| Current & Former Employee Coverage & Rates for the 2025/26 Plan Year, effective 7/1/2025 through 6/30/2026. |
| X | Member | |||
| X | Child | |||
| X | Children | |||
| X | Spouse | |||
| X | Spouse & Child | |||
| X | Spouse & Children |
| Covered Individuals Pay Zero Out-of-Pocket for: | ||
| Transplants | ||
| Cancer Care | ||
| Cardiac Surgeries | ||
| Spine Surgeries | ||
| Hip & Knee Replacements | ||
| Maternity Care | ||
| Cellular Immunotherapy | ||
| 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: | BlueAdvantage | |||
| Customer Service: | 800 672 2567 | |||
| Website: | www.bcbsok.com |
| The following Out-of-Pocket costs apply to covered benefits received from BlueAdvantage network providers. | ||||||
| $750 | Deductible - Individual | |||||
| $1,500 | Deductible - Family | |||||
| $3,250 | Maximum Out-of-Pocket - Individual | |||||
| $6,500 | 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 | |||||
| $25 | In-Person Primary & Pediatric Care Co-Pay | |||||
| Free | Virtual Counseling & Psychiatry - MDLIVE | |||||
| Free | Virtual Urgent Care - MDLIVE | |||||
| $25 | In-Person Urgent Care Co-Pay | |||||
| $50 | 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. | ||||||
| $1,500 | Deductible - Individual | |||||
| $3,000 | Deductible - Family | |||||
| $6,500 | Maximum Out-of-Pocket - Individual | |||||
| $13,000 | Maximum Out-of-Pocket - Family | |||||
| 30% | 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 | ||||
| $75 | Deductible per Individual applies to Brand Names only | |||
| $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 | ||||
| $10 | Generics | |||
| $45 | Preferred Brands | |||
| $60 | 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 | ||||
| $10 | Generics | |||
| $60 | Preferred Brands | |||
| $100 | 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.