U
O
THE UNIVERSITY OF OKLAHOMA
EMPLOYEE BENEFITS
2016
TABLE OF CONTENTS
Benefit Enrollment & Making
Changes During the Year . . . . . . . . . . . . . . . . . . . 1
Medical Plan Options. . . . . . . . . . . . . . . . . . . . . 1-3
BlueLincs HMOSM . . . . . . . . . . . . . . . . . . . . . . . . 4
BlueOptionsSM . . . . . . . . . . . . . . . . . . . . . . . . . . 4-5
BlueEdge HSASM . . . . . . . . . . . . . . . . . . . . . . . . . 6
What’s Not Covered. . . . . . . . . . . . . . . . . . . . . . . 7
ID Cards. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Wellness Guide . . . . . . . . . . . . . . . . . . . . . . . . 8-10
Resource Guide. . . . . . . . . . . . . . . . . . . . . . . . . 11
Plan Comparison Chart . . . . . . . . . . . . . . . . . 12-17
Contacts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Through It All.®
This enrollment guide highlights OU’s Benefits plans. A complete description of each plan can be found in your Certificate of Benefits Booklet or Member Handbook. Every effort has been made
to provide an accurate summary of the plans. However, this is a summary guide. If there is a conflict between this material and the Certificate of Benefits or Member Handbook, the Certificate
of Benefits Booklet or Member Handbook will govern. If you have any questions after reviewing your enrollment materials, please contact BCBSOK customer service.
WELCOME
Welcome to Blue Cross and Blue Shield of Oklahoma, and to your benefit
01
Except for coverage of a newborn or adopted child, all other
enrollment period. This is your opportunity to select health benefits for you and
Benefit Enrollment &
Making Changes During the Year
your family for the coming year.
During the open and new member enrollment period, you
on the child’s date of birth. Coverage for an adopted child is
For 75 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.
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.
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 options that are available
to you. You may also visit 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.
In order to change benefit elections outside of the enrollment
period, the employee must have:
1) Experienced an Applicable Qualifying Event, as defined by
the Internal Revenue Service (IRS). Changes based on financial
reasons alone are not allowed under the current IRS regulations.
AND
BCBSOK members don’t just have access to traditional insurance coverage; you also have a complete suite
2) The request for a change of benefits must be made within 31
of health and wellness resources and tools at your fingertips, to encourage healthier living and smarter health
days of the Applicable Qualifying Event.
decisions. Blue Cross and Blue Shield of Oklahoma is a health care industry leader in creating and promoting
Within the context of changing benefits, “Applicable” refers to a
wellness programs that you and your family can conveniently integrate into your daily life. Merging technology and
change that is directly related to the individual experiencing the
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.
Our goal at Blue Cross and Blue Shield of Oklahoma is to provide you with first class service, and to do the job
Stephania Grober
Vice President, Marketing and Sales
Blue Cross and Blue Shield of Oklahoma
the qualifying event. Coverage for the newborn is effective
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.
Please visit the “Benefits” section of the OU Human Resources
website for more information at hr.ou.edu.
Eligibility
Please visit the “Benefits” section of the OU Human Resources
website for information at hr.ou.edu.
Medical Plan Options
The following pages 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
qualifying event.
aren’t answered in the summary information in this guide,
A qualifying event includes:
detailed Certificate of Benefits or Member Handbook. Dental
please contact customer service at 888-881-4648 or review the
care benefits are offered separately, and are not highlighted in
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A birth or adoption
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Marriage, divorce or legal separation
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Death
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Child loses eligibility because of age
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Employee’s spouse gains or loses coverage through
QUALIFYING EVENT. In no event will you be able to switch from
employment
one plan to another during the year, unless you are on the HMO
right the first time, every time. We appreciate the opportunity to serve you.
Sincerely,
changes in coverage begin the first day of the month following
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Significant change in the financial terms of health benefits
provided through a spouse’s employer or another carrier
this benefit guide.
The medical plan you select during the enrollment period will
apply for the calendar year. You will not be able to make changes
to your medical plan during the year UNLESS YOU HAVE A
plan and move outside the service area. A brief description of
the various aspects of each program follows on the next pages.
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Medical Plan Comparisons
1) Benefit design – Each of the three plans promotes wellness,
3) Provider access – The Blue Choice PPO network is
The Away From Home Care Program does not cover the
offers preventive care and has unlimited lifetime maximums.
BCBSOK’s largest network. BlueEdge HSA utilizes the Blue
entire United States. If you are considering the HMO, and
Available Health Care Plans
However, there are notable differences among the plans, which
Choice PPO network, which means you will have the lowest out-
you have an out-of-state dependent or plans to move out-
There are 3 notably different benefit plans: BlueLincs HMO,
impact the coverage and out-of-pocket costs you’ll have when
of-pocket costs when you see providers in the Blue Choice PPO
of-state, please contact BCBSOK at 888-881-4648 to discuss
BlueOptions or BlueEdge HSA. The BlueLincs HMO plan is
you utilize your benefits.
network. The Blue Preferred PPO network is BCBSOK’s second
your options.
closed to new participants in 2016.
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.
organization (PPO) types of plans. Blue Cross and Blue Shield
of Oklahoma has negotiated discounts with medical providers
(doctors, hospitals etc) to reduce the cost of health care. The
discount is applied before there is any payment for services
from you or BCBSOK.
lowest out-of-pocket expense because the cost of services is
usually lower and the benefits you receive are higher.
