Highlights of the Plan

ProvidersYou choose any provider you wish. 

Annual Deductible
  • In-Network Plus (INP): None
  • Preferred Provider Organizations (PPO): $400 per person/$800 per family
  • Out-of-Network (OON): $2,000 per person/$4,000 per family

Your Cost for Services

Your costs for most services depend on whether the provider you choose is part of a participating network.

INP: For most eligible expenses, the Plan pays 100% of most Allowable Charges, including office visits, urgent care center visits, and most hospital services with no annual deductible.

PPO: For most eligible expenses, the Plan pays 80% of Allowable Charges after you have satisfied the annual deductible. You pay 20% coinsurance, plus any difference between the provider’s full charge and the Allowable Charge.

OON: For most eligible expenses, the Plan pays 60% of Allowable Charges after you have satisfied the annual deductible. You pay 40% coinsurance, plus any difference between the provider's full charge and the Allowable Charge.

Your costs for emergency room services per family, per calendar year are as follows. (For PPO and OON providers, you will first need to satisfy the annual deductible.):

  • Visits 1-2: You pay $150 copay (no coinsurance)
  • Visits 3-4: You pay $150 copay plus 20% coinsurance
  • 5 or more visits: You pay 50% coinsurance

For designated procedures, the Plan has identified Centers of Expertise. When you use a Plan-approved Center of Expertise for these procedures, the Plan pays 100% of Allowable Charges, and you avoid a 40% benefit penalty.

Annual Out-of-Pocket Limits

Out-of-pocket limits provide financial protection for you, by limiting certain cost-sharing amounts you must pay for Allowable Charges in a calendar year.

The medical out-of-pocket limit is:

  • INP: $2,000 per person; $4,000 per family
  • PPO: $4,000 per person; $8,000 per family
  • OON: $12,000 per person; $24,000 per family

The combined medical/prescription out-of-pocket limit is:

  • INP & PPO combined: $6,850 per person, $13,700 per family
  • OON: None

The medical limit does not include copays or prescription drugs. Neither the medical limit nor the combined medical/prescription limit include the 25% benefit penalty (100% benefit penalty for transplants) for preauthorization non-compliance (if required for a specific service), the 40% penalty for Care Coordination non-compliance (if required), the 40% penalty for using a provider that is not a Plan-approved Center of Expertise (if required), premiums, amounts paid above Allowable Charges, covered services not considered essential health benefits by federal law (such as chiropractic and acupuncture), any discounts or similar reductions by providers/manufacturers, and health care the Plan does not cover.

Care CoordinationCare Coordination helps participants with complex or chronic health conditions receive medically necessary treatment and avoid gaps in care. You may request Care Coordination by calling (855) 979-5206 toll free.

For some conditions, Care Coordination is required in order to receive the normal level of benefits. If this applies to you, Care Coordination Services will contact you. If you decline required services, you will be subject to a benefit penalty equal to 40% of the amount the Plan would normally pay.

Preauthorization RequirementTo avoid a benefit penalty, the following services and products require preauthorization:
  • Certain durable medical equipment (e.g., hospital bed, wheelchair)
  • Dialysis (effective July 15, 2017)
  • Genetic testing (effective July 15, 2017)
  • Home health care
  • Hospice care
  • Infusion services (e.g., chemotherapy, biological therapy)
  • Inpatient admissions (e.g., hospital, residential treatment center, skilled-nursing facility)
  • MRI, CT, echocardiography, and other imaging (except X-rays and routine ultrasounds)
  • Outpatient procedures
  • Oxygen (home and/or portable)
  • Private-duty nursing
To request preauthorization, you or your provider should call the Plan's Utilization Management (UM) Department at (877) 563-7427:
  • As soon as possible before a scheduled, nonemergency procedure
  • Within two business days after an unscheduled inpatient admission
Failure to obtain preauthorization when required will result in a 25% benefit penalty (100% benefit penalty for transplants). Preauthorization allows you to determine whether a service is medically necessary before you incur an expense. As with all claims, any services determined not to be medically necessary will not be covered.

Cost of CoverageYou and the Company share the cost of your medical care. You do not pay a premium contribution for your coverage, but both you and the Plan share the cost of eligible expenses.

How to Reach Customer Service
  • For assistance with selecting INP providers: Call INP Provider Information at (918) 730-9586
  • For preauthorization, denials and appeals: Call the UM Department at (877) 563-7427
  • For Care Coordination: Call (855) 979-5206
  • For medical coverage eligibility and claim information: Call WebTPA Customer Service at (888) 769-2432