OU
THE UNIVERSITY OF OKLAHOMA
EMPLOYEE BENEFITS
2009
Experience. Wellness. Everywhere.
Experience. Wellness. Everywhere.
TABLE OF CONTENTS
Benefit Enrollment & Making Changes During the Year. . . . . . . 2
Medical Plan Options. . . . . . . . . . . . . . . . . . . . . . . . . . . 2-3
BlueLincs® HMO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
BlueChoice® PPO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
BlueEdgeSM HCA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6-7
Plan Comparison Chart. . . . . . . . . . . . . . . . . . . . . . . . . 8-13
What’s Not Covered . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
ID Cards. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Wellness Guide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15-17
Resource Guide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Contacts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
WELCOME
Welcome to Blue Cross and Blue Shield of Oklahoma,
and to your benefit enrollment period. This is your opportunity to
select health benefits for you and your family for the coming year.
We are delighted that the University of Oklahoma has chosen us
as your health benefits company.
For more than 68 years, Blue Cross and Blue Shield of Oklahoma (BCBSOK) has delivered high value
products and unrivaled customer service to more Oklahomans than any other health insurance plan. And
our nationwide network of physicians and hospitals, coupled with local resources and friendly service,
keeps you connected to your health care coverage no matter where you are.
Through the University of Oklahoma, we are pleased to offer benefits that give you and your family the
best care possible and services that allow you to put your health care decisions and health education
closer to your fingertips. Please take a few minutes to look through this summary guide and review the
three plan options that are available to you – BlueLincs HMO, BlueChoice PPO, and BlueEdge Health Care
Account (HCA). You may also visit www.bcbsok.com/OU for more information. It is our desire during the
enrollment period that you gain a clear understanding of each option and to help you decide what is best
for your health care needs.
Being a member of BCBSOK doesn’t just provide you with traditional insurance coverage; you also have
a complete suite of health and wellness resources and tools at your fingertips, to encourage healthier
living and smarter health decisions. Blue Cross and Blue Shield of Oklahoma is a health care industry
leader in creating and promoting wellness programs that you and your family can conveniently integrate
into your daily life. Merging technology and medical management with online resources, education,
one-on-one coaching, rewards and multiple touch points, BCBSOK’s Blue Care Connection® program aims
to ultimately improve you and your family’s health and wellness.
01
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The interactive programs will help you manage personal wellness and
The following are key
encourage healthier behaviors by awarding Blue Points, which recognize
benefit changes to your
healthy activities.
2009 health care, including
The Personal Health Manager provides tools, information and
several enhancements to
encouragement to improve and maintain a healthier lifestyle.
your coverage:
By showing your BCBSOK ID card at participating locations, you can
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sm
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calendar year, rather than once every
save money through discounts and memberships on certain health care
24 months.
products and services, including participating Jenny Craig and Curves
locations, as well as GlobalFit, which operates through a number of
Routine Physicals are now covered every
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Smoking Cessation expenses, such as
over-the-counter medications, acupuncture,
different fitness facilities throughout Oklahoma.
hypnosis, and stop smoking aids will be
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The self-service Web site, Blue Access for Members , allows you access
reimbursed up to $500 annually ($1,500
to the Personal Health Manager, information and resources on medical
lifetime maximum per person).
®
conditions, and a history of your claims. Additionally, the BCBSOK Web
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Hospice Care is no longer a limited benefit.
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HMO Urgent Care – The BlueLincs HMO
site for OU located at www.bcbsok.com/OU, has a wealth of general
information available, including provider directories.
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copayment for urgent care visits has been
lowered to $50.
The 24/7 Nurseline provides telephone access to registered nurses
at any time, day or night, to help with your health-related questions
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Chiropractic, physical, occupational, and
speech therapies are subject to a 60 visit
and issues.
combined calendar year maximum.
These benefits, plus many more wellness-related programs, are offered along
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side your health care coverage for a total health and wellness package.
related to autism are not covered under your
Our goal at Blue Cross and Blue Shield of Oklahoma is to provide
you with first class service, and to do the job right the first time,
every time. We appreciate the opportunity to serve you.
Sincerely,
Speech Therapy for Autism – Although services
plan, benefits will now be available for 20
speech therapy visits per calendar year.
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Pharmacy Changes – Changes have been
made to the Formulary and Tiers.
Please refer to www.bcbsok.com/OU for a list
Jeffrey R. Tikkanen
Vice President, Marketing and Sales
Blue Cross and Blue Shield of Oklahoma
of the most frequently used prescription drugs to
see if any tier changes will impact you.
02
Benefit Enrollment & Making
Changes During the Year
During the open and new member enrollment period, you can
add or delete dependents from your health care coverage without
a “qualifying event”. The enrollment period is the time to make
sure all of your eligible dependents are enrolled and that Human
Resources has all the correct information about your dependents
on file.
The health care plan options you select during the enrollment
period will remain in effect during the calendar year.
In order to change benefit elections outside of the enrollment
Please visit the “Benefits” section of the OU Human Resources
Web site for more information at www.hr.ou.edu.
Eligibility
Please visit the “Benefits” section of the OU Human Resources
Web site for information at www.hr.ou.edu
Medical Plan Options
The following pages (2 – 14) provide an overview of the
health benefits of each of the program options. These are
only summaries – not the actual plan descriptions. If you have
questions that aren’t answered in the summary information in this
period, the employee must have:
booklet, please contact customer service at 1-888-881-4648 or
1) Experienced an Applicable Qualifying Event, as defined by
quarter 2009). Dental care benefits are offered separately, and
the Internal Revenue Service (IRS). Changes based on financial
are not highlighted in this benefit guide.
reasons alone are not allowed under the current IRS regulations.
AND
2) The request for a change of benefits must be made within 31
review the detailed Summary Plan Descriptions (available late first
The medical plan you select during the enrollment period will
apply for the calendar year. You will not be able to make
days of the Applicable Qualifying Event.
changes to your medical plan during the year UNLESS YOU
Within the context of changing benefits, “Applicable” refers to a
switch from one plan to another during the year, unless you are
change that is directly related to the individual experiencing the
on the HMO plan and move outside the service area. A brief
qualifying event.
description of the various aspects of each program follows on
A qualifying event includes:
HAVE A QUALIFYING EVENT. In no event will you be able to
the next pages.
