THE UNIVERSITY OF OKLAHOMA EMPLOYEE BENEFITS Experience. Wellness. Everywhere.

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1 OU THE UNIVERSITY OF OKLAHOMA EMPLOYEE BENEFITS 2012 Experiece. Welless. Everywhere.

2 Experiece. Welless. Everywhere.

3 TABLE OF CONTENTS 2012 Beefit Highlights & Chages...Welcome Beefit Erollmet & Makig Chages Durig the Year...1 Medical Pla Optios BlueLics HMO...4 BlueOptios PPO...5 BlueEdge SM HCA Pla Compariso Chart What s Not Covered...14 ID Cards...14 Welless Guide Resource Guide & Cotacts...18

4 WELCOME Welcome to Blue Cross ad Blue Shield of Oklahoma, ad to your beefit erollmet period. This is your opportuity to select health beefits for you ad your family for the comig year. For more tha 70 years, Blue Cross ad Blue Shield of Oklahoma (BCBSOK) has delivered high value products ad urivaled customer service to more Oklahomas tha ay other health isurace pla. Ad our atiowide etwork of physicias ad hospitals, coupled with local resources ad friedly service, keeps you coected to your health care coverage o matter where you are. Through the Uiversity of Oklahoma, we are pleased to offer beefits that give you ad your family the best care possible ad services that allow you to put your health care decisios ad health educatio closer to your figertips. Please take a few miutes to look through this summary guide ad review the optios that are available to you. You may also visit bcbsok.com/ou for more iformatio. It is our desire durig the erollmet period that you gai a clear uderstadig of each optio ad to help you decide what is best for your health care eeds. BCBSOK members do t just have access to traditioal isurace coverage; you also have a complete suite of health ad welless resources ad tools at your figertips, to ecourage healthier livig ad smarter health decisios. Blue Cross ad Blue Shield of Oklahoma is a health care idustry leader i creatig ad promotig welless programs that you ad your family ca coveietly itegrate ito your daily life. Mergig techology ad medical maagemet with olie resources, educatio, oe-o-oe coachig, rewards ad multiple touch poits, BCBSOK s Blue Care Coectio program aims to ultimately improve you ad your family s health ad welless. Our goal at Blue Cross ad Blue Shield of Oklahoma is to provide you with first class service, ad to do the job right the first time, every time. We appreciate the opportuity to serve you. Sicerely, Liza Joes Vice Presidet, Marketig ad Sales Blue Cross ad Blue Shield of Oklahoma 2012 Beefit Highlights & Chages OU is committed to providig a healthy eviromet for you ad your family. Our health care program with Blue Cross ad Blue Shield of Oklahoma offers health isurace coverage ad welless programs that offer flexible ad affordable optios for you ad your family - as well as help us all achieve ad maitai a healthier lifestyle. OU has made modificatios to the 2012 health beefit package, icludig: Itroducig BlueOptios PPO The BlueOptios PPO pla replaces the BlueChoice pla - providig greater flexibility ad freedom to choose your provider ad etwork, ad ultimately determie your copaymet ad deductible amouts. The flexibility of BlueOptios PPO allows you to make smarter health care decisios for you ad your family. Prevetive Care Services Fully Covered Uder BlueOptios PPO Most prevetive care services for members with BlueOptios PPO are fully covered if usig i-etwork providers, which meas you will pay o copaymet or coisurace for services such as well child ad adult immuizatios, routie exams, gyecological exams, mammograms ad prostate specific atige (PSA) tests. BlueLics HMO Deductible ad Copaymet Amouts The additio of a caledar year deductible for certai services, icludig but ot limited to ipatiet/outpatiet hospital services, skilled ursig facilities, durable medical equipmet, ad certai imagig services such as MRI, PET ad CT scas. Adjustmet of the copaymet amout for certai imagig services such as MRI, PET ad CT scas.

5 01 Beefit Erollmet & Makig Chages Durig the Year Durig the ope ad ew member erollmet period, you ca add or delete depedets from your health care coverage without a qualifyig evet. The erollmet period is the time to make sure all of your eligible depedets are erolled ad that Huma Resources has all the correct iformatio about your depedets o file. The health care pla optios you select durig the erollmet period will remai i effect durig the caledar year. I order to chage beefit electios outside of the erollmet period, the employee must have: 1) Experieced a Applicable Qualifyig Evet, as defied by the Iteral Reveue Service (IRS). Chages based o fiacial reasos aloe are ot allowed uder the curret IRS regulatios. AND 2) The request for a chage of beefits must be made withi 31 days of the Applicable Qualifyig Evet. Withi the cotext of chagig beefits, Applicable refers to a chage that is directly related to the idividual experiecig the qualifyig evet. A qualifyig evet icludes: A birth or adoptio Marriage, divorce or legal separatio Death Child loses eligibility because of age Employee s spouse gais or loses coverage through employmet Sigificat chage i the fiacial terms of health beefits provided through a spouse s employer or aother carrier Except for coverage of a ewbor or adopted child, all other chages i coverage begi the first day of the moth followig the qualifyig evet. Coverage for the ewbor is effective o the child s date of birth. Coverage for a adopted child is effective o the date of placemet. I both istaces, the employee must iitiate ad complete the appropriate paperwork. Chages i provider etworks (for example, your doctor leavig the etwork) are ot cosidered acceptable reasos for you to be able to chage your product electio outside of the erollmet period. Please visit the Beefits sectio of the OU Huma Resources website for more iformatio at hr.ou.edu. Eligibility Please visit the Beefits sectio of the OU Huma Resources website for iformatio at hr.ou.edu. Medical Pla Optios The followig pages (1 14) provide a overview of the health beefits of each of the program optios. These are oly summaries ot the actual pla descriptios. If you have questios that are t aswered i the summary iformatio i this booklet, please cotact customer service at or review the detailed Summary Pla Descriptios. Detal care beefits are offered separately, ad are ot highlighted i this beefit guide. The medical pla you select durig the erollmet period will apply for the caledar year. You will ot be able to make chages to your medical pla durig the year UNLESS YOU HAVE A QUALIFYING EVENT. I o evet will you be able to switch from oe pla to aother durig the year, uless you are o the HMO pla ad move outside the service area. A brief descriptio of the various aspects of each program follows o the ext pages.

