       The combined medical and
                                                                                                       pharmacy deductible must be

H                                                                 Applies after Plan pays first $250
                                                                  of Allowed Charges
                                                                                                       met before benefits are paid

                            High and USA Plans                    Basic Plan                           $3,000 individual
                            $2,800 Network individual             $5,500 individual                    $6,000 family
                            $8,400 Network family                 $11,000 family                       Non-Network charges do not
P     Calendar Year
                            $3,300 non-Network individual
                            $9,900 non-Network family, plus
                                                                                                       apply
                            amounts over Allowed Charges
L     out-of-PoCket
          limit
                            High Alternative Plan                 Basic Alternative Plan
                            $3,050 Network individual             $5,750 individual
A                           $9,150 Network family
                            $3,550 non-Network individual
                                                                  $11,500 family


N                           $10,650 non-Network family, plus
                            amounts over Allowed Charges
                            $30 copay/physician office visit*     •Copays do not apply                 You pay 100% of Allowed
        offiCe visit        $50 copay/specialist office visit     •All covered services, benefits,     Charges until deductible is met
       (Professional                                              exceptions, limitations, and         $50 office visit copay applies
C        serviCes)                                                conditions are identical to the
                                                                  HealthChoice High Plan
                                                                                                       after deductible


O                           20% of Allowed Charges after
                            deductible
                                                                  Basic Plan
                                                                  •$0 the first $500 of Allowed
                                                                                                       20% of Allowed Charges after
                                                                                                       deductible
     diagnostiC X-raY
M        and laB
                                                                  Charges
                                                                  •100% of the next $500 of
                                                                  Allowed Charges (deductible)
P                           20% of Allowed Charges after
                                                                  Only Allowed Charges count
                                                                  toward the deductible                20% of Allowed Charges after
A        hosPital
         inPatient
                            deductible
                            Additional $300 copay per non-
                                                                  Basic Alternative Plan
                                                                  •$0 the first $250 of Allowed
                                                                                                       deductible
                                                                                                       Additional $300 copay per

R        admission          Network admission                     Charges
                                                                  •100% of the next $750 of
                                                                                                       non-Network admission

                                                                  Allowed Charges (deductible)
I        hosPital
      outPatient visit
                            20% of Allowed Charges after
                            deductible
                                                                  Only Allowed Charges count
                                                                  toward the deductible
                                                                                                       20% of Allowed Charges after
                                                                                                       deductible

S                           $0 copay; no deductible
                                                                  Both Basic Plans
                                                                  •50% of the next $10,000 of          $0 copay; no deductible
        well Child                                                                                     applies
O
                                                                  Allowed Charges
        Care visit                                                •$0 of Allowed Charges over the
                                                                  individual or family out-of-pocket
N                           No charge for well child and adult
                            immunizations
                                                                  limit
                                                                  •No deductible for well child care
                                                                                                       No charge for well child and
                                                                                                       adult immunizations
                            $30/$50 office visit copay and/or     visit.                               $50 office visit copay and/or
       immunizations        administration fee may apply          •You can use non-Network             administration fee may apply
                                                                  providers, but it will be more
                                                                  costly
    *The $30 copay applies to general practitioners, internal medicine physicians, OB/GYNs, pediatricians, physician assis-
    tants, and nurse practitioners. Plan changes are indicated by bold text.
    Plan Year 2013 ComParison Chart                              16
       COMPARISON Of BENEfITS fOR HEALTH PLANS
                                                                                    Your Costs
      CommunitYCare hmo                           gloBalhealth hmo                 for network
                                                                                                      H
No deductible                              No deductible
                                                                                     serviCes         E
                                                                                                      A
                                                                                   Calendar Year      L
                                                                                    deduCtiBles
                                                                                                      T
                                                                                                      H
$3,000 individual                          $3,000 individual
$6,000 family                              $5,000 family



                                                                                   Calendar Year
                                                                                                      P
                                                                                   out-of-PoCket
                                                                                       limit
                                                                                                      L
                                                                                                      A
                                                                                                      N
$35 copay/PCP                              $25 copay/PCP
$50 copay/specialist                       $50 copay/specialist
                                                                                     offiCe visit
                                                                                    (Professional
                                                                                      serviCes)       C
No additional copay for laboratory
services or outpatient radiology
                                           $0 copay
                                           $250 copay per MRI, MRA, PET, CAT, or                      O
$200 copay per MRI, CAT, MRA, or PET       nuclear scan                            diagnostiC X-raY
scan                                                                                   and laB        M
$500 copay                                 $250 copay per day
                                                                                                      P
Preauthorization required                  $750 maximum per admission
                                           Preauthorization required
                                                                                      hosPital
                                                                                      inPatient
                                                                                                      A
                                                                                      admission
                                                                                                      R
$300 copay                                 $250 copay
                                           Preauthorization required
                                                                                      hosPital
                                                                                   outPatient visit
                                                                                                      I
$0 copay                                   $0 copay ages 0 – 21                                       S
                                                                                     well Child
                                                                                     Care visit       O
$0 copay ages birth through age 18 years
$0 copay ages 19 and over
                                           $0 copay birth through age 18 years
                                           $0 copay ages 19 and over
                                                                                                      N
When medically necessary                   When appropriate following the
                                           recommendation of ACIP                   immunizations
                                           Office visit copay may apply



                            Plan changes are indicated by bold text.
                                                  17            Plan Year 2013 ComParison Chart
                    COMPARISON Of BENEfITS fOR HEALTH PLANS
H      Your Costs                healthChoiCe                        healthChoiCe
                                                                                                      healthChoiCe
      for network            high, high alternative,                 BasiC and BasiC
E       serviCes                 and usa Plans                      alternative Plans
                                                                                                     s-aCCount Plan