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A birth or adoption
Medical Plan Comparisons
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Marriage, divorce or legal separation
What type of plans do I have to choose from? There are three
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Death
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Child loses eligibility because of age or marriage
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Employee’s spouse gains or loses coverage through
employment
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Significant change in the financial terms of health benefits
provided through a spouse’s employer or another carrier
Except for coverage of a newborn or adopted child, all other
changes in coverage begin the first day of the month following
the qualifying event. Coverage for the newborn is effective on the
child’s date of birth. Coverage for an adopted child is effective
on the date of placement. In both instances, the employee must
initiate and complete the appropriate paperwork.
Changes in provider networks (for example, your doctor leaving
the network) are not considered acceptable reasons for you
to be able to change your product election outside of the
enrollment period.
notably different benefit plans to choose from:
1) BlueLincs HMO
2) BlueChoice PPO
3) BlueEdge HCA
The BlueLincs HMO is a health maintenance organization type
of plan, otherwise known as a “managed care” plan. It requires
selection and use of a primary care physician (PCP), and referrals
are usually needed for specialty care. The BlueChoice PPO plan
is a preferred provider organization type of plan, which gives
you the flexibility to choose between a PPO provider or non-PPO
provider. Benefits are almost always higher if you use a PPO
provider. The BlueEdge HCA is considered a consumer-driven
health plan (CDHP), which pairs a high deductible PPO plan with
a health fund that can be used to pay for certain out-of-pocket
medical expenses.
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What should I consider when choosing between the PPO, HMO
3) Provider access – The BlueChoice network, which is used for
and HCA plan options? There are four key areas (in no particular
both the BlueChoice PPO and BlueEdge HCA plan, is BCBSOK’s
order) to consider when comparing benefit plans:
largest network in the state. There are fewer providers in the
BlueLincs HMO network than there are in the BlueChoice network.
1) Benefit design
Be sure to verify that your current physicians are in the network
2) Rates
for the plan you are considering. If you are joining the HMO and
3) Provider access
want to choose a new primary care physician (PCP), make sure
4) Flexibility
that physician is accepting new patients.
There are important differences between the plans that should be
considered. Here are some factors to keep in mind:
With BlueLincs HMO, out-of-state coverage is generally limited to
emergency treatment. If you have a dependent living out-of-state
1) Benefit design – There are notable differences between the
(for example, a college student), or if you are moving out-of-state
plans, which impacts the coverage and the out-of-pocket costs
during the year, you may be eligible to enroll in the Away From
you’ll have when you utilize your benefits. The BlueLincs HMO
Home Care Program, which connects BlueLincs HMO members
has very low out-of-pocket costs with just applicable copays.
to a participating out-of-state HMO.
And, there is no calendar year deductible to satisfy.
The Away From Home Care Program does not cover the entire
The BlueChoice PPO has a calendar year deductible to satisfy
United States. If you are considering the HMO, and you have
before coverage begins. But, like the HMO plan, many services
an out-of-state dependent, please contact BCBSOK to discuss
are covered with just a copay, so depending on the type
your options.
of services you need, you may not even need to meet your
deductible during the year.
PPO members (BlueChoice PPO and BlueEdge HCA) have
nationwide access to contracting providers through the BlueCard®
The BlueEdge HCA has a notably higher deductible to satisfy
Program when you or your covered family members live, work, or
each year, and most services, except for some of your preventive
travel anywhere in the country.
care benefits, are subject to that deductible before your coverage
begins. To help offset the higher deductible with this plan, money
is put into a health care account each year on your behalf, which
can be applied to your deductible or other eligible out-of-pocket
medical expenses.
members have access to contracting providers in more than 200
countries through BlueCard Worldwide®.
4) Flexibility – Both the BlueChoice PPO and BlueEdge HCA
2) Rates – The BlueLincs HMO plan has the lowest rates of the
three medical plans. Keep in mind, however, that as an HMO it
has less flexibility than the other two plans, and it has a smaller
network of providers to choose from. The BlueEdge HCA is
the middle cost plan. It provides a high level of flexibility, but
it has higher out-of-pocket costs than the other two plans. The
BlueChoice PPO has higher rates than the other two plans, but it
provides both a high level of flexibility and an overall high level
of coverage.
Additionally, when you travel outside the United States, PPO
give you the most flexibility since you have coverage for both
in-network (PPO) and out-of-network providers. Keep in mind that
you will always receive your highest level of benefits available
when choosing an in-network provider. The BlueLincs HMO
plan is a managed care plan that requires the use of BlueLincs
contracted providers. You also are required to select a PCP to
provide or coordinate most of your care, and because it is an
HMO, referrals from your PCP are required for most specialty
care. The other two plans do not have those requirements; you
“manage” your own care.
Nourish to flourish.
People sometimes turn to popular diets to achieve quick weight loss.
For lasting changes and healthy eating, balance what you eat to meet
your need for nutrition and enjoyment. Enjoy a variety of foods while
keeping key food groups in mind and use moderation when choosing
less nutritious foods.
04
Enjoy a state of balance.
BlueLincs HMO
If you are enrolling in BlueLincs HMO, you must specify a Primary Care Physician (PCP) during your enrollment. During your online
enrollment process, you will be asked to provide your PCP’s ID number.
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You must select your own PCP from the HMO provider network, and you must see him or her to coordinate care in order to
receive benefits.
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You may choose a different PCP for each family member, or you may select the same one for the entire family.
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If you receive non-emergency care outside the HMO network or from a provider without a referral from your PCP (except as
noted in the following bullet), you receive no benefits.
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To visit a specialist, a referral is required from your PCP for most care. Referrals are not required when you receive an annual
exam from a network OB/GYN or from a network ophthalmologist or optometrist for routine exams.