6 02 Medical Pla Comparisos Available Health Care Plas There are three otably differet beefit plas to choose from: BlueLics HMO, BlueOptios PPO or BlueEdge HCA. The BlueLics HMO is a health maiteace orgaizatio type of pla, otherwise kow as a maaged care pla. It requires selectio ad use of a primary care physicia (PCP), ad referrals are usually eeded for specialty care. BlueOptios PPO ad BlueEdge HCA are preferred provider orgaizatio (PPO) types of plas. Blue Cross ad Blue Shield of Oklahoma has egotiated discouts with medical providers (doctors, hospitals etc) to reduce the cost of health care. The discout is applied before there is ay paymet for services from you or BCBSOK. Whe you see a provider that is i-etwork, you will have the lowest out-of-pocket expese because the cost of services is usually lower ad the beefits you receive are higher. BlueEdge HCA uses the BlueChoice etwork, which is BCBSOK s largest PPO etwork. BlueOptios PPO offers a uique tiered structure that allows you the flexibility to see providers i the BlueChoice or BluePreferred etworks. However, you will have the lowest outof-pocket expese whe you see providers i the BluePreferred etwork (see pages 2-3 ad 5 for additioal iformatio) because the discouts are greater. The BluePreferred etwork has fewer providers tha the BlueChoice etwork. BlueOptios PPO ad BlueEdge HCA also give you the flexibility to choose a out-of-etwork provider, with whom BCBSOK does ot have a cotract, ad still receive health care beefits. However, you may have more out-of-pocket expese whe you choose a out-of-etwork provider. The BlueEdge HCA pairs a high deductible ad the BlueChoice etwork with a health care accout (HCA). The HCA ca be used to pay for certai out-of-pocket medical expeses. Key Areas to Cosider Whe Choosig a Health Pla You should choose the pla best suited for you ad your family. There are importat differeces betwee the plas that should be cosidered. Details ad beefits of each pla are listed o the followig pages for easy compariso. Here are some additioal factors to keep i mid: 1) Beefit desig Each of the three plas promotes welless, offers prevetive care ad has ulimited lifetime maximums. However, there are otable differeces amog the plas, which impact the coverage ad out-of-pocket costs you ll have whe you utilize your beefits. The BlueLics HMO has very low out-of-pocket costs with oly applicable copaymets ad a low caledar year deductible that is applicable to some services. There is o caledar year deductible to satisfy except for certai services such as ipatiet/ outpatiet hospital services, skilled ursig facilities, durable medical equipmet, ad certai imagig services such as MRI, PET ad CT scas. BlueOptios PPO has a caledar year deductible to satisfy before coverage begis. However, like the HMO pla, may services are covered with just a copaymet, so depedig o the type of services you eed, you may ot eve eed to meet your deductible durig the year. Most prevetive care services are fully covered uder BlueOptios PPO if usig i-etwork providers, which meas you will pay o copaymet or coisurace for services such as well child ad adult immuizatios, routie exams, gyecological exams, mammograms ad prostate specific atige (PSA) tests. Whe you see providers i the BluePreferred etwork, you will have the lowest out-of-pocket expese because the discouts are greater. The BlueEdge HCA has a otably higher deductible to satisfy each year, ad some services, except for some of your prevetive care beefits, are subject to that deductible before your coverage begis. (If you have family coverage, the full family deductible must be satisfied before coisurace begis.) To help offset the higher deductible, moey is put ito a health care accout each year o your behalf, which ca be applied to your deductible or other eligible out-of-pocket medical expeses. Blue Edge HCA uses the BlueChoice etwork, so you will have the lowest out-ofpocket costs whe you use providers i the BlueChoice etwork. 2) Rates It s importat to compare the rates of each pla, while keepig i mid the beefits that come with each pla. The rates for BlueLics HMO are slightly higher tha the other plas, but BlueLics HMO also has the most predictable out-of-pocket costs whe you eed to utilize your beefits. Keep i mid, however, that as a HMO, BlueLics HMO has less flexibility tha the other two plas, ad it has a smaller etwork of providers to choose from. BlueOptios PPO is the middle cost pla, ad ulike BlueLics HMO, it provides a high level of flexibility whe choosig your providers ad out-of-pocket costs. BlueEdge HCA has the lowest premiums. It provides a high level of flexibility, but it has higher out-of-pocket costs tha the other two plas.