A                           $0 copay for one preventive
                            service office visit per
                                                               $0 copay for one preventive
                                                               service office visit per
                                                                                            $0 copay for one preventive
                                                                                            service office visit per

L     PeriodiC health
                            calendar year for members and
                            dependents age 20 and older
                                                               calendar year for members and
                                                               dependents age 20 and older
                                                                                            calendar year for members and
                                                                                            dependents age 20 and older
           eXams            One mammogram per year at no                                    One mammogram per year at no
T                           charge for women age 40 and
                            older
                                                               One mammogram per year at no charge for women age 40 and
                                                               charge for women age 40 and  older
H                           20% of Allowed Charges after
                            deductible
                                                               over                         20% of Allowed Charges after
                                                                                               deductible
          allergY                                       •Copays do not apply
                            Limit: 60 tests every 24 months                                    Limit: 60 tests every 24 months
       treatment and                                    •All covered services, benefits,
           testing                                      exceptions, limitations, and
P                                                       conditions are identical to the
                                                        HealthChoice High Plan

L        emergenCY
                      20% of Allowed Charges after
                      deductible
                                                        Basic Plan
                                                        •$0 the first $500 of Allowed
                                                                                               20% of Allowed Charges after
                                                                                               deductible
        health Care
A                     Additional $100 ER copay –        Charges                                Additional $100 ER copay –
          faCilitY    waived if admitted                •100% of the next $500 of              waived if admitted
            visit                                       Allowed Charges (deductible)
N                     20% of Allowed Charges after
                                                        Only Allowed Charges count
                                                        toward the deductible                  20% of Allowed Charges after
                      deductible                        Basic Alternative Plan                 deductible
        after hours                                     •$0 the first $250 of Allowed
        urgent Care                                     Charges
C                                                       •100% of the next $750 of
                                                        Allowed Charges (deductible)
O     suBstanCe aBuse
                      20% of Allowed Charges after
     mental health or deductible                        Only Allowed Charges count
                                                        toward the deductible
                                                                                               20% of Allowed Charges after
                                                                                               deductible

M         inPatient
         admission
                                                        Both Basic Plans
                      No limit on the number of days •50% of the next $10,000 of
                      per year
                                                                                               No limit on the number of days
                                                                                               per year
                                                        Allowed Charges
P                     20% of Allowed Charges after
                                                        •$0 of Allowed Charges over
                                                        the individual or family out-of-
                                                                                               20% of Allowed Charges after
                      deductible                                                               deductible
A    mental health or                                   pocket limit
      suBstanCe aBuse Limit of 15 services per calendar •No deductible for well child          Limit of 15 services per calendar
R
                                                        care visit.
         outPatient   year without certification
                                                        •You can use non-Network
                                                                                               year without certification
            visit                                       providers, but it will be more
I                                                       costly
                            20% of Allowed Charges after                                       20% of Allowed Charges after
S                           deductible for purchase, rental,
                            repair, or replacement
                                                                                               deductible for purchase, rental,
                                                                                               repair, or replacement
     duraBle mediCal
O    equiPment (dme)

N
          This is only a sample of the services covered by each plan. For services that are not listed in this
        comparison chart, contact each plan. See Help Lines on page 28 for contact information.

                                            Plan changes are indicated by bold text.
    Plan Year 2013 ComParison Chart                            18
              COMPARISON Of BENEfITS fOR HEALTH PLANS
                                                                                            Your Costs          H
             CommunitYCare hmo                         gloBalhealth hmo                    for network
                                                                                             serviCes           E
       $0 copay                                 $0 copay/PCP
                                                Limit: One per year
                                                                                                                A
                                                                                          PeriodiC health
                                                                                               eXams            L
                                                                                                                T
       $35 copay/PCP                            $25 copay/PCP
       $50 copay/specialist
       $30 serum and shots including a 6-week
                                                $50 copay/specialist
                                                $30 serum and shots including a 6-week       allergY            H
       supply of antigen                        supply of antigen                          treatment and
                                                                                              testing

       $200 copay; waived if admitted           $150 copay; waived if admitted
                                                                                                                P
                                                                                             emergenCY
                                                                                            health Care         L
                                                                                              faCilitY
                                                                                               visit            A
       $50 copay per visit                      $50 copay
                                                Must use Network facilities                                     N
                                                                                            after hours
                                                                                            urgent Care

       $500 copay                               $250 per day
                                                                                          mental health or
                                                                                                                C
                                                                                                                O
       Must be preauthorized and approved       $750 maximum per admission
       through CCOK Behavioral Health           Must be preauthorized by MHNet             suBstanCe aBuse
       Services                                                                               inPatient
                                                                                              admission         M
       $35 copay/PCP/specialist
       Must be preauthorized and approved
                                                $25 copay
                                                Must be preauthorized by MHNet
                                                                                          mental health or
                                                                                                                P
       through CCOK Behavioral Health
       Services                                                                            suBstanCe aBuse
                                                                                             outPatient
                                                                                                                A
                                                                                                visit           R
       20% coinsurance initial device
       20% coinsurance repair and replacement
                                                20% coinsurance
                                                Must be preauthorized and obtained from
                                                                                                                I
                                                Network Provider
                                                                                          duraBle mediCal       S
                                                                                          equiPment (dme)
                                                                                                                O
                                                                                                                N
  This is only a sample of the services covered by each plan. For services that are not listed in this
comparison chart, contact each plan. See Help Lines on page 28 for contact information.