SM
network, which is
BCBSOK’s largest PPO network.
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applicable to some services. There is no calendar year deductible
to satisfy except for certain services such as inpatient/outpatient
equipment, and certain imaging services such as MRI, PET and
CT scans.
BlueOptions has a calendar year deductible to satisfy before
coverage begins. However, like the HMO plan, many services
are covered with just a copayment, so depending on the type
of services you need, you may not even need to meet your
When you see a provider that is in-network, you will have the
BlueEdge HSA uses the Blue Choice PPO
applicable copayments and a low calendar year deductible that is
hospital services, skilled nursing facilities, durable medical
BlueOptions and BlueEdge HSA are preferred provider
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The BlueLincs HMO has very low out-of-pocket costs with only
BlueOptions offers a unique tiered structure that allows you
the flexibility to see providers in the Blue Choice PPO or Blue
Preferred PPOSM networks. However, you will have the lowest
out-of-pocket expense when you see providers in the Blue
Preferred PPO network because the discounts are greater. The
Blue Preferred PPO network has fewer providers than the Blue
Choice PPO network.
BlueOptions and BlueEdge HSA also give you the flexibility
to choose an out-of-network provider, with whom BCBSOK
does not have a contract, and still receive health care
benefits. However, you may have more out-of-pocket
expense when you choose an out-of-network provider.
The BlueEdge HSA pairs a high deductible and the Blue Choice
PPO network with a health savings account (HSA). The HSA can
be used to pay for certain out-of-pocket medical expenses.
deductible during the year. Most preventive care services are fully
covered under BlueOptions if using in-network providers, which
largest network, including providers in the Tulsa and Oklahoma
City metro areas as well as many providers in the rest of the
state. BlueOptions offers a unique tiered structure that allows
you the flexibility to see providers in the Blue Choice PPO
or Blue Preferred PPO networks. However, you will have the
lowest out-of-pocket costs when you see providers in the Blue
Preferred PPO network because the discounts are greater.
BlueOptions and BlueEdge HSA also give you the
flexibility to choose an out-of-network provider, with
whom BCBSOK does not have a contract, and still receive
health care benefits. However, you may have more outof-pocket expense when you choose an out-of-network
provider.
There are fewer providers in the BlueLincs HMO network
such as well child and adult immunizations, routine exams,
than there are in the Blue Choice PPO or Blue Preferred PPO
gynecological exams, mammograms and prostate specific antigen
network. Be sure to verify that your current physicians are in
(PSA) tests. When you see providers in the Blue Preferred PPO
the network for the plan you are considering. If you are joining
network, you will have the lowest out-of-pocket expense because
the HMO and want to choose a new primary care physician
the discounts are greater.
(PCP), make sure that physician is accepting new patients.
The BlueEdge HSA has a notably higher deductible to satisfy
With BlueLincs HMO, out-of-state coverage is generally limited
each year, and some services, except for some of your
to emergency treatment. If you have a dependent living out-of-
preventive care benefits, are subject to that deductible before
state (for example, a college student), or if you are moving out-
your coverage begins. To help offset the higher deductible,
of-state during the year, you may be eligible to enroll in the Away
money is put into a health savings account each year on your
From Home Care® Program, which connects BlueLincs HMO
behalf, which can be applied to your deductible or other eligible
members to a participating out-of-state HMO.
Choice PPO network, so you will have the lowest out-of-pocket
costs when you use providers in the Blue Choice PPO network.
access to contracting providers through the BlueCard® Program
when you or your covered family members live, work, or travel
anywhere in the country.
Additionally, when you travel outside the United States, PPO
members have access to contracting providers in more than 200
countries through BlueCard Worldwide®.
You can verify that your current physicians are in the network for
the plan you are considering by checking the online provider
directory at bcbsok.com/ou.
4) Flexibility – BlueOptions and BlueEdge HSA give you the
means you will pay no copayment or coinsurance for services
out-of-pocket medical expenses. BlueEdge HSA uses the Blue
BlueOptions and BlueEdge HSA members have nationwide
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 and lowest out-ofpocket costs when choosing an in-network provider. BlueOptions
gives you additional freedom of choice and flexibility because
you can see providers in the Blue Choice PPO or Blue Preferred
PPO networks and still receive benefits. (For BlueOptions
members, you will have the lowest out-of-pocket costs when
you see providers in the Blue Preferred PPO network.) The
BlueLincs HMO plan is a managed care plan that requires the
use of BlueLincs HMO contracted providers. You also are
required to select a primary care physician (PCP) to provide or
coordinate most of your care. Referrals are generally required
from your PCP for most specialty care. BlueOptions and
BlueEdge HSA do not have these requirements; you “manage”
your own care.
2) Rates – It’s important to compare the rates of each plan,
while keeping in mind the benefits that come with each plan.
BlueLincs HMO has the most predictable out-of-pocket costs
when you need to utilize your benefits. Keep in mind, however,
that as an HMO, BlueLincs HMO has less flexibility than the
Key Areas to Consider
other two plans, and it has a smaller network of providers to
You should choose the plan best suited for you and your family.
choose from. BlueOptions provides a high level of flexibility
There are important differences between the plans that should
when choosing your providers and out-of-pocket costs.
be considered. Details and benefits of each plan are listed on the
BlueEdge HSA has the lowest premiums. It provides a high level
People sometimes turn to popular diets to achieve quick weight
following pages for easy comparison. Here are some additional
of flexibility, but it has higher out-of-pocket costs than the other
loss. For lasting changes and healthy eating, balance what you eat
factors to keep in mind:
two plans.
to meet your need for nutrition and enjoyment. Enjoy a variety of
Nourish to flourish.
foods while keeping key food groups in mind and use moderation
when choosing less nutritious foods.
