Medical Coverage - In-Network Coverage

Quick Links:
» Resources
» Rates
» Network
» Plan Year Out-of-Pocket Maximum
» Primary Care Services
» Specialist Physician Services
» Urgent Care Services
» Emergency Room Services
» Plan Year Deductible
» Co-Insurance
Top of Page »

Additional Coverage Details:

» Prescription Coverage
» Preventive Services
» Out of Network Coverage
» MDLIVE - Telehealth
» Benefits Value Advisor
» ConnectDME - Medical Equipment
» Dependent Deductible Reimbursement
» Dependent Accident Reimbursement
Top of Page »


Resources

» Provider Search: Click Here
» Video: Watch
» Out of Network Claim Form: Click Here
Top of Page »

Monthly Rates (for Active Employees)

BluePreferred        BlueChoice          Coverage Level
563.48    602.82    Employee Only
1,235.46    1,321.72    Employee & Spouse
838.06    896.56    Employee & Child
1,010.48    1,081.00    Employee & Children
1,510.04    1,615.46    Employee, Spouse & Child
1,682.46    1,799.90    Employee, Spouse & Children
» Premium Rates for all Coverage Lines: Click Here
» Contact Us for Retiree, COBRA or Disability COBRA Rates
Top of Page »

Network

BluePreferred
» from BlueCross BlueShield of Oklahoma
» 94% of Oklahoma Providers are In-Network
BlueChoice
» from BlueCross BlueShield of Oklahoma
» 97% of Oklahoma Providers are In-Network
Top of Page »

Plan Year Out-of-Pocket Maximum

$5,000
» $10,000 Maximum for a Family of 2 or More
» No Lifetime
» No Plan Year Limits
Top of Page »

Out-of-Pocket Maximum is Reached with any Combination of the Following:

Primary Care Physician Services

$20 Office Visit Co-Pay
» Co-Pay Counts Towards the Annual Out-of-Pocket Maximum
» Non Office Visit Services are Subject to Deductible & Co-Insurance
Top of Page »

Specialist Physician Services

$50 Office Visit Co-Pay
» Co-Pay Counts Towards the Annual Out-of-Pocket Maximum
» Non Office Visit Services are Subject to Deductible & Co-Insurance
Top of Page »

Urgent Care Services

$20 per Visit Co-Pay
» Co-Pay Counts Towards the Annual Out-of-Pocket Maximum
» Non Office Visit Services are Subject to Deductible & Co-Insurance
Top of Page »

Emergency Room Services

Subject to Plan Year Deductible & Co-Insurance after $50 per Visit Fee
» Per Visit Fee Waived if Visit is for Emergency Services
» Per Visit Fee Waived if Individual is Admitted
» Per Visit Fee Counts Towards the Annual Out-of-Pocket Maximum
Top of Page »

Plan Year Deductible

$750
» Counts Towards the Annual Out-of-Pocket Maximum
» $1,500 Maximum for a Family of 2 or More
» $250 Employee & Spouse Deductible Reduction: Learn More
» $375 Dependent Deductible Reimbursement: Learn More
Top of Page »

Co-Insurance

20%
» Member Paid of Allowable Charges After Plan Year Deductible
Top of Page »