                                   Plan changes are indicated by bold text.
                                                          19                  Plan Year 2013 ComParison Chart
                    COMPARISON Of BENEfITS fOR HEALTH PLANS
H      Your Costs                healthChoiCe                          healthChoiCe
                                                                                                   healthChoiCe
      for network            high, high alternative,                   BasiC and BasiC
E       serviCes                 and usa Plans                        alternative Plans
                                                                                                  s-aCCount Plan


A                           20% of Allowed Charges after
                            deductible
                                                         •Copays do not apply
                                                         •All covered services, benefits,
                                                                                            20% of Allowed Charges after
                                                                                            deductible

L    oCCuPational and
                            Occupational therapy*        exceptions, limitations, and
                            Limit: 20 visits per year without
                                                         conditions are identical to the
                                                                                            Occupational therapy*
                                                                                            Limit: 20 visits per year without
      sPeeCh theraPY        certification                HealthChoice High Plan             certification
T          visits           Speech therapy*              Basic Plan
                            Certification not required for age
                                                         •$0 the first $500 of Allowed
                                                                                            Speech therapy*
                                                                                            Certification not required for age
H                           18 and older                 Charges
                            *Maximum of 60 visits per year
                                                         •100% of the next $500 of
                                                                                            18 and older
                                                                                            *Maximum of 60 visits per year
                       20% of Allowed Charges after      Allowed Charges (deductible)       20% of Allowed Charges after
                       deductible                        Only Allowed Charges count         deductible
                       Limit: 20 visits per year without toward the deductible
P    PhYsiCal theraPY/                                                                      Limit: 20 visits per year without
                       certification                     Basic Alternative Plan             certification
     PhYsiCal mediCine Maximum of 60 visits per year •$0 the first $250 of Allowed          Maximum of 60 visits per year
L          visit                                         Charges
                                                         •100% of the next $750 of

A                      Chiropractic services:
                                                         Allowed Charges (deductible)
                                                         Only Allowed Charges count         Chiropractic services:
                                                         toward the deductible
N                      20% of Allowed Charges after
                       deductible                        Both Basic Plans
                                                                                            20% of Allowed Charges after
                                                                                            deductible
                       Limit: 20 visits per year without •50% of the next $10,000 of        Limit: 20 visits per year without
                                                         Allowed Charges
     ChiroPraCtiC and certification                      •$0 of Allowed Charges over
                                                                                            certification
                       Maximum of 60 visits per year                                        Maximum of 60 visits per year
       maniPulative
C
                                                         the individual or family out-of-
         theraPY       Manipulative therapy: see         pocket limit                       Manipulative therapy: see
           visit       Physical Therapy/Physical         •No deductible for well child      Physical Therapy/Physical
O                      Medicine                          care visit.
                                                         •You can use non-Network
                                                                                            Medicine


M                                                        providers, but it will be more
                                                         costly

P                           20% of Allowed Charges after
                            deductible
                                                                                            20% of Allowed Charges after
                                                                                            deductible
         maternitY
A
                            Includes one postpartum home                                    Includes one postpartum home
        Pre and Post        visit - criteria must be met                                    visit - criteria must be met
        natal Care
R
I                           $50 copay/specialist
                            $30 copay/primary care
                                                                                            $50 copay after deductible
                                                                                            Basic hearing screening
S          hearing
                            physician**
                            Basic hearing screening
                                                                                            Limit: one per year


O      sCreening and
       hearing aids
                            Limit: one per year                                             Hearing aids are covered as
                                                                                            durable medical equipment for
                            Hearing aids are covered as                                     children up to age 18
N                           durable medical equipment for
                            children up to age 18


    **The $30 copay applies to general practitioners, internal medicine physicians, OB/GYNs, pediatricians, physician assis-
    tants, and nurse practitioners.

                                             Plan changes are indicated by bold text.
    Plan Year 2013 ComParison Chart                              20
               COMPARISON Of BENEfITS fOR HEALTH PLANS
                                                                                                Your Costs        H
             CommunitYCare hmo                           gloBalhealth hmo                      for network
                                                                                                 serviCes         E
       No copay inpatient
       $50 copay outpatient therapy
                                                  No copay inpatient
                                                  $50 copay per outpatient therapy
                                                                                                                  A
       Limit: 60 days per illness                 Limit: 60 consecutive days per illness      oCCuPational or
                                                                                              sPeeCh theraPY      L
                                                                                                   visit
                                                                                                                  T
       No copay inpatient
       $50 copay outpatient therapy
                                                  No copay inpatient
                                                  $50 copay per outpatient visit
                                                                                                                  H
       Limit: 60 days per illness                 Limit: 60 consecutive days per illness      PhYsiCal theraPY/
                                                                                              PhYsiCal mediCine
                                                                                                    visit         P
                                                                                                                  L
       $50 copay                                  $20 copay
       Limit: 15 visits per year
       PCP referral required
                                                  Must be preauthorized                                           A
                                                                                              ChiroPraCtiC and
                                                                                                                  N
                                                                                               maniPulative
                                                                                                  theraPY
                                                                                                   visit
                                                                                                                  C
                                                                                                                  O
       $35 copay for initial visit
       $500 copay per hospital admission
                                                  $0 copay for prenatal care
                                                  $25 copay for delivery and all post natal
                                                                                                                  M
                                                  care
                                                  $250 per day, $750 maximum per hospital
                                                                                                 maternitY
                                                                                                Pre and Post
                                                                                                                  P
                                                  admission
                                                                                                natal Care        A
       $0 copay                                   $0 copay children birth – age 21
                                                                                                                  R
       Limit: One per year                        $25 copay age 22 and over
                                                  Limit: One per year                                             I
       Hearing aids – 20% coinsurance for                                                         hearing
       children up to age 18                      Hearing aids – 20% coinsurance
                                                  For children up to age 18
                                                                                                sCreening and     S
                                                                                                hearing aids
                                                                                                                  O
                                                                                                                  N
  This is only a sample of the services covered by each plan. For services that are not listed in this
comparison chart, contact each plan. See Help Lines on page 28 for contact information.