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05
BlueLincs HMO
BlueOptions
In BlueLincs HMO, you must specify a Primary Care Physician
BlueOptions is a preferred provider organization (PPO) plan, which
(PCP) during your enrollment. During your online enrollment
gives you the flexibility to choose your provider and network at the
process, you will be asked to provide your PCP’s National
time of service. BlueOptions gives you the freedom to select any
Provider Identification (NPI) number.
health care provider (whether they are in-network or not). You do
How do my benefits work when I am out-of-state?
Choice PPO network. If you visit your doctor, your benefits will
not need to select a primary care physician. Your choice of health
BlueOptions members have nationwide access to contracting
be applied for the Blue Preferred PPO network, which means
care providers can affect the level of health care benefits (including
providers through the BlueCard Program when you or your
that you will have the lowest out-of-pocket expense.
copayment and deductible amounts) – based on the network your
covered family members live, work, or travel anywhere in the
provider is in. With the BlueOptions plan, you can choose from two
country. Your benefits will generally be paid at the highest
different networks each time you need health care. Or, you may
benefit level, since Blue Preferred PPO providers are mostly
choose to see providers that are not in a network (out-of-network).
located in Oklahoma. You can search for BlueCard providers in
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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 for
most services 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
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without a referral from your PCP, you receive no benefits.
and pays your benefits at the highest level, which means
you will have the lowest out-of-pocket costs when you use
BlueLincs HMO Frequently Asked Questions
Where do I get my PCP’s NPI number? Visit bcbsok.com/ou
providers in the Blue Preferred PPO network.
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and click on your plan type in the Find a Doctor section. There
the same with the Blue Preferred PPO and Blue Choice PPO
that is available through the BlueLincs HMOSM network. You
online enrollment process.
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 4
times a year. Consult the provider directory on bcbsok.com/
ou to choose a PCP in the BlueLincs HMO network. During
the enrollment period, include the PCP’s NPI. During the year,
simply call BCBSOK 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,
The Blue Choice PPO network will pay your benefits at the
second highest level, although some aspects of coverage are
you can search for a PCP you currently use or locate a new PCP
must enter the PCP’s NPI (as shown on the website) during the
The Blue Preferred PPO network provides the biggest discount
networks.
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If you see out-of-network providers, you will receive no
discounts and your benefits will be paid at the lowest allowed
amount.
Finding out which network your providers are located in is
easy! Simply visit bcbsok.com/ou and click on your plan type
in the Find a Doctor section. You can search for a doctor by
name, location, network, or specialty, such as dermatology or
cardiology.
BlueOptions Frequently Asked Questions
How do I find a doctor in the Blue Preferred PPO or
Blue Choice PPO network? Go to bcbsok.com/ou and use the
provider directory, or call BCBSOK customer service.
the online provider directory at bcbsok.com/ou.
Do I need a referral from my doctor to see a specialist? No.
With the BlueOptions plan you can see any doctor at any time
without a referral. If you see a specialist who is part of the Blue
Preferred PPO network, your benefits will be paid at the highest
level and your out-of-pocket costs will be lowest. You can also
see a specialist in the Blue Choice PPO network or not part of
the network, but your benefits will be paid at a lower level.
Can I see providers in both the Blue Preferred PPO and
Blue Choice PPO networks? Yes, with BlueOptions, you have
the freedom to see any doctor you choose at any time. You can
choose different networks for different health care services and/
or for different members of your family. For example, you can
see a physician in the Blue Preferred PPO network while your
spouse and children see a physician in the Blue Choice PPO
network. Your benefits are determined at the point of service,
The office copayments and deductible are lower for the Blue
which means that your copayment and deductible amounts
Preferred PPO network than the Blue Choice PPO network. The
depend on which network you choose. Your choice can affect
coinsurance paid by BCBSOK and the out-of-pocket maximums
the amount of benefits you receive. You will have the lowest
are the same for the Blue Preferred PPO and Blue Choice PPO
out-of-pocket expense when you see providers in the Blue
network.
Preferred PPO network. Keep in mind that deductibles vary
depending on the network you choose. The deductibles update
which connects BlueLincs HMO members to a participating out-
Most preventive care services for in-network providers are fully
each other, which means that at one point during the year, you
of-state HMO. The program is designed for members who:
covered under the BlueOptions plan, which means you will pay
may have satisfied your Blue Preferred PPO deductible but still
no copayment or coinsurance for services such as well child
have more to satisfy for the Blue Choice PPO network. If you
and adult immunizations, routine exams, gynecological exams,
were to continue to see Blue Preferred PPO providers, then
mammograms and prostate specific antigen (PSA) tests.
your deductible is met. If you visit a Blue Choice PPO (or out-
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have a child attending school out-of-state
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
BlueLincs HMO, and you have an out-of-state dependent or
plans to move out-of-state, please contact BlueLincs HMO
at 800-580-6202 to discuss your options.
of-network) provider, you will first have to satisfy the difference
between the deductible for that network and the Blue Preferred
PPO deductible before coinsurance applies again.
Can my doctor be a part of both networks? What happens if
this is the case? Be sure to ask your provider which network(s)
they are in. They may be in more than one network. If that is the
case, your benefits will be applied at the highest network level.
