Current & Former Employee Coverage & Rates for the 2025/26 Plan Year, effective 7/1/2025 through 6/30/2026. |
667.96 | Member | |||
319.12 | Child | |||
519.50 | Children | |||
780.98 | Spouse | |||
1,100.10 | Spouse & Child | |||
1,300.48 | 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. | ||
Cellular Immunotherapy |
Resource Links | ||
BlueDistinction+ Provider Search | ||
Cardiac Surgery Procedure Codes | ||
Spine Surgery Procedure Codes | ||
Hip & Knee Replacement Procedure Codes |
Vendor: | BlueCross BlueShield | |||
Network: | BluePreferred | |||
Customer Service: | 800 672 2567 | |||
Website: | www.bcbsok.com |
The following Out-of-Pocket costs apply to covered benefits received from BluePreferred network providers. | ||||||
$3,250 | Deductible - Individual | |||||
$6,500 | Deductible - Family | |||||
$7,000 | Maximum Out-of-Pocket - Individual | |||||
$14,000 | 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 | |||||
$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. | ||||||
$6,500 | Deductible - Individual | |||||
$13,000 | Deductible - Family | |||||
$14,000 | Maximum Out-of-Pocket - Individual | |||||
$28,000 | 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 | ||||
$100 | 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 | ||||
25% up to a maximum of $80 | Preferred Brands | |||
40% up to a maximum of $120 | 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 |