                                      Plan changes are indicated by bold text.
                                                            21                Plan Year 2013 ComParison Chart
                   COMPARISON Of BENEfITS fOR HEALTH PLANS
      Your Costs
                      healthChoiCe high, high alternative,                                       healthChoiCe
     for network
                      BasiC, BasiC alternative, and usa Plans                                   s-aCCount Plan
       serviCes
                   NETWORK                                                       After combined medical and pharmacy deductible
                                   UP TO A 30-DAY SUPPLY                         ($1,500 individual/$3,000 family) has been met, the
                                     Of ANY MEDICATION                           pharmacy benefits are:
                    •Generic medication –You pay cost of medication up to a
                    maximum copay of $10                                         NETWORK
                    •Preferred brand-name medication – If cost of medication                 UP TO A 30-DAY SUPPLY
                    is $60 or less, you pay maximum copay of $15 or cost                       Of ANY MEDICATION
                    of medication, if less. If cost of medication is more than    •Generic medication –You pay cost of medication
                    $60, you pay 25% of cost up to a maximum copay of $30 up to a maximum copay of $10
                    •Non-Preferred brand-name medication – If cost of             •Preferred brand-name medication – If cost of
       PharmaCY     medication is $60 or less, you pay maximum copay of           medication is $60 or less, you pay maximum copay
        Benefits    $30 or cost of medication, if less. If cost of medication     of $15 or cost of medication, if less. If cost of
                    is more than $60, you pay 50% of cost up to a maximum         medication is more than $60, you pay 25% of cost
                    copay of $60                                                  up to a maximum copay of $30

P                                  UP TO A 90-DAY SUPPLY
                                     Of ANY MEDICATION
                                                                                  •Non-Preferred brand-name medication – If cost of
                                                                                  medication is $60 or less, you pay maximum copay
                    •Generic medication – You pay cost of medication up to        of $30 or cost of medication, if less. If cost of
H                   a maximum copay of $25
                    •Preferred brand-name medication – If cost of
                                                                                  medication is more than $60, you pay 50% of cost
                                                                                  up to a maximum copay of $60
A                   medication is $120 or less, you pay maximum copay of
                    $30 or cost of medication, if less. If cost of medication is             UP TO A 90-DAY SUPPLY

R
                    more than $120, you pay 25% of cost up to a maximum                        Of ANY MEDICATION
                    copay of $60                                                  •Generic medication – You pay cost of medication
                    •Non-Preferred brand-name medication – If cost of             up to a maximum copay of $25
M                   medication is $120 or less, you pay maximum copay of          •Preferred brand-name medication – If cost of
                    $60 or cost of medication, if less. If cost of medication is medication is $120 or less, you pay maximum

A                   more than $120, you pay 50% of cost up to a maximum
                    copay of $120.
                                                                                  copay of $30 or cost of medication, if less. If cost
                                                                                  of medication is more than $120, you pay 25% of
                                     Specialty Medications                        cost up to a maximum copay of $60
C                   Specialty medications are covered for a 30-day supply
                    only when ordered through Accredo Health.
                                                                                  •Non-Preferred brand-name medication – If cost
                                                                                  of medication is $120 or less, you pay maximum
Y                   •Preferred medication - $60 copay
                    •Non-Preferred medication - $120 copay
                                                                                  copay of $60 or cost of medication, if less. If cost
                                                                                  of medication is more than $120, you pay 50% of
                   Note: All Plan provisions apply. Only costs for Preferred      cost up to a maximum copay of $120.
                   medications purchased at Network Pharmacies apply to
                   the annual $2,500 out-of-pocket limit. Some medications                   Specialty Medications
                   are subject to prior authorization and/or quantity            Specialty medications are covered for a 30-day
                   limitations. If you choose a brand-name medication            supply only when ordered through Accredo Health.
                   when a generic is available, you are responsible for the      •Preferred medication - $60 copay
                   difference in the cost in addition to the copay.              •Non-Preferred medication - $120 copay

                   Pharmacy out-of-pocket maximum – $2,500 per person            Combined Medical/Pharmacy out-of-pocket limit
                   using Preferred products at Network pharmacies, then you      – $3,000 individual/$6,000 family
                   pay $0 for the rest of the calendar year.
                    HealthChoice covers the following tobacco cessation medications at 100% when purchased at a Network
                    Pharmacy:
                      ● Buproban 150mg SA Tabs               ● Chantix 0.5mg and 1mg Tabs       ● Nicotrol NS 20mg/m Nasal
                      ● Bupropion HCL SR 150mg Tabs          ● Nicotrol 10mg Cartridge            Spray
                    HealthChoice covers two 90-day courses of a prescription product each calendar year. Additionally,
                    HealthChoice partners with the Tobacco Settlement Endowment Trust (TSET) and Alere Wellbeing to provide
                    members with over-the-counter nicotine replacement therapy products (patches, gum, and lozenges) and
                    telephone coaching at no charge to HealthChoice health plan members. See page 8.


                                       Plan changes are indicated by bold text.
    Plan Year 2013 ComParison Chart                          22
              COMPARISON Of BENEfITS fOR HEALTH PLANS
                                                                                            Your Costs
             CommunitYCare hmo                          gloBalhealth hmo                   for network
                                                                                             serviCes
       Tier 1: $10                               Tier 1: $10
       Tier 2: $40                               Tier 2: $50
       Tier 3: $65                               Tier 3: $75

       $0 copay for selected generics            $4 copay for selected generics

       Up to $65 non-formulary (non-Preferred)   30-day supply                              PharmaCY
                                                                                             Benefits
       These copays do not apply to the          Certain medications may have restricted
       maximum out-of-pocket                     quantities

       30-day supply                             These copays do not apply to the
                                                 maximum out-of-pocket
       Certain medications have restricted
       quantities                                Home delivery is available. Contact
                                                                                                          P
       Convenient mail-order is available.
                                                 GlobalHealth for details.
                                                                                                          H
       Contact Plan for details
                                                                                                          A
                                                                                                          R
                                                                                                          M
                                                                                                          A
                                                                                                          C
                                                                                                          Y




  This is only a sample of the services covered by each plan. For services that are not listed in this
comparison chart, contact each plan. See Help Lines on page 28 for contact information.