For example, your doctor is in the Blue Preferred PPO and Blue
Can I see a doctor or use a service that is out of network?
Yes. However, the amount your plan pays for covered services
is based on the allowed amount described in your Certificate of
Benefits. If an out-of-network provider charges more than the
allowed amount, you may have to pay the difference.
06
07
BlueEdge HSA
What’s Not Covered
ID Cards
What is it?
Your plan options do not cover all health care expenses, and
You should present your ID card when visiting a physician’s office
include exclusions and limitations. You should refer to plan-
or hospital, and verify that they have the correct insurance
never need a referral to see a specialist.
specific documents to determine which health care services
information on file for you. Your card will resemble the card
are covered and to what extent. The following is a partial
below, and will be customized with your name and plan
Under BlueEdge HSA, some of your well child and adult
list of services and supplies that are generally not covered.
information. Additional cards can be ordered through BCBSOK
preventive care services are covered at 100% of allowed
However, your plan documents may contain exceptions
customer service or by logging in to the Blue Access for
amount, including routine OB/GYN exams and mammograms,
to this list based on state mandates, the plan design or
MembersSM (BAM) website at bcbsok.com/ou.
and well child immunizations.
rider(s) purchased. Visit the “Benefits” section of the OU HR
With the BlueEdge HSA plan, a specific amount of money is
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deposited each benefit year in a health savings account (HSA).
When you need any covered medical care, the first out-of-pocket
costs you have can be paid from available funds in this account.
The money paid from your health account is applied toward
meeting your annual plan deductible or other copayment or
coinsurance amounts you may be responsible for.
Benefits
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You do not have to select a primary care physician, and you
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providers that are covered under the BlueEdge HSA is the Blue
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As an HSA member, you have access to an extensive network
of providers and hospitals throughout the country. You can
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Services that BCBSOK determines are experimental/
Group Number
Effective Date
Subscriber:
BenefitQ.
Network
John
Sample
Plan
Name
Any condition to the extent payment would have been made
Office Visit Copay:
The University of Oklahoma
Specialist Copay:
Identification Number:
Rx Copay:
Group Number
Effective Date
Benefit Network
Office Visit Copay:
ABC12345678
Specialist Copay:
Rx Copay:
Diagnosis, treatment or medications for infertility and fertilization
procedures, including artificial insemination; ovulation induction
www.bcbsok.com/OU
procedures; in vitro fertilization; embryo transfer. (Coverage for
level of benefits and lowest out-of-pocket costs. When you
infertility is limited to diagnosis and treatment of underlying
receive care from an out-of-network provider, you receive a
www.bcbsok.com/OU
cause.)
lower level of benefits. The amount the plan pays for covered
n
Certificate of Benefits. If an out-of-network provider charges
more than the allowed amount, you may have to pay the
The University of Oklahoma
Identification Number:
claimed Medicare benefits
a Blue Choice PPO network provider, you receive the highest
services is based on the allowed amount described in the
John Q. Sample
under Medicare if the member had applied for Medicare and
select any provider for care within the Blue Choice PPO
network or outside the network. When you receive care from
Subscriber:
ABC12345678
investigational in nature
Choice PPO network.
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Charges above the allowed amount for out-of-network
services
The HSA plan that Blue Cross and Blue Shield of Oklahoma
offers is called BlueEdge HSA. However, the network of
Plan
Name
website for plan-specific information at hr.ou.edu.
Cosmetic surgery or complications resulting there from,
including surgery to improve or restore your appearance
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Reverse sterilization
n
Treatment of sexual problems not caused by organic disease
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Foot care only to improve comfort or appearance, such as care
difference.
for flat feet, subluxation, corns, bunions (except capsular and
Customer Service
Preauthorization
Provider Locator
24/7 Nurseline
RX Tech Support
RX Cust Svc*
1-800-XXX-XXXX
1-800-XXX-XXXX
1-800-XXX-XXXX
1-800-XXX-XXXX
1-877-XXX-XXXX
1-877-XXX-XXXX
Customer Service
Preauthorization
Provider Locator
24/7 Nurseline
RX Tech Support
RX Cust Svc*
1-800-XXX-XXXX
1-800-XXX-XXXX
1-800-XXX-XXXX
1-800-XXX-XXXX
1-877-XXX-XXXX
1-877-XXX-XXXX
L13
L13
bone surgery), calluses, toenails, etc
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Acupuncture, whether for medical or anesthesia purposes
except for services in relation to tobacco cessation
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Massage Therapy
If you lose or misplace your ID card, you can print a temporary ID
card and order a replacement card by logging in to Blue Access
for Members (BAM) at bcbsok.com/ou.
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8
Tools for Healthy Living
Blue Care Connection
Well onTarget® – A Dynamic Wellness Program
Through the Blue Care Connection program, you’ll find tools and
At Blue Cross and Blue Shield of Oklahoma, we believe in
supporting your health and well-being. Well onTarget offers
personalized tools and resources to help all members— no
matter where you may be on the path to health and wellness.
Program highlights include:
onmyway Health Assessment (HA)
The HA features adaptable questions to learn more about you.
onmywayTM Health Assessment
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onmytime Self-directed Courses on topics such as healthy
eating, stress, weight management and fitness
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Health and Wellness content
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Tools and Trackers such as a food diary
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Blue PointsSM program
participate call BCBSOK customer service. There is also a
tobacco cessation benefit described on the plan comparison
Support for a slimmer, healthier you
chart.