Besides the BlueLincs HMO plan, an additional HMO plan is available for Tulsa employees. Please visit the “Benefits” section of the
OU Human Resources Web site for more information at www.hr.ou.edu.
BlueLincs HMO Frequently Asked Questions
Where do I get my PCP’s ID number? A provider directory is available through www.bcbsok.com/OU. There you can search for a
PCP you currently use or locate a new PCP that is available through the BlueLincs HMO network. You must enter the entire ID number,
including all zeros. The ID must be five numeric digits (no letters), including any zeros. (Example: 00123)
I had an HMO last year, and want to keep my current PCP. What do I do during the enrollment period? You should verify through
the provider directory on www.bcbsok.com/OU that your current PCP is covered under the BlueLincs HMO network. If your PCP is
covered, you will need to “re-enroll” your PCP during the enrollment period.
I want to change my current PCP. Can I do that during the enrollment period? Yes, and you are able to do that up to four times a year
as well. Consult the provider directory on www.bcbsok.com/OU to choose a PCP in the HMO network. During the enrollment period,
include the PCP’s ID number on the application. During the year, simply call customer service to make this change.
My dependents live out-of-state. Can I choose BlueLincs HMO? With BlueLincs HMO, out-of-state coverage is generally limited to
emergency treatment only. If you have a dependent living out-of-state (for example, a college student), or if you are moving out-of-state
during the year, you or your dependent may be eligible to enroll in the Away From Home Care Program, which connects BlueLincs
HMO members to a participating out-of-state HMO. The program is designed for members who:
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have a child attending school out-of-state
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have family members living in different service areas
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have a long-term work assignment in another state
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are retired with dual residence
The Away From Home Care Program does not cover every area in the entire United States. If you are considering the HMO, and you
have an out-of-state dependent, please contact BlueLincs HMO toll free at 1-800-580-6202 to discuss your options.
05
BlueChoice PPO
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You have access to an extensive network of providers and hospitals throughout the country, including therapists, chiropractors,
behavioral health professionals and other specialists.
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You are not required to select a Primary Care Physician, and no referrals are required.
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You can select any covered provider for care within the PPO network or outside the network.
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When you receive care from in-network PPO providers, you receive the highest level of benefits.
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When you receive care from out-of-network providers, you not only receive a lower level of benefits, but you may also be
subject to out-of-pocket costs for amounts the provider charges that are above the maximum allowable charge.
National and International Coverage
As a PPO member, you have nationwide access to contracting providers through the BlueCard® Program when you or your
covered family members live, work or travel anywhere in the country. You can easily locate PPO network doctors and hospitals at
www.bcbs.com or by calling BlueCard Access at 1-800-810-BLUE (2583). When you use BlueCard providers, you receive the highest
level of benefits. You usually do not have to pay up front or file claim forms, and you take advantage of the savings the local plan has
negotiated with area providers.
When you travel outside the United States, you have access to contracting providers in more than 200 countries through BlueCard
Worldwide®. If you receive care from a non-BlueCard Worldwide provider, you will have to pay the doctor or hospital for care at the
time of service and then submit a claim for reimbursement.
BlueChoice PPO Frequently Asked Questions
How do I find a doctor in the PPO network? Go to www.bcbsok.com/OU and use the provider directory, or call customer service.
I travel out-of-state fairly often. What happens if I need emergency care while I’m traveling? When you or covered family members
need emergency care, go immediately to the nearest emergency facility. You don’t need to try to find a network physician or hospital
for emergency care.
Do I need a referral from my doctor to see a specialist? No. With the PPO plan you can see any doctor at any time without a referral. If
you see a specialist who is part of the PPO network, your benefits will be paid at the highest level. You can also see a specialist who is
not part of the network, but your benefits will be paid at a lower level.
The BlueChoice PPO network is one of the largest in the state, with more
than 5,400 physicians and specialists and over 125 hospitals contracting
with Blue Cross and Blue Shield of Oklahoma. The National PPO network
includes more than 800,000 doctors and 5,000 hospitals contracting with
Blue Cross and Blue Shield Plans nationwide.
You can easily locate PPO network doctors and hospitals at www.bcbs.com
or by calling BlueCard Access at 1-800-810-BLUE (2583).
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Live a life of commitment.
BlueEdge HCA
What is it?
With the BlueEdge HCA plan, a specific amount of money is deposited each benefit year in a health care account (HCA). In 2009 for
example, $500 is deposited for an individual employee, or $1,000 is deposited for an employee with enrolled dependents. In both
cases, that amount is pro-rated if you are enrolling in the middle of the year. This includes new employees starting after the beginning
of the calendar year (see the pro-ration schedule at right). When you need any covered medical care, the first out-of-pocket costs you
have are paid from available funds in this account. The money paid from your health care account is applied toward meeting your
annual plan deductible or other copay or coinsurance amounts you may be responsible for. Any unused health care account funds roll
over year to year, as long as you remain in the BlueEdge HCA.
Benefits
The HCA that Blue Cross and Blue Shield of Oklahoma offers is called BlueEdge. However, the network of providers that are covered
under the BlueEdge HCA is the same network as the BlueChoice PPO plan.
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As a PPO member, you have access to an extensive network of providers and hospitals throughout the country. You can select
any provider for care within the PPO network or outside the network. When you receive care from a PPO provider, you receive
the highest level of benefits. When you receive care from a non-PPO provider, you receive a lower level of benefits.
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You do not have to select a primary care physician, and you never need a referral to see a specialist.
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Under BlueEdge HCA, some of your well child and adult preventive care services are covered in full, including routine
OB/GYN exams and mammograms, and well child immunization. Many other well child and adult preventive care services
are covered at 100 percent up to the first $250 each year. (Additional preventive services are covered under your
regular benefits.)
How does it work?
1) At the beginning of each year, funds are deposited into your HCA account. In 2009, $500 is deposited for an individual employee,
or $1,000 for an employee with enrolled dependents. Available funds in the HCA are used to pay for your initial health care
deductible expenses each year.