                                    Plan changes are indicated by bold text.
                                                          23            Plan Year 2013 ComParison Chart
                   COMPARISON Of BENEfITS fOR DENTAL PLANS

D     Your Costs
     for network
                              healthChoiCe
                                                            assurant emPloYee
                                                             Benefits freedom
                                                                                            assurant emPloYee
                                                                                           Benefits heritage Plus
                                 dental
E      serviCes                                                 Preferred                   & heritage seCure

N                       Network: $25 Basic and Major
                        services combined
                                                        $25 per person, per policy
                                                        year, waived for in-Network
                                                                                           No deductibles


T       annual
       deduCtiBle
                        Non-Network: $25 Preventive,
                        Basic, and Major services
                                                        preventive services

                        combined plus amounts above
A                       Allowed Charges
                        Network: $0                     Network: $0                        No charge for routine cleaning
L     diagnostiC &
       Preventive
                        Non-Network: $0 of Allowed
                        Charges after deductible
                                                        Plan pays 100% of negotiated fee
                                                        No deductible
                                                                                           (once every 6 months)
                                                                                           No charge for topical fluoride
          Care                                          Non-Network: $0                    application (up to age 18)
      eX: Cleaning,                                     Plan pays 100% of usual and        No charge for periodic oral

P   routine oral eXam                                   customary
                                                        Deductible applies
                                                                                           evaluations


L   allowed Charges
          aPPlY

A      BasiC Care
    eX: eXtraCtions,
                        Network:
                        Non-Network:
                                           15%
                                           30% plus
                                                        Network:           15%
                                                        Plan pays 85% of usual and
                                                                                           Fillings
                                                                                           Minor oral surgery

N     oral surgerY
                        amounts above Allowed Charges
                        Deductible applies
                                                        customary
                                                        Non-Network:       30%
                                                                                           Refer to the copayment schedule
                                                                                           for each plan
                                                        Plan pays 70% of usual and
    allowed Charges                                     customary
          aPPlY                                         Deductible applies

C      major Care
                        Network:
                        Non-Network:
                                           40%
                                           50% plus
                                                        Network:           40%
                                                        Plan pays 60% of usual and
                                                                                           Root canal
                                                                                           Periodontal

O     eX: dentures,
      Bridge work
                        amounts above Allowed Charges
                        Deductible applies
                                                        customary
                                                        Deductible applies
                                                                                           Crowns
                                                                                           Refer to the copayment schedule
                                                        Non-Network:       50%             for each plan
M   allowed Charges
                                                        Plan pays 50% of usual and
                                                        customary
P         aPPlY                                         Deductible applies
                    Network:          50%               Network:          40%              25% discount
A                   Non-Network:      50% plus
                    amounts above Allowed Charges
                                                        Plan pays 60% of negotiated fee
                                                        Non-Network:       50%
                                                                                           Adults and children


R     orthodontiC
         Care
                    12-month waiting period may
                    apply
                                                        Plan pays 50% of usual and
                                                        customary – deductible applies
                                                        Network and non-Network:
I                   No lifetime maximum for
    allowed Charges Network or non-Network
                                                        $2,000 lifetime maximum
                                                        Coverage only for dependent
S        aPPlY
                    Covered for members under age
                    19 and members age 19 and older
                                                        children under age 19
                                                        12-month waiting period may
                    with TMD
O                                                       apply



N      Plan Year
       maXimum
                        Network and non-Network:
                        $2,500 per person, per year
                                                        $2,000 per person, per policy
                                                        year
                                                                                           No annual maximum for general
                                                                                           dentist

                        Network: No claims to file      Member/provider must file          No claims to file
      filing Claims     Non-Network: You file claims    claims

        This is only a sample of the services covered by each plan. For services that are not listed in this
      comparison chart, contact each plan. See Help Lines on page 28 for contact information.
    Plan Year 2013 ComParison Chart                      24
                    COMPARISON Of BENEfITS fOR DENTAL PLANS

                                     delta dental PPo delta dental Premier                               delta dental
   Cigna dental Care
     Plan (PrePaid)
                                       in-network and                  in-network and                    PPo – ChoiCe                 D
                                       out-of-network                  out-of-network                    PPo network
                                                                                                                                      E
No deductible or plan maximum
$5 office copay applies
                                    $25 per person, per year,
                                    applies to Basic and Major
                                                                  $50 per person, per year,
                                                                  applies to Diagnostic,
                                                                                                   $100 per person, per year,
                                                                                                   applies to Major Care only         N
                                    Care only                     Preventive, Basic, and Major     (Level 4)
                                                                  Care                                                                T
Sealant: $15 per tooth              $0 of allowable amounts       $0 of allowable amounts after    Schedule of covered services
                                                                                                                                      A
No charge for routine cleaning
once every 6 months
                                    No deductible applies         deductible                       and copays
                                                                                                   Copay examples:                    L
No charge for topical fluoride                                                                     Routine cleaning $5
application (through age 18)                                                                       Periodic oral evaluation $5
No charge for periodic oral                                                                        Topical fluoride application
evaluations                                                                                        (up to age 19) $5
                                                                                                                                      P
                                                                                                                                      L
Amalgam: One surface,               15% of allowable amounts      30% of allowable amounts         Schedule of covered services
permanent teeth $21                 after deductible              after deductible                 and copays
                                                                                                   Copay example:
                                                                                                                                      A
                                                                                                   Amalgam - one surface,
                                                                                                   primary or permanent tooth
                                                                                                                                      N
                                                                                                   $12