The program offers guidance and support through behavioral and
24/7 Nurseline
Your answers will be used to tailor the Liveon portal with the
Blue Points
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discounts for wellness-related products and services. To
The confidential record offers tips for living your healthiest life.
The Liveon portal is the heart of the Well onTarget program.
offers you a gateway to a suite of interactive programs:
The program provides personal coaching, online tools and
Weight Management
programs that may help you reach your goals.
online courses, tools and trackers. Leading-edge technology
to wellness.
Support for tobacco users who want to quit
After you take the HA, you will get a personal wellness report.
Liveon Member Wellness Portal
It inspires and supports you through healthy living programs,
services that inform, support and motivate you on your journey
Tobacco Cessation
With the Blue Points program, you can earn points by taking part
motivational coaching, personalized goal setting with an action
plan, online tools and discounts to wellness-related products
and services. To get started, call BCBSOK customer service.
in healthy activities. This program makes it easy for you to track
Fitness Program
your points from 1 screen. Real-time granting of points lets you
Join a network of gyms
instantly use your points. Points can be redeemed for a host of
products from the online shopping mall. To earn a larger reward,
you can add to your point total at checkout.
Well onTarget is a registered mark of HCSC. Blue Points Program Rules are subject to change without prior notice.
See the Program Rules on the Well onTarget Member Wellness Portal for further information.
Health concerns don’t always follow a 9-to-5 schedule.
Fortunately, you can call the toll-free 24/7 Nurseline 24 hours a
day, 7 days a week to get the information you need…when you
need it.
The 24/7 Nurseline is staffed by registered nurses who can
Take advantage of a gym membership to a nationwide network
answer your general health questions, direct you to your doctor
of fitness centers. To get started, access the Well onTarget
or encourage you to seek emergency services if necessary. A
portal, or call BCBSOK customer service.
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.
Call the 24/7 Nurseline toll free at 800-581-0407.
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11
Special Beginnings® – Maternity Program
Biometric Screenings
If you are expecting, this prenatal program can help guide you
Biometric screenings will continue to be available to all OU
through your pregnancy and postpartum care. The program
employees in 2016. Please watch your email and employee
provides support and education, pregnancy risk assessment and
bulletin boards for more information on dates and locations.
ongoing attention/monitoring.
A biometric screening provides a detailed assessment of your
Enrolled members receive frequent, personal contact from
obstetrical nurses who can help them better understand and
manage their pregnancies. Educational materials promote
healthy behaviors, preventive care, and identify warning signs of
complications. Topics also include nutrition, fetal development
and newborn care. Additionally, members can call a 24-hour tollfree BabyLine staffed by maternity nurses.
For more information or to enroll in Special Beginnings, call
877-904-2229.
basic health indicators, including blood pressure, body mass
and LDL) and blood glucose. This screening will give you an
awareness of potential health conditions.
Other Resources to Help You
made available via bcbsok.com/OU. This is a good source of
If you have certain chronic health conditions or are at risk for
associations. You can learn about recommended screenings, and
through regularly scheduled telephone calls, these registered
recommendations set by national health agencies and medical
nurses and other health care professionals can help you learn to
Be Smart. Be Well.® is our website dedicated to raising
manage your condition more successfully, identify behaviors that
awareness of largely preventable health and safety issues.
may be barriers to better health, set goals for improving your
You’ll find in-depth information on a variety of issues, including
health and help you adopt healthier habits.
traumatic brain injuries, drug interactions and mental health at
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:
n
Helping to explain your medical problem(s) and
treatment plan(s)
n
Facilitating communication among your many health
care providers
n
Coordinating a treatment plan(s)
n
Explaining your health care benefits and how to get the
most out of them
n
n
Helping you access the right resources and services
Assisting with transitions from one health care setting
to another
Go to bcbsok.com/ou
Blue Access
for Members
(BAM)
Website provides:
•Ability to print a temporary member ID card and
order a new card
•Claim Status
•Find a doctor or hospital
•Access to Well onTarget
• Explanation of Benefits (EOB)
Go to bcbsok.com/ou
•Enter Blue Access for Members user ID
and password
•If you do not have a user ID and password,
click on “Register Now”
Blue Points
Earn points, redeemable for rewards, for health-related
activities
Go to BAM at bcbsok.com/ou
• Click on Well onTarget
Locate a Health
Care Provider
Find a doctor, specialist, or hospital in
your area
Go to bcbsok.com/ou
• Click on your plan type in the Find a Doctor
section
OU Benefits
website
Find benefit related information
Go to hr.ou.edu
Pharmacy
•
•
•
•
Go to myprime.com
immunizations and doctor visits for all ages, from prenatal care
and infancy through the senior years.
HOW TO ACCESS
• Log in to Blue Access for Members to access the
Well onTarget portal or view claims
• View/print benefit brochures
• Locate a doctor or hospital
health and wellness information.
Preventive Health Care Guidelines are published each year and
PURPOSE
BCBSOK
website for OU
Blue Cross and Blue Shield of Oklahoma also provides other
information on preventive care guidelines, which are based on
offer health counseling, coaching and support. Working with you
RESOURCE
index (calculated from height and weight), cholesterol (HDL
Blue Care AdvisorsSM
medical complications, a Blue Care Advisor may contact you to
ONLINE BENEFIT RESOURCES
Compare drugs
Find generic alternatives
Obtain cost estimates
View drug formulary
besmartbewell.com.