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The $1,000 credit for employees with dependents can be used in any combination by the covered members of one family
for covered expenses, including the entire $1,000 being used by one family member.
2) Once your available HCA funds are depleted, you are responsible for any remaining deductible and coinsurance.
3) Once the deductible is met, benefits for covered services begin. As with any PPO, you need to use an in-network provider to receive
the highest level of benefits.
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When providers submit their claims to BCBSOK, out-of-pocket expenses for covered services are automatically paid from
available funds in your HCA. There is no special paperwork to be submitted for reimbursement, and you will receive an
Explanation of Benefits (EOB) showing what benefits are payable under your plan, noting the amount paid from your HCA.
You can also keep track of your HCA and deductible balance online.
07
4) Once your out-of-pocket maximum is reached, eligible health care services will be covered at 100 percent of the allowable amount
for the remainder of the calendar year.
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If you don’t spend all of your HCA funds in one year, the balance rolls over to the next year and is added to the annual amount
contributed to your account. There is no maximum on the amount you can accumulate in your HCA. The higher your HCA
balance is, the less you’ll have to pay out-of-pocket when you do need to utilize your health benefits.
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Any funds accumulated in excess of your deductible will be used to pay for any coinsurance you incur. If you switch to a
different product option at a future enrollment, you will forfeit any balance in your HCA. The HCA will not be paid out in cash
under any circumstance.
Additional information about the BlueEdge HCA
Pro-ration
HCA funds are pro-rated for employees starting work after the beginning of the calendar
year, following this pro-ration schedule:
Jan. 1 – March 31
100% contribution
$500 individual /$1,000 family
April 1 – June 30
75% contribution
$375 individual /$750 family
July 1 – Sept. 30
50% contribution
$250 individual /$500 family
Oct. 1 – Dec. 31
25% contribution
$125 individual /$250 family
Wellness Services
Many wellness services are paid at 100% and are not subject to your annual deductible.
Additionally, the preventive care services that are covered at 100% are not paid with any of
the funds in your HCA.
Eligible expenses that can be paid
Deductible, coinsurance and copayment amounts you are responsible for under your benefit
from available HCA funds
plan for covered services.
Annual Enrollment Required
Enrollment in an HCA does not automatically continue from year to year. If you enroll in the
BlueEdge HCA, it will be necessary for you to re-enroll in it every year during the enrollment
period.
Most people compare covered benefits, network providers, the cost of coverage and other out-of-pocket
expenses when choosing a health plan. Since BlueEdge is a relatively new health plan, BCBSOK has
developed the Health Care Cost Advisor – an innovative online tool available through www.bcbsok.com/OU
that features a series of questions to help you decide if BlueEdge HCA meets your needs, and a budgeting
tool to assist in the plan selection process.
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Plan Comparison Chart
Coverage (Benefit period is one calendar year)
BlueLincs HMO
HMO Network Only
Calendar Year Deductible Individual/Family
Out-of-Pocket Maximum Individual/Family
Health Care Account Fund
Lifetime Health Care maximum (per person)
$0
$2,000/$4,000
Does not include copays for
prescription drugs
Not applicable
Unlimited
PHYSICIAN SERVICES The amounts shown below are what you are responsible for paying for each type of service or treatment.
Office visit & services (excluding surgery) /consultation /second opinion
$25 copay per visit
($35 copay for specialist)
Physical, Occupational, Speech, and Chiropractic Therapies
(60 visit maximum combined for all therapies)
$35 copay
Allergy Injections
$25 copay
Allergy Testing
$35 copay
Allergy Serum
Covered in full
Inpatient Physician Services
Covered in full
Outpatient Physician Services
$35 copay
Lab & X-ray (Physician Office)
Covered in full after office visit copay
Lab & X-ray (Outpatient Facility)
$35 copay (covered in full if done in
conjunction with an office visit)
MRI, CT, PET, EEG, and other similar imaging tests
$35 copay
PREVENTIVE CARE SERVICES The amounts shown below are what you are responsible for paying for each type of service or treatment.
Routine Physical (once every calendar year)
$25 copay (age 19 and older)
Adult Immunizations
$25 copay
Well Child Exams
$25 copay
Routine Eye Exam* (does not include hardware)
$25 copay
Routine Hearing Exam* (does not include hardware/hearing aids)
$25 copay
Routine Ob/Gyn Exam
$25 copay
Routine Mammograms
Covered in full
Routine Prostate Specific Antigen (PSA) and Digital Rectal Exams (DRE)
Well Child Immunizations
*Routine vision and hearing exams limited to once every 24 months.
$25 copay
Covered in full
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BlueChoice PPO
Traditional
Indemnity
BlueEdge HCA
(over 65 Retirees Only)
In-Network
Out-of-Network
$500/$1,000
$750/$1,500
$3,000/$6,000
Does not include copay
amounts
$4,000/$8,000
Does not include copay
amounts
In-Network
Out-of-Network
$1,500/$3,000
$2,500/$5,000
Your deductible is reduced by your HCA fund amount
$3,000/$6,000
Includes deductible and
copay amounts
$6,000/$12,000
Includes deductible and
copay amounts
No Network
None
$3,000/
$6,000
Not applicable
$500 Individual $1,000 Family
(see BlueEdge HCA section)
Not
Applicable
Unlimited
Unlimited
Unlimited
$25 copay per visit
($35 copay for specialist)
30% after deductible
15% after deductible
35% after deductible
20%
$35 copay
30% after deductible
15% after deductible
35% after deductible
20%
$25 copay
($35 copay for specialist)
30% after deductible
15% after deductible
35% after deductible
20%
$35 copay
30% after deductible
15% after deductible
35% after deductible
20%
$25 copay
30% after deductible
15% after deductible
35% after deductible
20%
20% after deductible
30% after deductible
15% after deductible
35% after deductible
20%
20% after deductible
30% after deductible
15% after deductible
35% after deductible
20%
Covered in full after office
visit copay
30% after deductible
15% after deductible
35% after deductible
20%
Covered in full if done in
conjunction with an office visit
30% after deductible
15% after deductible
35% after deductible
20%
20% after deductible
30% after deductible
15% after deductible
35% after deductible
20%
$25 copay
(age 19 and older)
30% after deductible
$25 copay
($35 copay for specialist)
30% after deductible
$25 copay
30% after deductible
$35 copay
30% after deductible
100%
Covered in full for the first $250, then subject
to deductible and coinsurance.