7 03 3) Provider access The BlueChoice etwork is BCBSOK s largest etwork. BlueEdge HCA utilizes the BlueChoice etwork, which meas you will have the lowest out-of-pocket costs whe you see providers i the BlueChoice etwork. The BluePreferred etwork is BCBSOK s secod largest etwork, icludig providers i the Tulsa ad Oklahoma City metro areas as well as may providers i the rest of the state. BlueOptios PPO offers a uique tiered structure that allows you the flexibility to see providers i the BlueChoice or BluePreferred etworks. However, you will have the lowest out-of-pocket costs whe you see providers i the BluePreferred etwork (see pages 2-3 ad 5 for additioal iformatio) because the discouts are greater. BlueOptios PPO ad BlueEdge HCA also give you the flexibility to choose a out-of-etwork provider, with whom BCBSOK does ot have a cotract, ad still receive health care beefits. However, you may have more out-of-pocket expese whe you choose a out-of-etwork provider. There are fewer providers i the BlueLics HMO etwork tha there are i the BlueChoice or BluePreferred etwork. Be sure to verify that your curret physicias are i the etwork for the pla you are cosiderig. If you are joiig the HMO ad wat to choose a ew primary care physicia (PCP), make sure that physicia is acceptig ew patiets. With BlueLics HMO, out-of-state coverage is geerally limited to emergecy treatmet. If you have a depedet livig out-of-state (for example, a college studet), or if you are movig out-of-state durig the year, you may be eligible to eroll i the Away From Home Care Program, which coects BlueLics HMO members to a participatig out-of-state HMO. The Away From Home Care Program does ot cover the etire Uited States. If you are cosiderig the HMO, ad you have a out-of-state depedet or plas to move out-of-state, please cotact BCBSOK at to discuss your optios. BlueOptios PPO ad BlueEdge HCA members have atiowide access to cotractig providers through the BlueCard Program whe you or your covered family members live, work, or travel aywhere i the coutry. Additioally, whe you travel outside the Uited States, PPO members have access to cotractig providers i more tha 200 coutries through BlueCard Worldwide. You ca verify that your curret physicias are i the etwork for the pla you are cosiderig by checkig the olie provider directory at bcbsok.com/ou. 4) Flexibility BlueOptios PPO ad BlueEdge HCA give you the most flexibility sice you have coverage for both i-etwork (PPO) ad out-of-etwork providers. Keep i mid that you will always receive your highest level of beefits ad lowest out-of-pocket costs whe choosig a i-etwork provider. BlueOptios PPO gives you additioal freedom of choice ad flexibility because you ca see providers i the BlueChoice or BluePreferred etworks ad still receive beefits. (For BlueOptios members, you will have the lowest out-of-pocket costs whe you see providers i the BluePreferred etwork.) The BlueLics HMO pla is a maaged care pla that requires the use of BlueLics HMO cotracted providers. You also are required to select a primary care physicia (PCP) to provide or coordiate most of your care. Referrals are geerally required from your PCP for most specialty care. BlueOptios PPO ad BlueEdge HCA do ot have these requiremets; you maage your ow care. 5) Pre-existig coditios - The BlueLics HMO has o pre-existig coditio restrictios. I some istaces where idividuals have had o prior group isurace coverage immediately before erollig, the BlueOptios PPO ad the BlueEdge HCA may have pre-existig coditio limitatios. Refer to the Summary Pla Descriptios available o the OU Huma Resources website for details. Nourish to flourish. People sometimes tur to popular diets to achieve quick weight loss. For lastig chages ad healthy eatig, balace what you eat to meet your eed for utritio ad ejoymet. Ejoy a variety of foods while keepig key food groups i mid ad use moderatio whe choosig less utritious foods.

8 04 Ejoy a state of balace. BlueLics HMO If you are erollig i BlueLics HMO, you must specify a Primary Care Physicia (PCP) durig your erollmet. Durig your olie erollmet process, you will be asked to provide your PCP s Natioal Provider Idetificatio (NPI) umber. You must select your ow PCP from the HMO provider etwork, ad you must see him or her to coordiate care for most services i order to receive beefits. You may choose a differet PCP for each family member, or you may select the same oe for the etire family. If you receive o-emergecy care outside the HMO etwork or from a provider without a referral from your PCP (except as oted i the followig bullet), you receive o beefits. To visit a specialist, a referral is usually required from your PCP for most care. Referrals are ot required whe you receive a aual exam from a etwork OB/GYN or from a etwork ophthalmologist or optometrist for routie exams. Besides the BlueLics HMO pla, a additioal HMO pla is available for Tulsa employees. Please visit the Beefits sectio of the OU Huma Resources website for more iformatio at hr.ou.edu. BlueLics HMO Frequetly Asked Questios Where do I get my PCP s NPI umber? Visit bcbsok.com/ou ad click o Search for Doctors ad Hospitals i your area to fid a provider directory. There you ca search for a PCP you curretly use or locate a ew PCP that is available through the BlueLics HMO etwork. You must eter the PCP s NPI (as show o the website) durig the olie erollmet process. I wat to chage my curret PCP. Ca I do that durig the erollmet period? Yes, ad you are able to do that up to four times a year as well. Cosult the provider directory o bcbsok.com/ou to choose a PCP i the BlueLics HMO etwork. Durig the erollmet period, iclude the PCP s NPI. Durig the year, simply call BCBSOK customer service to make this chage. My depedets live out-of-state. Ca I choose BlueLics HMO? With BlueLics HMO, out-of-state coverage is geerally limited to emergecy treatmet oly. If you have a depedet livig out-of-state (for example, a college studet), or if you are movig out-of-state durig the year, you or your depedet may be eligible to eroll i the Away From Home Care Program, which coects BlueLics HMO members to a participatig out-of-state HMO. The program is desiged for members who: have a child attedig school out-of-state have family members livig i differet service areas have a log-term work assigmet i aother state are retired with dual residece The Away From Home Care Program does ot cover every area i the etire Uited States. If you are cosiderig BlueLics HMO, ad you have a out-of-state depedet or plas to move out-of-state, please cotact BlueLics HMO at to discuss your optios.

