| Current & Former Employee Coverage & Rates for the 2024/25 Plan Year, effective 7/1/2024 through 6/30/2025. |
| 538.86 | Member | |||
| 257.44 | Child | |||
| 419.10 | Children | |||
| 630.04 | Spouse | |||
| 887.48 | Spouse & Child | |||
| 1,049.14 | Spouse & Children |
| Covered Individuals Pay Zero Out-of-Pocket for: | ||
| Transplants | ||
| Cancer Care | ||
| Cardiac Surgeries | ||
| Spine Surgeries | ||
| Hip & Knee Replacements | ||
| Maternity Care | ||
| FREE Major Medical Coverage is Available from BlueDisctinction+ Providers Only, No Out-of-Network Coverage Exists, Except for Cancer & Maternity Care. |
| Resource Links | ||
| BlueDistinction+ Provider Search | ||
| Cardiac Surgery Procedure Codes | ||
| Spine Surgery Procedure Codes | ||
| Hip & Knee Replacement Procedure Codes | ||
| Carrier: | BlueCross BlueShield | |||
| Network: | BluePreferred | |||
| Customer Service: | 800 313 5162 | |||
| Website: | www.bcbsok.com |
| Personal Support When You & Your Family Need It Most | ||
| What is a Health Advocate? | ||
| Provides access to you and your dependents to an all-around benefits specialist and personal health care resources | ||
| Health Advocates are more than just customer service personnel, they are part of a dedicated support team | ||
| The health advocate is assigned to you and your covered family members | ||
| This way, you will have a familiar person to talk to whenever you may have a question, concern or health issue needing to be addressed | ||
| How Do You Reach a Health Advocate? | ||||
| Availability: | Monday – Friday, 7am – 7pm CST | |||
| Phone: | 800 313 5162 | |||
| Online: | www.bcbsok.com | |||
| Text: | BCBSOKAPP** to 33633 to download the App | |||
| App Store: | Search for BCBSOKAPP on the Apple App Store or Google Play Store | |||
| What Can a Health Advocate Assist You With? | ||
| Access to Programs/Services | ||
| Medical Information | ||
| Claims History/Status | ||
| Benefit Details | ||
| Claims Questions | ||
| Health Care Support | ||
| Navigation Guidance | ||
| Cost Estimates for Services | ||
| Wellness Resources | ||
| Personal Holistic Care | ||
| Support for Behavioral Health Issues | ||
| Managing a Chronic Condition or Health Concern | ||
| Specialized Clinician Support | ||
| Who's Part of the Health Advocate Support Team? | ||
| Registered Nurse (RN) | ||
| Behavioral Health Specialist | ||
| Pharmacist | ||
| Holistic Health Advisor | ||
| Social Workers | ||
| Medical Doctor | ||
| When Do Health Advocates Reach Out Directly to You? | ||
| Welcome | ||
| Health Event/Chronic Condition | ||
| New Diagnosis | ||
| Finding Care | ||
| Virtual Visits Guidance | ||
| Connectivity with Other Programs/Services | ||
| The following Out-of-Pocket costs apply to covered benefits received from BluePreferred network providers. | ||||||
| $5,500 | Deductible - Individual | |||||
| $11,000 | Deductible - Family | |||||
| $7,500 | Maximum Out-of-Pocket - Individual | |||||
| $15,000 | Maximum Out-of-Pocket - Family | |||||
| 20% | Co-Insurance | |||||
| Preventive Services | ||||||
| Office Visit Co-Pays only apply to the Office Visit charge. | ||||||
| Additional charges received during an Office Visit are subject to Deductible & Co-Insurance. | ||||||
| Free | Virtual Primary & Pediatric Care - MDLIVE | |||||
| Deductible & Co-Insurance | In-Person Primary & Pediatric Care Co-Pay | |||||
| Free | Virtual Counseling & Psychiatry - MDLIVE | |||||