The first $250 (covered in full) is not
counted against the HCA Fund.
100%
100%
100%
$25 copay
30% after deductible
$25 copay
($35 copay for specialist)
100%
30% after deductible
Covered in full
Covered in full
Covered in full
Covered in full
100%
$25 copay
30%, no deductible
15%, no deductible
35%, no deductible
100%
Covered in full
Covered in full
Covered in full
Covered in full
100%
100%
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Coverage (Benefit period is one calendar year)
BlueLincs HMO
HMO Network Only
HOSPITAL SERVICES The amounts shown below are what you are responsible for paying for each type of service or treatment.
Inpatient Hospital
Outpatient Surgery
Emergency Room
Urgent Care
$250 copay per admission
$100 copay per surgery
$100 copay per visit – waived if admitted
$50 copay
Extended Care Inpatient/Home
Skilled Nursing Facility
Skilled Nursing Facility Maximum
Home Health
Home Health Maximum
Private Duty Nursing
Private Duty Nursing Maximum
Hospice - Inpatient (no benefit limit)
Hospice - Outpatient (no benefit limit)
$250 copay per admission
No limit
Covered in full
No limit
Covered in full
No limit
$250 copay
Covered in full
MATERNITY & FAMILY PLANNING The amounts shown below are what you are responsible for paying for each type of service or treatment.
Prenatal & Postnatal visits
Inpatient Hospital
$35 copay for initial visit then no charge
$250 per admission
Infertility Testing & Treatment Infertility coverage provided for diagnosis and treatment of
underlying cause only.
Covered with applicable copay
Voluntary Sterilization
Covered with applicable copay
Reversal of sterilization is not covered.
Pregnancy Termination (therapeutic & non-therapeutic)
Covered with applicable copay
Contraceptive Devices
Covered with applicable copay
11
BlueChoice PPO
Traditional
Indemnity
BlueEdge HCA
(over 65 Retirees Only)
In-Network
Out-of-Network
In-Network
Out-of-Network
No Network
20% after deductible
30% after deductible
15% after deductible
35% after deductible
20%
20% after deductible
30% after deductible
15% after deductible
35% after deductible
20%
20% after $100 copay and deductible –
copay waived if admitted
15% after deductible
20%
20% after $50 copay and
deductible
30% after deductible
15% after deductible
35% after deductible
20%
20% after deductible
30% after deductible
15% after deductible
35% after deductible
20%
90 visits per calendar year, combined in- and out-of-network
20% after deductible
30% after deductible
120 days per calendar year, combined in- and out-of-network
20% after deductible
30% after deductible
70 visits per calendar year, combined in- and out-of-network
90 visits per calendar year, combined in- and out-of-network
15% after deductible
35% after deductible
120 days per calendar year, combined in- and out-of-network
15% after deductible
35% after deductible
70 visits per calendar year, combined in- and out-of-network
90 visits
per calendar year
20%
120 visits
per calendar year
20%
70 visits
per calendar year
20% after deductible
30% after deductible
15% after deductible
35% after deductible
20%
20% after deductible
30% after deductible
15% after deductible
35% after deductible
20%
$25 copay/$35 copay
for specialist for initial visit;
all other services
20% after deductible
30% after deductible
15% after deductible
35% after deductible
20%
20% after deductible
30% after deductible
15% after deductible
35% after deductible
20%
$25 copay
($35 for specialist)
30% after deductible
15% after deductible
35% after deductible
20%
20% after deductible
30% after deductible
15% after deductible
35% after deductible
20%
20% after deductible
30% after deductible
15% after deductible
35% after deductible
20%
Covered with
applicable copay
30% after deductible
15% after deductible
35% after deductible
20%
12
Coverage (Benefit period is one calendar year)
BlueLincs HMO
HMO Network Only
MENTAL HEALTH The amounts shown below are what you are responsible for paying for each type of service or treatment.
Inpatient Hospital/Facility
$250 copay per admission
Inpatient Facility Day Maximum per Calendar Year
Outpatient Charges
30 days
$35 copay
Outpatient: Maximum per Calendar Year
20 days
SUBSTANCE ABUSE The amounts shown below are what you are responsible for paying for each type of service or treatment.
Inpatient Hospital/Facility
$250 copay per admission
Inpatient Facility Day Maximum per Calendar Year
Outpatient Charges
30 days
$35 copay
Outpatient: Maximum per Calendar Year
20 visits
PRESCRIPTIONS The amounts shown below are what you are responsible for paying for each type of service or treatment.
Retail Pharmacy Care Generic (Tier I)/Preferred Brand (Tier II)/Non-Preferred Band (Tier III)
(30 day supply with one copay or 31-90 day supply with two copays)
Mail Order RX Generic (Tier I)/Preferred Brand (Tier II)/Non-Preferred Band (Tier III)
(90 day supply)
$10/$30/$60
$20/$60/$120
Prescription Smoking Cessation Products
Covered
Oral Contraceptives
Covered
Sexual Dysfunction Drugs (limited to eight doses per 30 days - no mail order)
Not covered
Diabetic Supplies – Diabetic Supplies can be covered under medical benefits (applicable deductible and coinsurance would apply) or under pharmacy benefit (applicable copays will apply).
Covered
Step Therapy – For listing of drugs that apply to Step Therapy, please see Formulary at
www.bcbsok.com/OU.
Applies
Pre-Authorization – For listing of drugs that require Pre-Authorization, please see
Formulary at www.bcbsok.com/OU).
Applies
OTHER SERVICES AND SUPPLIES The amounts shown below are what you are responsible for paying for each type of service or treatment.