9 05 BlueOptios PPO BlueOptios PPO is a preferred provider orgaizatio (PPO) pla, which gives you the flexibility to choose your provider ad etwork at the time of service. BlueOptios PPO gives you the freedom to select ay health care provider (whether they are i-etwork or ot). You do ot eed to select a primary care physicia. Your choice of health care providers ca affect the level of health care beefits (icludig copaymet ad deductible amouts) based o the etwork your provider is i. With the BlueOptios PPO pla, you ca choose from two differet etworks each time you eed health care. Or, you may choose to see providers that are ot i a etwork (out-of-etwork). The BluePreferred etwork provides the biggest discout ad pays your beefits at the highest level, which meas you will have the lowest out-of-pocket costs whe you use providers i the BluePreferred etwork. The BlueChoice etwork will pay your beefits at the secod highest level, although some aspects of coverage are the same with the BluePreferred ad BlueChoice etworks. If you see out-of-etwork providers, you will receive o discouts ad your beefits will be paid at the lowest level. Fidig out which etwork your providers are located i is easy! Simply visit bcbsok.com/ou ad click o Search for Doctors ad Hospitals i your area. You ca search for a doctor by ame, locatio, etwork, or specialty, such as dermatology or cardiology. The office copaymets ad deductible are lower for the BluePreferred etwork tha the BlueChoice etwork. The coisurace paid by BCBSOK ad the out-of-pocket maximums are the same for the BluePreferred ad BlueChoice etwork. Most prevetive care services for i-etwork providers are fully covered uder the BlueOptios PPO pla, which meas you will pay o copaymet or coisurace for services such as well child ad adult immuizatios, routie exams, gyecological exams, mammograms ad prostate specific atige (PSA) tests. I some istaces where idividuals have had o prior group isurace coverage immediately before erollig, the BlueOptios PPO may have pre-existig coditio limitatios. Refer to the Summary Pla Descriptios available o the OU Huma Resources website for details. BlueOptios PPO Frequetly Asked Questios How do I fid a doctor i the BluePreferred or BlueChoice etwork? Go to bcbsok.com/ou ad use the provider directory, or call BCBSOK customer service. How do my beefits work whe I am out-of-state? BlueOptios PPO members have atiowide access to cotractig providers through the BlueCard Program whe you or your covered family members live, work, or travel aywhere i the coutry. Your beefits will geerally be paid at the BlueChoice beefit level, sice BluePreferred providers are mostly located i Oklahoma. You ca search for BlueCard providers i the olie provider directory at bcbsok.com/ou. Do I eed a referral from my doctor to see a specialist? No. With the BlueOptios PPO pla you ca see ay doctor at ay time without a referral. If you see a specialist who is part of the BluePreferred etwork, your beefits will be paid at the highest level ad your out-of-pocket costs will be lowest. You ca also see a specialist who is i the BlueChoice etwork or ot part of the etwork, but your beefits will be paid at a lower level. Ca I see providers i both the BluePreferred ad BlueChoice etworks? Yes, with BlueOptios PPO, you have the freedom to see ay doctor you choose at ay time. You ca choose differet etworks for differet health care services ad/or for differet members of your family. For example, you ca see a physicia i the BluePreferred etwork while your spouse ad childre see a physicia i the BlueChoice etwork. Your beefits are determied at the poit of service, which meas that your copaymet ad deductible amouts deped o which etwork you choose. Your choice ca affect the amout of beefits you receive. You will have the lowest out-of-pocket expese whe you see providers i the BluePreferred etwork. Keep i mid that deductibles vary depedig o the etwork you choose. The deductibles update each other, which meas that at oe poit durig the year, you may have satisfied your BluePreferred deductible but still have more to satisfy for the BlueChoice etwork. If you were to cotiue to see BluePreferred providers, the your deductible is met. If you visit a BlueChoice (or out-of-etwork) provider, you will first have to satisfy the differece betwee the deductible for that etwork ad the BluePreferred deductible before coisurace applies agai. Ca my doctor be a part of both etworks? What happes if this is the case? Be sure to ask your provider which etwork(s) they are i. They may be i more tha oe etwork. If that is the case, your beefits will be applied at the highest etwork level. For example, your doctor is i the BluePreferred ad BlueChoice etwork. If you visit your doctor, your beefits will be applied for the BluePreferred etwork, which meas that you will have the lowest out-of-pocket expese.