Glucose Meters help members with diabetes manage their
condition and can be ordered at no charge. For information
on available meters and how to place an order, call customer
service.
Start your journey to wellness today!
Prime Therapeutics LLC, a separate company, is a pharmacy benefit management company. Blue Cross and Blue Shield of Oklahoma (BCBSOK) contracts with Prime Therapeutics to provide
pharmacy benefit management and other related services. In addition, contracting pharmacies are contracted through Prime Therapeutics. The relationship between BCBSOK and contracting
pharmacies is that of independent contractors. BCBSOK, as well as several other independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics.
12
Plan Comparison Chart
13
The amounts shown below are what you are responsible for paying for each type of service or treatment.
Coverage
BlueLincs HMO
BlueOptions
Traditional
Indemnity††
BlueEdge HSA
HMO Network Only
Blue Preferred PPO Network
Blue Choice PPO Network
Out-of-Network
Blue Choice PPO Network
Out-of-Network
No Network
Calendar Year Deductible Individual/Family
$300 per person
$400/$800
$500/$1,000
$1,000/$2,000
$1,500/$3,000
$2,500/$5,000
$300
Out-of-Pocket Maximum Individual/Family
$2,000/$4,000
Includes deductible & medical
copay amounts
$3,000/$6,000
Includes deductible & medical
copay amounts
$3,000/$6,000
Includes deductible &
medical copay amounts
$4,000/$8,000
Includes deductible &
medical copay amounts
$3,000/$6,000
Includes deductible &
medical/pharmacy
copay amounts
$5,000/$10,000
Includes deductible &
medical/pharmacy
copay amounts
$3,000/$6,000
Unlimited
Unlimited
Unlimited
Unlimited
Unlimited
Unlimited
Unlimited
$25 copay per visit
($35 copay for specialist)
$20 copay per visit
($30 copay for specialist)
30% after deductible†
15% after deductible
40% after deductible†
20% after deductible
Physical, Occupational, Speech, and Chiropractic Therapies
(60 visit maximum combined for all therapies)
$35 copay
$30 copay
$35 copay
30% after deductible†
15% after deductible
40% after deductible†
20% after deductible
Allergy Injections
$25 copay
$30 copay
$35 copay
30% after deductible†
15% after deductible
40% after deductible†
20% after deductible
Allergy Testing
$35 copay
$30 copay
$35 copay
30% after deductible†
15% after deductible
40% after deductible†
20% after deductible
Allergy Serum
Covered at 100%
of allowed amount
$30 copay
$35 copay
30% after deductible†
15% after deductible
40% after deductible†
20% after deductible
Inpatient Physician Services
Subject to deductible then
Covered at 100%
of allowed amount
20% after deductible
20% after deductible
30% after deductible†
15% after deductible
40% after deductible†
20% after deductible
Outpatient Physician Services / non-routine office services
Subject to deductible and
applicable copay
20% after deductible
20% after deductible
30% after deductible†
15% after deductible
40% after deductible†
20% after deductible
Covered at 100%
of allowed amount
Covered at 100%
of allowed amount
Covered at 100%
of allowed amount
30% after deductible†
15% after deductible
40% after deductible†
20% after deductible
Routine Exam
Covered at 100%
of allowed amount
Covered at 100%
of allowed amount
Covered at 100%
of allowed amount
30% after deductible
Covered at 100%
of allowed amount
40% after deductible
Covered at 100%
of allowed amount
Adult Immunizations
Covered at 100%
of allowed amount
Covered at 100%
of allowed amount
Covered at 100%
of allowed amount
Covered up to the
allowed amount†
Covered at 100%
of allowed amount
Covered up to the
allowed amount
Covered at 100%
of allowed amount
Well Child Exams
Covered at 100%
of allowed amount
Covered at 100%
of allowed amount
Covered at 100%
of allowed amount
30% after deductible†
Covered at 100%
of allowed amount
40% after deductible
Covered at 100%
of allowed amount
Routine Eye Exam* (does not include hardware)
$25 copay
$30 copay
$35 copay
30% after deductible†
Covered at 100%
of allowed amount
40% after deductible
Covered at 100%
of allowed amount
Routine Hearing Exam* (does not include hardware/hearing aids)
$25 copay
$30 copay
$35 copay
30% after deductible†
Covered at 100%
of allowed amount
40% after deductible
Covered at 100%
of allowed amount
Routine Ob/Gyn Exam
Covered at 100%
of allowed amount
Covered at 100%
of allowed amount
Covered at 100%
of allowed amount
Covered up to the
allowed amount†
Covered at 100%
of allowed amount
Covered up to the
allowed amount
Covered at 100%
of allowed amount
Routine Mammograms
Covered at 100%
of allowed amount
Covered at 100%
of allowed amount
Covered at 100%
of allowed amount
Covered up to the
allowed amount†
Covered at 100%
of allowed amount
Covered up to the
allowed amount
Covered at 100%
of allowed amount
Routine Prostate Specific Antigen (PSA)
Covered at 100%
of allowed amount
Covered at 100%
of allowed amount
Covered at 100%
of allowed amount
30%, no deductible
Covered at 100%
of allowed amount
40%, no deductible
Covered at 100%
of allowed amount
Routine Colonoscopy
Covered at 100%
of allowed amount
Covered at 100%
of allowed amount
Covered at 100%
of allowed amount
30% after deductible†
Covered at 100%
of allowed amount
40% after deductible
Covered at 100%
of allowed amount
Well Child Immunizations
Covered at 100%
of allowed amount
CoCovered at 100%
of allowed amount
Covered at 100%
of allowed amount
Covered up to the
allowed amount†
Covered at 100%
of allowed amountt
Covered up to the
allowed amount†
Covered at 100%
of allowed amount
Lifetime Health Care maximum (per person)
PHYSICIAN SERVICES
Office visit & related routine services / consultation / second opinion
Lab & X-ray (Physician Office)
$25 copay per visit
($35 copay for specialist)
PREVENTIVE CARE SERVICES
*Routine vision and hearing exams limited to once every 24 months.