Smoking Cessation Benefit (non-RX) – 100% member reimbursement for over-the-counter
medications, acupuncture, hypnosis, stop smoking aids, etc., to a maximum of $500 per
calendar year, $1,500 lifetime maximum (per person)
Applies
Bariatric Surgery
Covered
Durable Medical Equipment
Covered in full
Ambulance (Ground/Air)
Covered in full
Routine Audiological Exam
$25 copay
Routine Audiological Exam for children up to age 18 including routine diagnostic audiological exam/evaluation and hearing aids, limited to 2 every
24 months. For children up to age 2, coverage includes 4 additional molds per years.
Speech Therapy for Autism – Although services related to Autism are not covered under your health plan, benefits will now be available for 20 speech
therapy visits per calendar year.
13
BlueChoice PPO
Traditional
Indemnity
BlueEdge HCA
(over 65 Retirees Only)
In-Network
Out-of-Network
In-Network
Out-of-Network
No Network
20% after deductible
30% after deductible
15% after deductible
35% after deductible
20%
Unlimited
$35 copay
Unlimited
30% after deductible
15% after deductible
Unlimited
20% after deductible
35% after deductible
Unlimited
30% after deductible
15% after deductible
30 days
$35 copay
Unlimited
Unlimited
35% after deductible
30 days
30% after deductible
15% after deductible
26 visits
20%
20%
30 days
35% after deductible
26 visits
20%
30 days
$15/$25/$40
30% after
$15/$25/$40
$15/$25/$40
after deductible
$30/$50/$80
after deductible
$8/$35/50%
($100 minimum;
$200 maximum)
$30/$50/$80
Not covered
$30/$50/$80
after deductible
Not covered
$16/$70/50% ($100
minimum; $200 maximum) out-of-network
not covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Covered
Not
covered
Covered
Covered
Covered*
Applies
Applies
Applies
Applies
Applies
Applies
Applies
Applies
Applies
Applies
Applies
Not covered
Not covered
Not covered
Not covered
Not
covered
20% after deductible
30% after deductible
15% after deductible
35% after deductible
20%
Covered in full
20% after deductible
30% after deductible
15% after deductible
15% after deductible
20%
35% after deductible
* Covered (syringes, needles, alcohol swabs). Diabetic management supplies (insulin, insulin pump, etc.) must be covered by Medicare Part B
20%
14
What’s Not Covered
g
for flat feet, subluxation, corns, bunions (except capsular and
bone surgery), calluses, toenails, etc.
Your plan options do not cover all health care expenses, and
include exclusions and limitations. You should refer to planspecific documents to determine which health care services are
covered and to what extent. The following is a partial list of
services and supplies that are generally not covered. However,
your plan documents may contain exceptions to this list based
on state mandates, the plan design or rider(s) purchased. Visit
the “Benefits” section of the OU HR Web site for plan-specific
information at www.hr.ou.edu
g
g
g
Acupuncture, whether for medical or anesthesia purposes
(acupuncture for smoking cessation is covered under the annual
smoking cessation benefit. See page 1 of this booklet.)
ID Cards
You will receive an ID card in the mail soon after the enrollment
period is complete. If you are enrolled with dependents, you will
Services that BCBSOK determines are experimental/
receive two ID cards. Additional cards can be ordered through
investigational in nature
customer service or online via the Blue Access for Members Web
Any condition to the extent payment would have been made
under Medicare if the member had applied for Medicare and
claimed Medicare benefits
g
Foot care only to improve comfort or appearance, such as care
Diagnosis, treatment or medications for infertility and
site. You should present your ID card when visiting a physician’s
office or hospital, and verify that they have the correct insurance
information on file for you. Your new card will resemble the
card below, and will be customized with your name and plan
Plan
information. Dependents’ names will not
Name be printed on the ID card.
fertilization procedures, including artificial insemination;
Subscriber:
ovulation induction procedures; in vitro fertilization; embryo
Identification Number:
transfer. (Coverage for infertility is limited to diagnosis and
treatment of underlying cause.)
John Q. Sample
Conditions related to autistic disease of childhood, hyperkinetic
syndromes, learning disabilities, behavioral problems, mental
Plan
Name
ABC12345678
Group Number
Effective
Date
Subscriber:
Benefit
Network
John Q.
Sample
Office Visit Copay:
The University of Oklahoma
Specialist Copay:
Identification Number:
Rx Copay:
Group Number
Effective Date
Benefit Network
Office Visit Copay:
ABC12345678
g
The University of Oklahoma
Specialist Copay:
Rx Copay:
retardation, or for inpatient confinement for environmental
change. However, the plan will cover medically necessary
services such as physician’s services related to the diagnosis
and treatment of ADD and ADHD, and prescription drug
www.bcbsok.com
therapy for treatment of ADD/ADHD for children.
g
Cosmetic surgery or complications resulting there from,
including surgery to improve or restore your appearance
g
g
Reverse sterilization
Treatment of sexual problems not caused by organic disease
www.bcbsok.com
Some services must be preauthorized
before you receive them. Your benefit
booklet has more information.
Network coverage is available through
participating network providers.
Non-network services will be covered
at a lower level.
Some
services
be preauthorized
All
mental
healthmust
and chemical
dependency
before youmust
receive
Your benefit
treatment
be them.
preauthorized.
booklet has more information.
Network coverage is available through
participating network providers.
Non-network services will be covered
at a lower level.
All mental health and chemical dependency
treatment must be preauthorized.