10 06 Live a life of commitmet. BlueEdge HCA What is it? With the BlueEdge HCA pla, a specific amout of moey is deposited each beefit year i a health care accout (HCA). I 2012 for example, $500 is deposited for a idividual employee, or $1,000 is deposited for a employee with erolled depedets. I both cases, that amout is pro-rated if you are erollig i the middle of the year. This icludes ew employees startig after the begiig of the caledar year (see the pro-ratio schedule o page 7). Whe you eed ay covered medical care, the first out-of-pocket costs you have are paid from available fuds i this accout. The moey paid from your health care accout is applied toward meetig your aual pla deductible or other copaymet or coisurace amouts you may be resposible for. Ay uused health care accout fuds roll over year to year, as log as you remai i the BlueEdge HCA. Beefits The HCA pla that Blue Cross ad Blue Shield of Oklahoma offers is called BlueEdge HCA. However, the etwork of providers that are covered uder the BlueEdge HCA is the BlueChoice etwork. As a HCA member, you have access to a extesive etwork of providers ad hospitals throughout the coutry. You ca select ay provider for care withi the BlueChoice etwork or outside the etwork. Whe you receive care from a BlueChoice etwork provider, you receive the highest level of beefits ad lowest out-of-pocket costs. Whe you receive care from a out-of-etwork provider, you receive a lower level of beefits. You do ot have to select a primary care physicia, ad you ever eed a referral to see a specialist. Uder BlueEdge HCA, some of your well child ad adult prevetive care services are covered i full, icludig routie OB/GYN exams ad mammograms, ad well child immuizatios. May other well child ad adult prevetive care services are fully covered up to the first $250 each year. (Additioal prevetive services are covered uder your regular beefits.) I some istaces where idividuals have had o prior group isurace coverage immediately before erollig, the BlueEdge HCA may have pre-existig coditio limitatios. Refer to the Summary Pla Descriptios available o the OU Huma Resources website for details. How does it work? 1) At the begiig of each year, fuds are deposited ito your HCA accout. I 2012, $500 is deposited for a idividual employee, or $1,000 for a employee with erolled depedets. Available fuds i the HCA are used to pay for your iitial health care deductible expeses each year. The $1,000 credit for employees with depedets ca be used i ay combiatio by the covered members of oe family for covered expeses, icludig the etire $1,000 beig used by oe family member. 2) Oce your available HCA fuds are depleted, you are resposible for ay remaiig deductible ad coisurace. 3) Oce the deductible is met, beefits for covered services begi. You eed to use a i-etwork provider to receive the highest level of beefits. Whe providers submit their claims to BCBSOK, out-of-pocket expeses for covered services are automatically paid from available fuds i your HCA. There is o special paperwork to be submitted for reimbursemet, ad you will receive a Explaatio of Beefits (EOB) showig what beefits are payable uder your pla, otig the amout paid from your HCA. You ca also keep track of your HCA ad deductible balace olie.

11 07 4) Oce your out-of-pocket maximum is reached, eligible health care services will be covered at 100 percet of the allowable amout for the remaider of the caledar year. If you do t sped all of your HCA fuds i oe year, the balace rolls over to the ext year ad is added to the aual amout cotributed to your accout. There is o maximum o the amout you ca accumulate i your HCA. The higher your HCA balace is, the less you ll have to pay out-of-pocket whe you do eed to utilize your health beefits. Ay fuds accumulated i excess of your deductible will be used to pay for ay coisurace you icur. If you switch to a differet product optio at a future erollmet, you will forfeit ay balace i your HCA. The HCA will ot be paid out i cash uder ay circumstace. Additioal iformatio about the BlueEdge HCA Pro-ratio HCA fuds are pro-rated for employees startig work after the begiig of the caledar year, followig this pro-ratio schedule: Ja. 1 March % cotributio $500 idividual /$1,000 family April 1 Jue 30 75% cotributio $375 idividual /$750 family July 1 Sept % cotributio $250 idividual /$500 family Oct. 1 Dec % cotributio $125 idividual /$250 family Welless Services May welless services are paid at 100% ad are ot subject to your aual deductible. Additioally, the prevetive care services that are covered at 100% are ot paid with ay of the fuds i your HCA. Eligible expeses that ca be paid from available HCA fuds Deductible, coisurace ad copaymet amouts you are resposible for uder your beefit pla for covered services. Aual Erollmet Erollmet i BlueEdge HCA automatically cotiues from year to year uless you make a pla chage. BlueEdge SM 1 Whe you eed ay covered medical care, the first dollars spet come from your HCA. The moey paid from your HCA is applied toward meetig your aual pla deductible. 2 3 Health Care Accout Deductible PPO