†
Up to the allowed amount. If an out-of-network provider charges more than the allowed amount, you may be responsible for the difference.
††
Medicare Part A and Part B coverage is required.
14
15
The amounts shown below are what you are responsible for paying for each type of service or treatment.
Coverage
BlueLincs HMO
BlueOptions
Traditional
Indemnity††
BlueEdge HSA
HMO Network Only
Blue Preferred PPO Network
Blue Choice PPO Network
Out-of-Network
Blue Choice PPO Network
Out-of-Network
No Network
Inpatient Hospital
Subject to deductible and
$250 copay per admission
20% after deductible
20% after deductible
30% after deductible†
15% after deductible
40% after deductible†
20% after deductible
Outpatient Surgery
Subject to deductible and
$100 copay per surgery
20% after deductible
20% after deductible
30% after deductible†
15% after deductible
40% after deductible†
20% after deductible
Emergency Room
Subject to deductible and
$100 copay per visit –
copay waived if admitted
20% after $100 copay
and deductible
20% after $100 copay
and deductible
20% after $100 copay
and deductible
15% after deductible
40% after deductible†
20% after deductible
$50 copay
20% after deductible
20% after deductible
30% after deductible†
15% after deductible
40% after deductible†
20% after deductible
Subject to deductible and
$250 copay per admission
20% after deductible
20% after deductible
30% after deductible†
15% after deductible
40% after deductible†
20% after deductible
No limit
90 days per calendar year,
combined in- and
out-of-network
90 days per calendar year,
combined in- and
out-of-network
90 days per calendar year,
combined in- and
out-of-network
90 days per calendar year,
combined in- and
out-of-network
90 days per calendar year
Subject to deductible then
Covered at 100%
of allowed amount
20% after deductible
20% after deductible
30% after deductible†
15% after deductible
40% after deductible†
20% after deductible
No limit
120 days per calendar year,
combined in- and
out-of-network
120 days per calendar year,
combined in- and
out-of-network
120 days per calendar year,
combined in- and
out-of-network
120 days per calendar year,
combined in- and
out-of-network
120 days per calendar year,
combined in- and
out-of-network
120 visits per calendar year
Subject to deductible then
Covered at 100%
of allowed amount
20% after deductible
20% after deductible
30% after deductible†
15% after deductible
40% after deductible†
20% after deductible
No limit
70 visits per calendar year,
combined in- and
out-of-network
70 visits per calendar year,
combined in- and
out-of-network
70 visits per calendar year,
combined in- and
out-of-network
70 visits per calendar year,
combined in- and
out-of-network
70 visits per calendar year,
combined in- and
out-of-network
70 visits per calendar year
Subject to deductible
plus $250 copay
20% after deductible
20% after deductible
30% after deductible†
15% after deductible
40% after deductible†
20% after deductible
Subject to deductible then
Covered at 100%
of allowed amount
20% after deductible
20% after deductible
30% after deductible†
15% after deductible
40% after deductible†
20% after deductible
$35 copay for initial visit
then no charge
$20 copay/$30 copay
for specialist for initial visit;
all other services
20% after deductible
$25 copay/$35 copay
for specialist for initial visit;
all other services
20% after deductible
30% after deductible†
15% after deductible
40% after deductible†
20% after deductible
Subject to deductible and
$250 per admission
20% after deductible
20% after deductible
30% after deductible†
15% after deductible
40% after deductible†
20% after deductible
Covered with applicable copay
$20 copay per visit
($30 copay for specialist)
$25 copay per visit
($35 for specialist)
30% after deductible†
15% after deductible
40% after deductible†
20% after deductible
Voluntary Sterilization (
Subject to deductible and
applicable copay
20% after deductible
20% after deductible
30% after deductible†
15% after deductible
40% after deductible†
20% after deductible
Pregnancy Termination (therapeutic & non-therapeutic)
Subject to deductible and
applicable copay
20% after deductible
20% after deductible
30% after deductible†
15% after deductible
40% after deductible†
20% after deductible
Covered with applicable copay
Covered with
applicable copay
Covered with
applicable copay
30% after deductible†
15% after deductible
40% after deductible†
20% after deductible
HOSPITAL SERVICES
Urgent Care Facility
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)
90 days per calendar year,
combined in- and
out-of-network
MATERNITY & FAMILY PLANNING
Prenatal & Postnatal visits
Inpatient Hospital
Infertility Testing & Treatment (
Contraceptive Devices
†
Up to the allowed amount. If an out-of-network provider charges more than the allowed amount, you may be responsible for the difference.
Medicare Part A and Part B coverage is required.
††
17
16
The amounts shown below are what you are responsible for paying for each type of service or treatment.