Root canal, anterior: $355
Periodontal/scaling/root planing
                                    40% of allowable amounts
                                    after deductible
                                                                  50% of allowable amounts
                                                                  after deductible
                                                                                                   Schedule of covered services
                                                                                                   and copays                         C
1-3 teeth (per quadrant): $71                                                                      Copay examples:
                                                                                                   Crown - porcelain/ceramic
                                                                                                   substrate $241
                                                                                                                                      O
                                                                                                   Complete denture - maxillary
                                                                                                   $320                               M
$2,280 out-of-pocket for children   40% of allowable amounts,     40% of allowable amounts, up     You pay amounts in excess of
                                                                                                                                      P
through age 18
$3,120 out-of-pocket for adults
                                    up to lifetime maximum of
                                    $2,000
                                                                  to lifetime maximum of $2,000
                                                                  No deductible
                                                                                                   $50 per month
                                                                                                   Lifetime maximum up to             A
                                    No deductible                 No waiting period                $1,800
24-month treatment excludes
orthodontic treatment plan and
                                    No waiting period
                                                                  Orthodontic benefits are
                                                                                                   No deductible
                                                                                                   No waiting period
                                                                                                                                      R
banding                             Orthodontic benefits are
                                    available to the employee
                                                                  available to the employee and
                                                                  their lawful spouse and eligible Orthodontic benefits are           I
                                    and their lawful spouse and   dependent children               available to the employee and
                                    eligible dependent children                                    their lawful spouse and eligible
                                                                                                   dependent children
                                                                                                                                      S
No maximum                          $2,500 per person, per year   $3,000 per person, per year      $2,000 per person, per year
                                                                                                                                      O
                                                                                                                                      N
No claims to file                   Claims are filed by           Claims are filed by              Claims are filed by
                                    participating dentists        participating dentists           participating dentists


   This is only a sample of the services covered by each plan. For services that are not listed in this
 comparison chart, contact each plan. See Help Lines on page 28 for contact information.
                                                                  25                Plan Year 2013 ComParison Chart
                      COMPARISON Of BENEfITS fOR VISION PLANS
                                          humana/ComPBenefits                                             PrimarY vision
V                                            visionCare Plan                                             Care serviCes, inC.

I    Covered serviCes                 in-network
                                                          out-of-
                                                          network
                                                                                                   in-network
                                                                                                                         out-of-
                                                                                                                        network
S         eYe eXams
                                 $10 copay
                                 One exam for
                                                               Plan pays up to $35; one $0 copay
                                                               exam every calendar      No Limit to frequency
                                                                                                                           Plan pays up to $40
                                                                                                                           Limit one exam
                                 eyeglasses                    year
I                                or contacts every
                                 calendar year

O                                $25 copay for single/
                                 multi-focal lenses
                                                               Plan pays up to:
                                                               $25 single
                                                                                              You pay wholesale cost You pay normal doctor’s
                                                                                              with no limit on number fee, reimbursed up to

N                                                              $40 bifocals
                                                               $60 trifocals
                                                                                              of pairs                $60 for one set of lenses
                                                                                                                      and frames annually
      lenses Per Pair                                          $100 lenticular



P
                                 $25 copay, up to plan     Plan pays up to $45                You pay wholesale cost.      You pay normal doctor’s
L           frames
                                 limits. One set of frames
                                 every calendar year
                                                                                              No limit to number of
                                                                                              frames
                                                                                                                           fee, reimbursed up to
                                                                                                                           $60 for one set of lenses

A                                $130 allowance                $130 allowance for             You pay wholesale cost
                                                                                                                           and frames per year
                                                                                                                           Limit of one set

N                                for conventional or
                                 disposable lenses and
                                 fitting fee in lieu of all
                                                               contacts and fitting
                                                               fee in lieu of all other
                                                               benefits
                                                                                              for annual supply of
                                                                                              contacts
                                                                                                                           annually in lieu of
                                                                                                                           eyeglasses
                                                                                                                           You pay normal doctor’s
                                 other benefits every                                                                      fees reimbursed up to
                                 calendar year                 Medically necessary                                         $60
      ContaCt lenses             Medically necessary           contacts, plan pays up
C                                contacts, plan pays
                                 100%
                                                               to $210


O
M                                Discount thru TLC,            No benefit                     Minimum 10% discount No benefit
P                                member will pay no
                                 more than $895 per eye
                                                                                              nationwide at The Laser
                                                                                              Center (TLC). Savings
         laser vision            for conventional Lasik,                                      of $1,000 on Lasik
A        CorreCtion              $1,295 custom plus
                                 bladeless when services
                                                                                              between June 1 – Sept.
                                                                                              30, 2013, at TLC in

R                                are rendered by a TLC
                                 network provider
                                                                                              OKC and Tulsa. Call
                                                                                              PVCS for details

I   NOTES:
    Humana: The contact lens benefit provides
                                                    $1,390.
                                                    Traditional Intralase (bladeless) with a lifetime
                                                                                                        therapy, 3) Non routine vision services and
                                                                                                        tests, 4) Luxury frames (wholesale cost of
                                                    plan with insurance discount is $1,395 per eye      frame exceeds $100, 5) Premium prescription
S
    a $130 yearly allowance for the annual
    vision exam to evaluate eye health, contact     equals $2,790.                                      lenses, and 6) Non prescription eye wear. For
    lens exam for fitting and evaluation, and       CustomVue Intralase (bladeless) with lifetime       more information, call 1-888-357-6912.
                                                    plan with insurance discount is $1,784.15 per
O
    the purchase of either conventional or                                                              *Superior: Materials copay applies to lenses
    disposable contacts. If a member prefers        eye equals $3,568.30.                               and/or frames. Discounts for lens add-ons will
    contact lenses, the plan provides the contact
                                         PVCS: Member must select either in-network                     be given by contracted providers with a “DP”