12 Pla Compariso Chart Coverage (Beefit period is oe caledar year) BlueLics HMO BlueOptios PPO HMO Network Oly BluePreferred Network BlueChoice Network Out-of-Network Caledar Year Deductible Idividual/Family $300 per idividual $400/$800 $500/$1,000 $1,000/$2,000 Out-of-Pocket Maximum Idividual/Family $2,000/$4,000 Does ot iclude copays for prescriptio drugs $3,000/$6,000 $3,000/$6,000 $4,000/$8,000 Health Care Accout Fud Not applicable Not applicable Lifetime Health Care maximum (per perso) Ulimited Ulimited PHYSICIAN SERVICES The amouts show below are what you are resposible for payig for each type of service or treatmet. Office visit & related routie services / cosultatio / secod opiio $25 copay per visit ($35 copay for specialist) $20 copay per visit ($30 copay for specialist) $25 copay per visit ($35 copay for specialist) 30% after deductible Physical, Occupatioal, Speech, ad Chiropractic Therapies (60 visit maximum combied for all therapies) $35 copay $30 copay $35 copay 30% after deductible Allergy Ijectios $25 copay $30 copay $35 copay 30% after deductible Allergy Testig $35 copay $30 copay $35 copay 30% after deductible Allergy Serum Covered i full $30 copay $35 copay 30% after deductible Ipatiet Physicia Services Outpatiet Physicia Services / o-routie office services Subject to deductible the covered i full Subject to deductible ad applicable copay Lab & X-ray (Physicia Office) Covered i full Covered i full Covered i full 30% after deductible PREVENTIVE CARE SERVICES The amouts show below are what you are resposible for payig for each type of service or treatmet. Routie Exam Covered i full Covered i full Covered i full Covered i full Adult Immuizatios Covered i full Covered i full Covered i full Covered i full Well Child Exams Covered i full Covered i Full Covered i Full 30% after deductible Routie Eye Exam* (does ot iclude hardware) $25 copay $30 copay $35 copay 30% after deductible Routie Hearig Exam* (does ot iclude hardware/hearig aids) $25 copay $30 copay $35 copay 30% after deductible Routie Ob/Gy Exam Covered i full Covered i full Covered i full Covered i full Routie Mammograms** Covered i full Covered i full Covered i full Covered i full Routie Prostate Specific Atige (PSA)*** Covered i full Covered i full Covered i full Covered i full Routie Colooscopy (age 50 ad above) Covered i full Covered i Full Covered i Full 30% after deductible Well Child Immuizatios Covered i full Covered i full Covered i full Covered i full *Routie visio ad hearig exams limited to oce every 24 moths. **Oe baselie screeig betwee ages Oe aual screeig age 40 ad over. ***Age 40 ad older oe exam every caledar year. 08

13 Coverage (Beefit period is oe caledar year) BlueEdge HCA Traditioal Idemity** (over 65 Retirees Oly) BlueChoice Network Out-of-Network No Network Caledar Year Deductible Idividual/Family $1,500/$3,000 $2,500/$5,000 Your deductible is reduced by your HCA fud amout Noe Out-of-Pocket Maximum Idividual/Family $3,000/$6,000 Icludes deductible amouts $6,000/$12,000 Icludes deductible amouts $3,000/ $6,000 Health Care Accout Fud $500 Idividual $1,000 Family (see BlueEdge HCA sectio) Not Applicable Lifetime Health Care maximum (per perso) Ulimited Ulimited PHYSICIAN SERVICES The amouts show below are what you are resposible for payig for each type of service or treatmet. Office visit & related routie services / cosultatio / secod opiio 15% after deductible 35% after deductible 20% Physical, Occupatioal, Speech, ad Chiropractic Therapies (60 visit maximum combied for all therapies) 15% after deductible 35% after deductible 20% Allergy Ijectios 15% after deductible 35% after deductible 20% Allergy Testig 15% after deductible 35% after deductible 20% Allergy Serum 15% after deductible 35% after deductible 20% Ipatiet Physicia Services 15% after deductible 35% after deductible 20% Outpatiet Physicia Services / o-routie office services 15% after deductible 35% after deductible 20% Lab & X-ray (Physicia Office) 15% after deductible 35% after deductible 20% PREVENTIVE CARE SERVICES The amouts show below are what you are resposible for payig for each type of service or treatmet. Routie Exam 100% Adult Immuizatios Well Child Exams Routie Eye Exam* (does ot iclude hardware) Routie Hearig Exam* (does ot iclude hardware/hearig aids) Covered i full for the first $250, the subject to deductible ad coisurace. The first $250 (covered i full) is ot couted agaist the HCA Fud. 100% 100% 100% 100% Routie Ob/Gy Exam 100% Routie Mammograms** Covered i full Covered i full 100% Routie Prostate Specific Atige (PSA)*** 15%, o deductible 35%, o deductible 100% Routie Colooscopy (age 50 ad above) 15% after deductible 35% after deductible 80% Well Child Immuizatios Covered i full Covered i full 100% ** Medicare Part A ad Part B coverage is required. 09

14 Coverage (Beefit period is oe caledar year) BlueLics HMO BlueOptios PPO HOSPITAL SERVICES The amouts show below are what you are resposible for payig for each type of service or treatmet. HMO Network Oly BluePreferred Network BlueChoice Network Out-of-Network Ipatiet Hospital Outpatiet Surgery Emergecy Room Subject to deductible ad $250 copay per admissio Subject to deductible ad $100 copay per surgery Subject to deductible ad $100 copay per visit copay waived if admitted 20% after $100 copay ad deductible Urget Care Facility $50 copay Exteded Care Ipatiet/Home Skilled Nursig Facility Subject to deductible ad $250 copay per admissio Skilled Nursig Facility Maximum No limit 90 visits per caledar year, combied i- ad out-of-etwork Subject to deductible the Home Health covered i full Home Health Maximum No limit 120 days per caledar year, combied i- ad out-of-etwork Subject to deductible the Private Duty Nursig covered i full Private Duty Nursig Maximum No limit 70 visits per caledar year, combied i- ad out-of-etwork Hospice - Ipatiet (o beefit limit) Subject to deductible plus $250 copay Hospice - Outpatiet (o beefit limit) Subject to deductible the covered i full MATERNITY & FAMILY PLANNING The amouts show below are what you are resposible for payig for each type of service or treatmet. Preatal & Postatal visits $35 copay for iitial visit the o charge $20 copay/$30 copay for specialist for iitial visit; all other services 20% after deductible $25 copay/$35 copay for specialist for iitial visit; all other services 20% after deductible 30% after deductible Ipatiet Hospital Subject to deductible ad $250 per admissio Ifertility Testig & Treatmet (Ifertility coverage provided for diagosis ad treatmet of uderlyig cause oly.) Covered with applicable copay $20 copay per visit ($30 copay for specialist) $25 copay per visit ($35 for specialist) 30% after deductible Volutary Sterilizatio (Reversal of sterilizatio is ot covered.) Pregacy Termiatio (therapeutic & o-therapeutic) Subject to deductible ad applicable copay Subject to deductible ad applicable copay Cotraceptive Devices Covered with applicable copay Covered with applicable copay Covered with applicable copay 30% after deductible 10