Coverage
BlueLincs HMO
BlueOptions
HMO Network Only
Blue Preferred PPO Network
Blue Choice PPO Network
Subject to deductible and
$250 copay per admission††††
20% after deductible
$35 copay††††
Traditional
Indemnity††
BlueEdge HSA
Out-of-Network
Blue Choice PPO Network
Out-of-Network
No Network
20% after deductible
30% after deductible†
15% after deductible
40% after deductible†
20% after deductible
$30 copay
$35 copay
30% after deductible†
15% after deductible
40% after deductible†
20% after deductible
Subject to deductible and
$250 copay per admission††††
20% after deductible
20% after deductible
30% after deductible†
15% after deductible
40% after deductible†
20% after deductible
$35 copay††††
$30 copay
$35 copay
30% after deductible†
15% after deductible
40% after deductible†
20% after deductible
$10/$30/$60
$10/$30/$60
$10/$30/$60
30% after $10/$30/$60†
15% after deductible
40% after deductible†
$8/$35/50%
($100 minimum;
$200 maximum)
MENTAL HEALTH
Inpatient Hospital/Facility
Outpatient Charges
SUBSTANCE ABUSE
Inpatient Hospital/Facility
Outpatient Charges
PRESCRIPTIONS
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)
$20/$60/$120
$20/$60/$120
$20/$60/$120
Not covered
15% after deductible
Not covered
Preferred Pharmacies†††
$16/$70/50%
($100 minimum;
$200 maximum)
out-of-network not covered
Specialty Pharmacy Medications (limited to 30 day supply)
Covered
Covered
Covered
Covered up to the
allowed amount†
Covered
40% after deductible†
Covered
Prescription Tobacco Cessation Products
Covered
Covered
Covered
Covered up to the
allowed amount†
Covered
40% after deductible†
Covered
Individual/Family Out-of-Pocket Maximum
$1,000/$2,000
Includes pharmacy
copay amounts
$1,000/$2,000
Includes pharmacy
copay amounts
$1,000/$2,000
Includes pharmacy
copay amounts
$1,000/$2,000
Includes pharmacy
copay amounts
N/A
Pharmacy and Medical
Out-of-Pocket are combined
N/A
Pharmacy and Medical
Out-of-Pocket are combined
N/A
Covered
Covered
Covered
Covered up to the
allowed amount†
Covered
40% after deductible†
Covered
Not covered
Covered
Covered
Covered up to the
allowed amount†
Covered
40% after deductible†
Not covered
Diabetic Supplies – Most
Covered
Covered
Covered
Covered up to the
allowed amount†
Covered
40% after deductible†
Covered*
Step Therapy –
Applies
Applies
Applies
Applies
Applies
Applies
Applies
Pre-Authorization –
Applies
Applies
Applies
Applies
Applies
Applies
Applies
Subject to deductible and $100
copay per occurrence
20% after deductible
20% after deductible
30% after deductible†
15% after deductible
40% after deductible†
20% after deductible
Covered at 100%
of allowed amount
Covered at 100%
of allowed amount
Covered at 100%
of allowed amount
30% after deductible†
15% after deductible
40% after deductible†
20% after deductible
Applies
Applies
Applies
Applies
Applies
Applies
Applies
Covered (subject to BCBSOK
medical policy criteria)
Not covered
Not covered
Not covered
Not covered
Not covered
Not covered
Subject to deductible then
Covered at 100%
of allowed amount
20% after deductible
20% after deductible
30% after deductible†
15% after deductible
40% after deductible†
20% after deductible
Covered at 100%
of allowed amount
Covered at 100%
of allowed amount
Covered up to the
allowed amount†
15% after deductible
15% after deductible†
20% after deductible
30% after deductible†
15% after deductible
40% after deductible†
20% after deductible
ESN/Mail Order RX Generic (Tier I)/Preferred Brand (Tier II)/Non-Preferred
Band (Tier III) (90 day supply)
Oral Contraceptives
Sexual Dysfunction Drugs (limited to eight doses per 30 days no mail order)
OTHER SERVICES & SUPPLIES
MRI, CT, PET, EEG, and other similar imaging tests
Diagnostic Lab & X-ray
Tobacco Cessation Benefit (non-RX) – 100% member reimbursement for
over-the-counter medications, acupuncture, hypnosis, stop smoking aids,
etc., to a maximum of 20 visits/services per calendar year (per person)
Bariatric/Weight Loss Surgery
Durable Medical Equipment
Ambulance (Ground/Air)
Routine Audiological Exam
Covered at 100%
of allowed amount
$25 copay
Up to the allowed amount. If an out-of-network provider charges more than the allowed amount, you may be responsible for the difference.
Medicare Part A and Part B coverage is required.
††††
Please see Annual Notice of Change (ANOC) for non-preferred pharmacy coverage.
††††
These services are coordinated though Magellan. Please contact 877-794-0678
†
††
$30 copay
$35 copay
18
CONTACTS
This enrollment guide highlights OU’s Benefits Program. A complete description of each benefit can be found in your Certificate of Benefits
Booklet or Member Handbook. 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 Certificate of Benefits or Member Handbook, the Certificate of Benefits Booklet or Member
Handbook will govern. If you have any questions after reviewing your enrollment materials, please contact BCBSOK customer service at
the phone numbers below.
SUBJECT
CONTACT
BCBSOK Customer Service
888-881-4648
Pharmacy
800-423-1973
BlueCard
800-810-BLUE (2583)
24/7 Nurseline
800-581-0407
Special Beginnings
877-904-2229
Through It All.
Through It All.®
bcbsok.com
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Blue Cross®, Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
70450.1015