N   lens allowance in lieu of all other benefits.
                                         or out-of-network for entire plan year. In-
    Instead, if a member opts for lenses and
                                         network services are unlimited. Out-of-network
    frames during the plan year a $25 copay
                                         services (one eye exam, one set of eyeglasses
                                                                                                        in their listing. Online, in-network contact lens
                                                                                                        materials available at www.svcontacts.com.
                                                                                                        Exams, lenses, and frames are provided once
    applies for these two material items. More
                                         or contacts) are limited to once annually. A                   per calendar year. Progressive Lenses (no-line
    than 23,000 frames are covered in full by
                                         $50 service fee applies to soft contact lens                   bifocals) – you pay the difference between
    the $25 copay with in-network providers.
                                         fittings; a $75 service fee applies to rigid or                the retail price of the selected progressive
    Exams, lenses, and frame benefits aregas permeable contact lens fittings; and a                     lens and the retail price of the provider’s lined
    provided once every 12 months. Oklahoma
                                         $150 service fee applies to hybrid contact lens                trifocal. The difference may also be subject to
    City LasikPlus Traditional Intralase fittings. Simple replacements are not assessed                 a discount. Standard contact lens fitting applies
    (bladeless) with a one year plan withwith these fees. Limitations/Exclusions include                to an existing contact lens user who wears
    insurance discount is $695 per eye equals
                                         the following: 1) Medical eye care, 2) Vision                  disposable, daily wear, or extended wear lenses
    Plan Year 2013           ComParison Chart                    26
                      COMPARISON Of BENEfITS fOR VISION PLANS
                                                                                                             vision serviCe Plan
          suPerior vision Plan                           unitedhealthCare vision
                                                                                                                    (vsP)                                    V
   in-network
                               out-of-
                               network
                                                         in-network
                                                                                  out-of-
                                                                                  network
                                                                                                         in-network
                                                                                                                           out-of-
                                                                                                                          network
                                                                                                                                                             I
 $10 copay                Plan pays:
                          $34
                                                     $10 copay                  Reimbursement $10 copay
                                                                                up to $40
                                                                                                                               $10 copay
                                                                                                                               Plan pays up to $35           S
                          Ophthalmologist,
                          $26 Optometrist                                                                                                                    I
 $25 copay                Plan pays:
                          Single up to $26
                                                     $25 copay
                                                     Standard single vision,
                                                                              Single up to
                                                                              $40
                                                                                                       $25 copay applies
                                                                                                       to lenses or frames.
                                                                                                                               $25 copay
                                                                                                                               then plan pays:
                                                                                                                                                             O
                          Bifocals up to $39
                          Trifocals up to $49
                                                     lined bifocal & trifocal
                                                     lenses covered in full
                                                                              Bifocals up to
                                                                              $60
                                                                                                       Single vision, lined
                                                                                                       bifocal, and trifocal
                                                                                                                               Single up to $25
                                                                                                                               Bifocals up to $40            N
                          Lenticular up to $78       Scratch resistant &      Trifocals up to          lenses covered in       Trifocals up to $55
 Standard                 Standard                   UV coating, tints        $80                      full.                   Lenticular up to
 Progressive:             Progressive:               polycarbonate lenses, Lenticular up               Average 35% to          $80

                                                                                                                                                             P
 $25 copay                Up to $49                  are also covered in full to $80                   40% discount on
 *See notes below         *See notes below                                                             lens options


                                                                                                                                                             L
 $25 copay then           Plan pays up to $68        $25 copay                  Reimbursement $25 copay then                   $25 copay, then
 plan pays up to                                     $130 retail frame          up to $45     plan pays up to                  plan pays up to $45
 $125 retail                                         allowance                                $120