| Free | Virtual Urgent Care - MDLIVE | |||||
| Deductible & Co-Insurance | In-Person Urgent Care Co-Pay | |||||
| Deductible & Co-Insurance | In-Person Specialist Care Co-Pay | |||||
| $50 | Emergency Room Co-Pay (Waived if Admitted) | |||||
| The following Out-of-Pocket costs apply to covered benefits received from Out-of-Network providers. | ||||||
| Amounts paid towards Out-of-Network Deductible and Maximum Out-of-Pocket do not count towards In-Network amounts and vice versa. | ||||||
| $5,500 | Deductible - Individual | |||||
| $11,000 | Deductible - Family | |||||
| $7,500 | Maximum Out-of-Pocket - Individual | |||||
| $15,000 | Maximum Out-of-Pocket - Family | |||||
| 50% | Co-Insurance of Allowable Cost | |||||
| 100% | Balance Billing for Amounts Over Allowable Cost | |||||
| $1,000 | In-Patient Pre-Authorization Penalty Deductible | |||||
| Per admission when using an Out-of-Network Provider and Pre-Authorization is not obtained, as required. | ||||||
| Waived if admission is Pre-Authorized by the Claims Administrator. | ||||||
| Does not apply towards the Maximum Out-of-Pocket. | ||||||
| Carrier: | Express Scripts (ESI) | |||
| Network: | National Preferred Formulary | |||
| Rx Formulary Search Tool | ||||
| Rx Formulary | ||||
| Rx Exclusions | ||||
| Customer Service: | 855 315 2460 | |||
| Specialty Pharmacy: | 800 803 2523 | |||
| Website: | http://www.express-scripts.com |
| The following Out-of-Pocket costs apply to prescription medications received from In-Network pharmacies | ||||
| $0 | Deductible per Individual applies to Brand Names & Generics | |||
| $2,000 | Maximum Out-of-Pocket - Individual | |||
| $4,000 | Maximum Out-of-Pocket - Family | |||
| 30-Day Supply Co-Pays | ||||
| For 90-Day Supply Co-Pays, Multiply by 2.5 | ||||
| $5 | Generics | |||
| $45 | Preferred Brands | |||
| $85 | Non-Preferred Brands | |||
| Co-Pay Assistance | ||||
| Some covered medications may have a manufacturers co-pay Patient Assistance Program available to help reduce the co-pay amount. Use the followng link to view a list of these medications. | ||||
| Co-Pay Patient Assistance Program Drugs | ||||
| Rx Resources | ||||
| Rx Formulary Search Tool | ||||
| Rx Formulary | ||||
| Rx Exclusions | ||||
| 30-Day Supply Co-Pays | ||||
| $5 | Generics | |||
| $95 | Preferred Brands | |||
| $195 | Non-Preferred Brands | |||
| Specialty Co-Pay Assistance | ||||
| Some covered specialty medications may have a manufacturers co-pay Patient Assistance Program available through the OPEH&W's partner SaveOn, to help reduce the co-pay amount. Use the followng link to view a list of these medications. | ||||
| SaveOn Specialty Co-Pay Patient Assistance Program Drugs | ||||
| Rx Resources | ||||
| Rx Formulary Search Tool | ||||
| Rx Formulary | ||||
| Rx Exclusions | ||||
| 30-Day Supply | ||||||
| Free | Contraceptives & Contraceptive Devices | |||||
| Free | Tobacco Quitting Solutions | |||||
| Free | GERD & Acid Reflux Over-The-Counter (OTC) Medications | |||||
| Includes: Nexium, Prevacid, Prilosec, Protonix, Omeprazole & Zegerid | ||||||
| $5 | Antihistamine Over-The-Counter (OTC) Medications | |||||
| Includes: Alavert, Claritin, Flonase, Mucinex, Nasacort, Nasonex & Zyrtec | ||||||
| $5 | Diabetic Generic Oral Medications | |||||
| $25 | Insulin - Select Brands Only | |||||
The only non-profit public trust health plan; owned, ran and for Oklahoma's local government organizations.