Diamond Preferred Health Plan
The OPEH&W Health Plan’s Plan Year runs from July 1, 2019 through June 30, 2020.
Rates and Coverage details are per plan year unless stated otherwise and are valid July 1, 2019 through June 30, 2020.
Rates shown are for Active Employees.

On this Page
Resources
Rates
In-Network Coverage
Office Visits
Durable Medical Equipment
Out-of-Network Coverage
Prescription Benefits
Prescription Management Programs
Prescription Co-Pays
Specialty Prescription Co-Pays
Enhancement Prescription Co-Pays


Resources
Coverage Highlight
Benefit Book (SPD)
Summary of Benefits & Coverage (SBC)
National Prescription Drug Formulary
Videos Explaining Coverage

Premium Rates
Monthly for Active Employees
Member     $586.02
Child     $285.58
Children     $464.90
Spouse     $698.88
Spouse & Child     $984.46
Spouse & Children     $1,163.78
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Medical Benefits
Vendor BlueCross BlueShield of Oklahoma
Network BluePreferred
Website www.bcbsok.com
Member Support 800.672.2567
Provider Search Search
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In-Network Coverage Highlights
Co-Insurance 20%
Maximum Out-of-Pocket - Individual $3,000
Maximum Out-of-Pocket - Families of 2 or more $6,000
Deductible - Individual $750
Deductible - Families of 2 or more $1,500
Dependent Child Deducitble Reimbursement 50% Learn More
Dependent Child Accident Reimbursement $500 Learn More
Preventive Benefits Learn More
Benefit Value Advisor Learn More
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In-Network Office Visit Co-Pays
MDLIVE Virtual Office Visits Free Learn More
Urgent Care $20
Primary Care Physicians $20
Specialist Physicians $50
Emergency Room $50
(for non-emergancies only)
》Office Visit Co-Pays only apply to the Office Visit charge
》Any additional charges are subject to Deductible and Co-Insurance
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Durable Medical Equipment
ConnectDME Free Learn More
In-Network Providers Subject to In-Network Deductible & Co-Insurance
Out-of-Network Providers Subject to Out-of-Network Deductible & Co-Insurance
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Diagnostic Imaging
MRI & CT Scan Failure to Call Penalty $100
》Penalty is per claim for failure to call the Benefit Value Advisor before receiving non-emergency MRI or CT scans
》Members must call the Benefit Value Advisor using the Customer Service phone number on the back the BlueCross BlueShield ID card prior to receiving an MRI or CT Scan that was prescribed by a doctor
》Members should state that they need to find an in-network provider to perform an MRI or CT Scan
》Members will be assisted in finding a low-cost, quality provider for the service
》Members will not be penalised if they fail to use the reccomended provider
》Members who fail to call prior to receiving a non-emergency MRI or CT scans will pay an extra $100 towards the cost of the claim
》Penalty will not apply if the call is within 60 days prior to the date of service
》Amounts paid towards this penalty do not apply towards the Maximum Out-of-Pocket
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Out-of-Network Coverage Highlights
Co-Insurance 30%
Maximum Out-of-Pocket - Individual $6,000
Maximum Out-of-Pocket - Families of 2 or more $12,000
Deductible - Individual $1,500
Deductible - Families of 2 or more $3,000
Office Visits Subject to Deductible & Co-Insurance
Emergency Room $50
(for non-emergancies only)
In-Patient Pre-Authorization Penalty Deductible $1,000
》The Pre-Authorization Penalty Deductible is per admission when using an Out-of-Network Provider and Pre-Authorization is not obtained, as required
》The Pre-Authorization Penalty Deductible will be waived if admission is Pre-Authorized by the Claims Administrator
》Amounts paid towards the Pre-Authorization Penalty Deductible do not apply towards the Maximum Out-of-Pocket
》Amounts paid towards Out-of-Network Deductible and Maximum Out-of-Pocket do not count towards In-Network amounts and vice versa
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Prescription Benefits
Vendor Express Scripts
Website www.express-scripts.com
Member Support 855.315.2460
Mail Order Pharmacy 855.315.2460
Specialty Pharmacy 800.803.2523
Provider Search Search
Formulary Learn More
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Prescription Coverage Highlights
Maximum Out-of-Pocket - Individual $2,000
Maximum Out-of-Pocket - Families of 2 or more $4,000
Deductible - Individual $50
》Deductible applies to Brand Names Only
》Deductible is Per Individual – Not Per Prescription
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Prescription Management Programs
Quantity & Age Limitations
Clinical Prior Authorizations (CPA's)
Step Therapies
Exclusions
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Regular Prescription Co-Pays
Retail or Mail Order 30-Day Supply 90-Day Supply
Generics $10 $25
Preferred Brands $45 $112
Non-Preferred Brands $60 $150
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Specialty Prescription Co-Pays *
Mail Order 30-Day Supply
Generics $10
Preferred Brands $60
Non-Preferred Brands $100

* Co-Pays for certain Specialty medications may be set to the greater of the current plan design or any available manufacturer-funded Co-Pay Assistance, any amount known to be paid by any sources of Patient Assistance will not be considered as true Out-of-Pocket for members and may not apply to Deductible and Maximum Out-of-Pocket amounts.
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Enhancement Prescription Co-Pays
Retail or Mail Order 30-Day Supply 90-Day Supply
Contraceptives & Contraceptive Devices Free Free
Smoking Cessation Products Free Free
OTC GERD & Acid Reflux Medications Free Free
Includes Nexium, Prevacid, Prilosec, Protonix, Omeprazole & Zegerid
Generic Oral Diabetic Medications $5 $12
OTC Anti-Histamines $5 $12
Includes Alavert, Claritin, Flonase, Mucinex, Nasacort, Nasonex & Zyrtec
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Videos
Videos are best viewed in full screen mode. To enter full screen mode, first hit play, then click the icon in the lower right of the video pane which looks like a square with gaps in each side
Having trouble viewing in-page videos, then use the following direct YouTube link
Health Benefits http://youtu.be/sm37LVjcI0k
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Additional Health Benefits http://youtu.be/9DayRp7WJx0
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