 $0 copay                 $0 copay                   $25 copay on covered-      Reimbursement          $0 copay                $0 copay
                                                                                                                                                             A
 Plan pays up to
 $120 all contacts
                          Plan pays up to $100
                          all contacts; $210
                                                     in-full qualifying
                                                     lenses (covers fittings
                                                                                up to $150
                                                                                elective contact
                                                                                                       Plan pays up to
                                                                                                       $120
                                                                                                                               Plan pays up to
                                                                                                                               $105 conventional             N
 Medically                medically necessary        and evaluation fees,       lenses; $210           conventional or         or disposable
 necessary contacts       contacts                   contact lenses and up      medically              disposable              $210 medically
 covered in full          (Contact lens fit          to 2 follow-up visits)     necessary              Medically               necessary contacts
 (Contact lens fit
 copay: Standard
 $25, after copay,
                          copay: Standard not
                          covered; specialty
                          not covered)
                                                     *See notes below           contact lenses         necessary contacts
                                                                                                       covered
                                                                                                       in full
                                                                                                                                                             C
 covered in full;
 specialty $25, after                                                                                                                                        O
 copay, plan pays up
 to $50)                                                                                                                                                     M
 5% - 50%                 No benefit                 15% discount off the       No benefit             15% average             No benefit
 Discount off
 surgical fees
                                                     usual & customary
                                                     price, 5% off
                                                                                                       off usual and
                                                                                                       customary price
                                                                                                                                                             P
                                                     promotional price                                 or 5% off the
                                                                                                       laser center’s
                                                                                                       promotional price
                                                                                                                                                             A
                                                                                                                    Plan utilizes the
                                                                                                             VSP Signature provider network
                                                                                                                                                             R
only. The Specialty contact lens fitting applies
to new contact lens wearers and/or a member
                                                     of contact lenses (material copay does not
                                                     apply). Toric and gas permeable contact lenses
                                                                                                          exam (fitting and evaluation) is covered in full
                                                                                                          after a copay up to $60. The $105 out-of-          I
who wears toric, gas permeable, or multifocal        are examples of contact lenses that are outside      network allowance applies to the contacts and
lenses.
UHCVision: For either glasses or contact
                                                     of our covered contacts. Necessary contacts are
                                                     covered-in-full after applicable copay. Exams,
                                                                                                          contact lens exam. Your contact lens exam
                                                                                                          is performed in addition to your routine eye       S
                                                     lenses, and frame benefits provided once every       exam to check for eye health risks associated
lenses, there is one $25 materials copay. In lieu
of lenses and frames, you may select contact
lenses. Covered contact lens benefit includes
                                                     calendar year.
                                                     VSP: Exam, lenses, and frame benefit provided
                                                                                                          with improper wearing or fitting of contacts.
                                                                                                          Prescription glasses - 30% off additional
                                                                                                                                                             O
                                                                                                                                                             N
                                                                                                          complete pairs of glasses and sunglasses,
the fitting/evaluation fee, contact lenses, and up   annually. The $25 materials copay applies to
                                                                                                          including lens options, from the same VSP
to two follow-up visits. If covered disposable       lenses or frames, but not to both. Copays/prices
                                                                                                          doctor on the same day as your WellVision
contact lenses are chosen, up to six boxes           listed are for standard lens options. Premium
                                                                                                          Exam. Or get 20% off from any VSP doctor
(depending on prescription) are included             lens options will vary. If you choose a frame
                                                                                                          within 12 months from your last WellVision
when obtained from a network provider. It is         valued at more than your allowance, you’ll
                                                                                                          Exam. Contact VSP or visit vsp.com to learn
important to note that UHC covered contact           save 20% on your out-of-pocket costs when
                                                                                                          about retail chain Affiliate Providers.
lenses may vary by provider. Should you              you use a VSP doctor. Contact lenses are in
choose contact lenses outside the covered            lieu of spectacle lenses and frame. The $120
selection, a $150 allowance will be applied          in-network allowance applies to the contact
toward the fitting/evaluation fees and purchase      lenses. With a VSP provider, the contact lens

                                                                           27                 Plan Year 2013 ComParison Chart
    HealthChoice (OSEEGIB)                                          Dental Plans’ Help Lines
                  Help Lines                                                Assurant, Inc. Dental
                                                              PPO Freedom Preferred                 1-800-442-7742
  Health, Dental, and Life Claims, Benefits,
   Verification of Coverage, and ID Cards                     Prepaid Heritage Plans                1-800-443-2995
                                                              Website              www.assurantemployeebenefits.com
Oklahoma City Area                     1-405-416-1800
All Other Areas                        1-800-782-5218                      CIGNA Prepaid Dental
TDD Oklahoma City Areas                1-405-416-1525         All Areas                                1-800-244-6224
TDD All Other Areas                    1-800-941-2160         Toll-free Hearing Impaired Relay Svc     1-800-654-5988
Website     www.sib.ok.gov or www.healthchoiceok.com          Website                                  www.cigna.com
                                                                                 Delta Dental
    Pharmacy Claims/Pharmacy ID Cards
                                                              Oklahoma City Area                    1-405-607-2100
All Areas                              1-800-903-8113         All Other Areas                       1-800-522-0188
TDD All Areas                          1-800-825-1230         Website                        www.DeltaDentalOK.org
     Member Services/Provider Directory
                                                                    Vision Plans’ Help Lines
Oklahoma City Area                      1-405-717-8780
All Other Areas                         1-800-752-9475                     Humana/CompBenefits
TDD         1-405-949-2281 or All Areas 1-866-447-0436                       VisionCare Plan
                                                              All Areas                           1-800-865-3676
                HealthChoice USA
                                                              TDD All Areas                       1-877-553-4327
Customer Service & Claims            1-800-782-5218           Website www.compbenefits.com/custom/stateofoklahoma
Provider Information        1-877-877-0715 ext. 4059
                                                               Primary Vision Care Services (PVCS)
TDD All Areas                        1-800-941-2160
                                                              All Areas                                1-888-357-6912
Website                   www.choicecarenetwork.com
                                                              TDD All Areas                            1-800-722-0353
      American fidelity Health Services                       Website                                www.pvcs-usa.com
              Administration                                                Superior Vision Plan
        Health Savings Account (HSA)
                                                              All Areas                             1-800-507-3800
Oklahoma City Area                     1-405-523-5699         TDD                                   1-916-852-2382
All Areas                              1-866-326-3600         Website                        www.superiorvision.com
Website                                www.afhsa.com                      UnitedHealthcare Vision
       HMO Plans’ Help Lines                                  All Areas                            1-800-638-3120
                                                              TDD All Areas                        1-800-524-3157
                CommunityCare                                 Website                         www.myuhcvision.com
All Areas                              1-800-777-4890
                                                                          Vision Service Plan (VSP)
TDD All Areas                          1-800-722-0353
                                                              All Areas                                1-800-877-7195
Website                                www.ccok.com
                                                              TDD All Areas                            1-800-428-4833
                GlobalHealth, Inc.                            Website                                   www.vsp.com
Oklahoma City Area                   1-405-280-5600
All Other Areas                      1-877-280-5600
TDD All Areas                        1-800-522-8506
Website                         www.globalhealth.com


                                                         28
HealthChoice
  Oklahoma State and Education
 Employees Group Insurance Board
  3545 NW 58 Street, Suite 110
   Oklahoma City, OK 73112




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