15 Coverage (Beefit period is oe caledar year) BlueEdge HCA Traditioal Idemity** (over 65 Retirees Oly) BlueChoice Network Out-of-Network No Network HOSPITAL SERVICES The amouts show below are what you are resposible for payig for each type of service or treatmet. Ipatiet Hospital 15% after deductible 35% after deductible 20% Outpatiet Surgery 15% after deductible 35% after deductible 20% Emergecy Room 15% after deductible 20% Urget Care Facility 15% after deductible 35% after deductible 20% Exteded Care Ipatiet/Home Skilled Nursig Facility 15% after deductible 35% after deductible 20% Skilled Nursig Facility Maximum 90 visits per caledar year, combied i- ad out-of-etwork 90 visits per caledar year Home Health 15% after deductible 35% after deductible 20% Home Health Maximum 120 days per caledar year, combied i- ad out-of-etwork 120 visits per caledar year Private Duty Nursig 15% after deductible 35% after deductible 20% Private Duty Nursig Maximum 70 visits per caledar year, combied i- ad out-of-etwork 70 visits per caledar year Hospice - Ipatiet (o beefit limit) 15% after deductible 35% after deductible 20% Hospice - Outpatiet (o beefit limit) 15% after deductible 35% after deductible 20% MATERNITY & FAMILY PLANNING The amouts show below are what you are resposible for payig for each type of service or treatmet. Preatal & Postatal visits 15% after deductible 35% after deductible 20% Ipatiet Hospital 15% after deductible 35% after deductible 20% Ifertility Testig & Treatmet (Ifertility coverage provided for diagosis ad treatmet of uderlyig cause oly.) 15% after deductible 35% after deductible 20% Volutary Sterilizatio (Reversal of sterilizatio is ot covered.) 15% after deductible 35% after deductible 20% Pregacy Termiatio (therapeutic & o-therapeutic) 15% after deductible 35% after deductible 20% Cotraceptive Devices 15% after deductible 35% after deductible 20% ** Medicare Part A ad Part B coverage is required. 11

16 Coverage (Beefit period is oe caledar year) BlueLics HMO BlueOptios PPO HMO Network Oly BluePreferred Network BlueChoice Network Out-of-Network MENTAL HEALTH The amouts show below are what you are resposible for payig for each type of service or treatmet. Ipatiet Hospital/Facility Subject to deductible ad $250 copay per admissio Outpatiet Charges $35 copay $30 copay $35 copay 30% after deductible SUBSTANCE ABUSE The amouts show below are what you are resposible for payig for each type of service or treatmet. Ipatiet Hospital/Facility Subject to deductible ad $250 copay per admissio Outpatiet Charges $35 copay $30 copay $35 copay 30% after deductible PRESCRIPTIONS The amouts show below are what you are resposible for payig for each type of service or treatmet. Retail Pharmacy Care Geeric (Tier I)/Preferred Brad (Tier II)/No-Preferred Bad (Tier III) (30 day supply with oe copay or day supply with two copays) $10/$30/$60 $10/$30/$60 $10/$30/$60 Mail Order RX Geeric (Tier I)/Preferred Brad (Tier II)/No-Preferred Bad (Tier III) (90 day supply) Specialty Pharmacy Medicatios (limited to 30 day supply) Covered Covered Prescriptio Tobacco Cessatio Products Covered Covered Oral Cotraceptives Covered Covered Sexual Dysfuctio Drugs (limited to eight doses per 30 days - o mail order) Not covered Covered Diabetic Supplies Most Diabetic Supplies ca be covered uder medical beefits (applicable deductible ad coisurace would apply) or uder pharmacy beefit (applicable Covered Covered copays will apply). Step Therapy For listig of drugs that apply to Step Therapy, please see Formulary at bcbsok.com/ou. Pre-Authorizatio For listig of drugs that require Pre-Authorizatio, please see Formulary at bcbsok.com/ou. 30% after $10/$30/$60 $20/$60/$120 $20/$60/$120 $20/$60/$120 Not covered Applies Applies OTHER SERVICES & SUPPLIES The amouts show below are what you are resposible for payig for each type of service or treatmet. Applies Applies MRI, CT, PET, EEG, ad other similar imagig tests Subject to deductible ad $100 copay per occurrece Diagostic Lab & X-ray Covered i full Covered i full Covered i full 30% after deductible Tobacco Cessatio Beefit (o-rx) 100% member reimbursemet for over-thecouter medicatios, acupucture, hyposis, stop smokig aids, etc., to a maximum of 20 visits/services per caledar year (per perso) Bariatric/Weight Loss Surgery Durable Medical Equipmet Applies Covered (subject to BCBSOK medical policy criteria) Subject to deductible the covered i full Applies Not covered Ambulace (Groud/Air) Covered i full Covered i full Routie Audiological Exam $25 copay $30 copay $35 copay 30% after deductible Routie Audiological Exam for childre up to age 18 icludig routie diagostic audiological exam/evaluatio ad hearig aids, limited to 2 every 24 moths. For childre up to age 2, coverage icludes 4 additioal molds per years. 12