Customer Web Address:
www.bcbsok.com/OU
Customer Service:
1-877-XXX-XXXX
Pharmacy:
1-877-XXX-XXXX
24/7 Nurseline:
1-877-XXX-XXXX
Provider Locator:
1-877-XXX-XXXX
Delta Dental:
1-877-XXX-XXXX
Customer Web Address:
Payflex Customer Svc: 1-877-XXX-XXXX
www.bcbsok.com/OU
Customer
Service:
1-877-XXX-XXXX
A
Division of
Health Care Service
Corporation,
aPharmacy:
Mutual Legal Reserve Company,
an
1-877-XXX-XXXX
Independent
Licensee of1-877-XXX-XXXX
the Blue Cross
24/7 Nurseline:
and
BlueLocator:
Shield Association
Provider
1-877-XXX-XXXX
Delta Dental:
1-877-XXX-XXXX
L13
Payflex Customer Svc: 1-877-XXX-XXXX
A Division of Health Care Service Corporation,
a Mutual Legal Reserve Company, an
Independent Licensee of the Blue Cross
and Blue Shield Association
L13
You can print a temporary ID card and order a replacement card on Blue Access for Members (BAM) if you ever lose or misplace
your card.
In the future, the magnetic stripe on the back of the ID card will allow BCBSOK and your providers to take advantage of emerging
“card-reading” technologies. For providers who have card readers, office staff will be able to “swipe” your ID card when registering
your new insurance information, and in real time, he/she can verify your eligibility and benefits (such as copayment amounts).
Currently, the magnetic stripe on your ID card only includes your general information (such as name, birth date, ID number and
group ID number) and can be read only by health care providers with certain card readers, software, and connectivity.
15
Experience. Wellness. Everywhere.
g
Get health and wellness questions answered by Blue Care
Advisor nurses and other health care professionals via secure
e-mail.
New for OU! Biometric screenings will be available to all OU
employees in 2009. Please watch your email and employee
g
bulletin boards for more information on dates and locations. In
Ask registered nurses (Blue Care Advisors) your health-related
questions with the Ask A Nurse feature.
addition to the confidential Health Risk Assessment on the Personal
g
Health Manager, a biometric screening provides a detailed
Request fitness and weight loss advice from a team of personal
trainers with Ask A Trainer.
assessment of your basic health indicators, including blood
pressure, body mass index (calculated from height and weight),
g
Ask registered dietitians for nutrition advice with Ask A
Dietitian.
cholesterol (HDL and LDL) and blood glucose. This screening will
give you an awareness of potential health conditions.
g
Receive help on managing stress, workplace conflicts and
other similar issues with Ask A Life Coach.
Personal Health Manager Online Resources
g
Adopt healthier behaviors and stay motivated using the
Through the Blue Care Connection program, you’ll find tools
interactive Get Fit, Eat Right and Live Well tools in the For Your
and services that inform, support and motivate you on your
Health section. Find information on fitness, nutrition and lifestyle
journey to wellness.
issues that can be customized to meet your needs. Plus, you can
keep track of your activities and results online to keep
Our online health resources are available through Blue Access
you motivated.
for Members at www.bcbsok.com/OU. Set goals toward a
healthier lifestyle, understand and manage a health condition,
g
Learn more about health conditions and medical procedures to
and keep track of your health care. Interactive tools and extensive
help you manage your care or prepare for diagnostic testing or
information cover all aspects of health and wellness, including
treatments by searching the health encyclopedia.
nutrition, fitness, work-life balance, medical conditions and more.
g
Use the Personal Health Manager to:
g
Learn about your health status and possible health risks by
completing the confidential Health Risk Assessment. After you
complete and submit your Health Risk Assessment, you will
immediately receive information on your overall health status
and specific health categories such as sleep and nutrition, as
well as helpful tips. When health risks are revealed, you also
receive recommendations for making healthy changes. You may
also receive online messages or outreach phone calls from
Blue Care Advisors to help you take action to reduce your
health risks and improve your health. Before starting the Health
Risk Assessment, it’s helpful—but not essential—to know your
most recent:
Set up a personal health record to keep track of and manage
your family’s health information – within one secure location.
Using tracking tools, you can also track your progress by
entering values such as cholesterol, blood pressure and blood
glucose levels, and view a graph showing how you are doing
over a time period.
Reward Yourself with Blue PointsSM
†
At Blue Cross and Blue Shield of Oklahoma, we understand
how hard it can be to change habits and maintain healthy
lifestyle changes. That’s why Blue Care Connection builds
in a reward program to keep you motivated and offers
additional programs that can help you start on a healthy
path, and support you along the way. Every time you use
the Personal Health Manager to track a fitness workout,
g
Height and weight
g
Blood pressure
g
Total cholesterol level
Blue Points. Redeem your Blue Points for reward items such
g
HDL cholesterol level
as health-related products, popular merchandise and gift
g
Blood glucose level
report a meal, use the Ask A features, and participate in For
Your Health interactive programs, you automatically earn
certificates at the Blue Points Redemption Center, accessed
through the Personal Health Manager.
† Please review the Blue Points Program Rules listed on the Personal Health Manager for complete information on the program. Program rules are subject to change
without prior notice.
16
Weight Management
Support for a slimmer, healthier you
24/7 Nurseline
The program offers guidance and support through behavioral
Health concerns don’t always follow a 9-to-5 schedule.
and motivational coaching, personalized goal setting with
Fortunately, you can call the toll-free 24/7 Nurseline
an action plan, online tools and discounts to wellness-related
24 hours a day, seven days a week to get the information
products and services. To get started, go to the Personal Health
you need…when you need it.
Manager available through Blue Access for Members at
www.bcbsok.com/OU and click the Weight Loss button. Or,
call customer service.
Tobacco Cessation
Support for smokers who want to quit
The program provides personal coaching, online tools and
discounts to wellness-related products and services. To
participate, go to the Personal Health Manager and select the
Stop Smoking button/link – or call customer service. Also, see
page 1 of this booklet for more information on an annual smoking
cessation benefit.
The 24/7 Nurseline is staffed by registered nurses who
can answer your general health questions and direct you to
your doctor or encourage you to seek emergency services if
necessary. In a matter of minutes, a nurse can help identify
options and provide information to help you choose the
appropriate care for your concerns. Plus, when you call, you
also have the option to access an audio library of more than
1,000 health topics – from allergies to women’s health –
with more than 600 topics available in Spanish.
Call the 24/7 Nurseline toll free at (800) 581-0407.
The BlueExtrasSM Discount Program†
Special Beginnings – A Healthy Start for Mothers
and Babies
With BlueExtras, you can take advantage of discounts on health-
If you are expecting, this prenatal program can help guide you
related products and services that help support a healthy lifestyle.
through your pregnancy and postpartum care. The program
These discounts apply to health care products and services not
provides support and education, pregnancy risk assessment and
usually covered by your health care benefits plan. Plus, there
ongoing attention/monitoring.
are no claims to file, no referrals or pre-authorizations and no
additional fees to participate. To find out more about BlueExtras,
Enrolled members receive frequent, personal contact from
visit www.bcbsok.com/OU.
obstetrical nurses who can help them better understand and
BlueExtras provides discounts to:
healthy behaviors, preventive care, and identify warning signs
manage their pregnancies. Educational materials promote
of complications. Topics also include nutrition, fetal development
g
Jenny Craig weight management program
g
Curves fitness and weight loss facilities
toll-free BabyLine staffed by maternity nurses.
g
Complementary Alternative Medicine items, such as vitamins,
For information on enrolling, call the toll-free Special Beginnings
health and wellness magazines, gym memberships, massages,
spas, acupuncture, yoga, tai chi and more
and newborn care. Additionally, members can call a 24-hour
phone number at (877) 904-2229.
g
Vision care and hearing aid products
Blue Care Advisors
g
Safety products, such as bicycle helmets, childproofing and
If you have certain chronic health conditions or are at risk for
home safety items
medical complications, a Blue Care Advisor may contact you.
GHS auto insurance
g
BlueExtras is a discount program available to BCBSOK members. This is NOT
insurance. Some of the services offered through BlueExtras may be covered under your
health plan. Please refer to your benefit booklet or call the customer service number
on the back of your ID card for specific benefit information under your health plan.
Use of BlueExtras does not affect your premium, nor do costs of BlueExtras’ services
or products count toward your plan deductible, calendar year or lifetime maximums.
Discounts are only available through participating vendors.
BCBSOK does not guarantee or make any claims or recommendations regarding
the services or products offered under BlueExtras. You may want to consult with your
physician prior to use of these services and products. Services and products are
subject to availability by location. BCBSOK reserves the right to discontinue or change
this discount program at any time without notice.
Working with you through regularly scheduled telephone calls,
these registered nurses and other health care professionals offer
health counseling, coaching and support.
The Blue Care Advisor can help you learn to manage your
condition more successfully, identify behaviors that may be
barriers to better health, set goals for improving your health and
help you adopt healthier habits.
17
Case Managers
In the event that you or a covered family member experiences multiple or complex
medical problems, our case management nurses – registered nurses with specialized
training and clinical experience – can work with you.
At a time that’s usually stressful, case managers can be your advocate by:
g
Helping to explain your medical problems and treatment plans
g
Facilitating communication among many health care providers
g
Coordinating treatment plans
g
Explaining your health care benefits and how to get the most out of them
g
Helping you access the right resources and services
g
Assisting with transitions from one health care setting to another
Other Resources to Help You
Blue Cross and Blue Shield of Oklahoma also provides other health and wellness
information.
Preventive Health Care Guidelines are published each year and made available
Commit to Wellness.
via www.bcbsok.com/OU. This is a good source of information on preventive care
Wellness is the state of being
guidelines, which are based on recommendations set by national health agencies and
medical associations. You can learn about recommended screenings, and immunizations
and doctor visits for all ages, from prenatal care and infancy through the senior years.
Be Smart. Be Well.TM is our Web site dedicated to raising awareness of largely
preventable health and safety issues. You’ll find in-depth information on a variety of
issues, including traumatic brain injuries, drug interactions and mental health at www.
besmartbewell.com.
healthy in body and mind,
especially as the result of
deliberate effort. It is the actively
sought goal of good physical
and mental health, maintained by
proper diet, exercise and habits.
Glucose Meters help members with diabetes manage their condition and can be ordered
at no charge. For information on the meters that are available, call customer service.
Start your journey to wellness today!
It’s easy to use the Personal Health Manager! Just log in to our secure
Blue Access® for Members Web site at www.bcbsok.com/OU. Access
the Personal Health Manager from the My Health tab on Blue Access for
Members or just click on the Personal Health Manager icon.
18
online benefit resources
Resource
Purpose
HOW TO ACCESS
Blue Access for
Members
Site provides:
• Temporary ID card
• View claim status
• Find a doctor or hospital
• View HCA account balances
• View Wellness Rewards points
• Access to BlueExtras
Go to www.bcbsok.com/OU
• E nter Blue Access for Members user ID
and password
• If you do not have a user ID and password,
go to “Sign Up Today”.
Blue Points
Earn points, redeemable for rewards, for
health-related activities
Go to BAM at www.bcbsok.com/OU
• Click on Personal Health Manager
• Click on any of the For Your Health links
(Get Fit, Eat Right, Live Well)
• Click on the Blue Points tab to see how many
points you’ve earned
Locate a Health
Care Provider
Find a doctor, specialist, or hospital in
your area
o to www.bcbsok.com/OU
G
• Click on “Doctors & Hospitals”
OU Benefits
Web Site
Find benefit related information
www.hr.ou.edu
BCBSOK Web
Site for OU
• Access the Personal Health Manager
• View/print benefit brochures
• Locate a doctor or hospital
www.bcbsok.com/OU
CONTACTS
This enrollment guide highlights OU’s Benefits Program. A complete description of each benefit can be found in the legal documents
governing the plans. Every effort has been made to provide an accurate summary of the plans in this guide. However, if there is a conflict
between this material and the legal documents, the legal documents will govern. If you have any questions after reviewing your enrollment
materials, please contact customer service at the number below.
Subject
Contact
Customer Service
1-888-881-4648
Pharmacy
1-800-423-1973
BlueCard
1-800-810-BLUE (2583)
24/7 Nurseline
1-800-581-0407
Special Beginnings
1-877-904-2229
Experience. Wellness. Everywhere.
Experience. Wellness. Everywhere.
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
70450.0908