17 Coverage (Beefit period is oe caledar year) BlueEdge HCA Traditioal Idemity** (over 65 Retirees Oly) MENTAL HEALTH The amouts show below are what you are resposible for payig for each type of service or treatmet. BlueChoice Network Out-of-Network No Network Ipatiet Hospital/Facility 15% after deductible 35% after deductible 20% Outpatiet Charges 15% after deductible 35% after deductible 20% SUBSTANCE ABUSE The amouts show below are what you are resposible for payig for each type of service or treatmet. Ipatiet Hospital/Facility 15% after deductible 35% after deductible 20% Outpatiet Charges 15% after deductible 35% after deductible 20% PRESCRIPTIONS The amouts show below are what you are resposible for payig for each type of service or treatmet. Retail Pharmacy Care Geeric (Tier I)/Preferred Brad (Tier II)/No-Preferred Bad (Tier III) (30 day supply with oe copay or day supply with two copays) Mail Order RX Geeric (Tier I)/Preferred Brad (Tier II)/No-Preferred Bad (Tier III) (90 day supply) $15/$25/$40 after deductible $30/$50/$80 after deductible $30/$50/$80 after deductible Not covered $8/$35/50% ($100 miimum; $200 maximum) $16/$70/50% ($100 miimum; $200 maximum) out-of-etwork ot covered Specialty Pharmacy Medicatios (limited to 30 day supply) Covered Covered Prescriptio Tobacco Cessatio Products Covered Covered Oral Cotraceptives Covered Covered Sexual Dysfuctio Drugs (limited to eight doses per 30 days - o mail order) Covered Not covered Diabetic Supplies Most Diabetic Supplies ca be covered uder medical beefits (applicable deductible ad coisurace would apply) or uder pharmacy beefit (applicable copays will apply). Covered Covered* Step Therapy For listig of drugs that apply to Step Therapy, please see Formulary at bcbsok.com/ou. Pre-Authorizatio For listig of drugs that require Pre-Authorizatio, please see Formulary at bcbsok.com/ou. Applies Applies OTHER SERVICES & SUPPLIES The amouts show below are what you are resposible for payig for each type of service or treatmet. MRI, CT, PET, EEG, ad other similar imagig tests 15% after deductible 35% after deductible 20% Diagostic Lab & X-ray 15% after deductible 35% after deductible 20% Tobacco Cessatio Beefit (o-rx) 100% member reimbursemet for over-thecouter medicatios, acupucture, hyposis, stop smokig aids, etc., to a maximum of 20 visits/services per caledar year (per perso) Applies Applies Applies Applies Applies Bariatric/Weight Loss Surgery Not covered Not covered Durable Medical Equipmet 15% after deductible 35% after deductible 20% Ambulace (Groud/Air) 15% after deductible 20% Routie Audiological Exam 15% after deductible 35% after deductible 20% * Covered (syriges, eedles, alcohol swabs). Diabetic maagemet supplies (isuli, isuli pump, etc.) must be covered by Medicare Part B Not covered 13

18 14 What s Not Covered Your pla optios do ot cover all health care expeses, ad iclude exclusios ad limitatios. You should refer to plaspecific documets to determie which health care services are covered ad to what extet. The followig is a partial list of services ad supplies that are geerally ot covered. However, your pla documets may cotai exceptios to this list based o state madates, the pla desig or rider(s) purchased. Visit the Beefits sectio of the OU HR website for pla-specific iformatio at hr.ou.edu Services that BCBSOK determies are experimetal/ ivestigatioal i ature Ay coditio to the extet paymet would have bee made uder Medicare if the member had applied for Medicare ad claimed Medicare beefits ID Cards You should preset your ID card whe visitig a physicia s office or hospital, ad verify that they have the correct isurace iformatio o file for you. Your card will resemble the card below, ad will be customized with your ame ad pla iformatio. Additioal cards ca be ordered through BCBSOK customer service or by loggig i to the Blue Access for Members SM (BAM) website at bcbsok.com/ou. Subscriber: Joh Q. Sample Idetificatio Number: ABC Group Number Effective Date Beefit Network The Uiversity of Oklahoma Office Visit Copay: Specialist Copay: Rx Copay: Pla Name Diagosis, treatmet or medicatios for ifertility ad fertilizatio procedures, icludig artificial isemiatio; ovulatio iductio procedures; i vitro fertilizatio; embryo trasfer. (Coverage for ifertility is limited to diagosis ad treatmet of uderlyig cause.) Cosmetic surgery or complicatios resultig there from, icludig surgery to improve or restore your appearace Reverse sterilizatio Customer Service Preauthorizatio Provider Locator 24/7 Nurselie RX Tech Support RX Cust Svc* XXX-XXXX XXX-XXXX XXX-XXXX XXX-XXXX XXX-XXXX XXX-XXXX Treatmet of sexual problems ot caused by orgaic disease L13 Foot care oly to improve comfort or appearace, such as care for flat feet, subluxatio, cors, buios (except capsular ad boe surgery), calluses, toeails, etc. Acupucture, whether for medical or aesthesia purposes except for services i relatio to tobacco cessatio. Massage Therapy If you ever lose or misplace your ID card, you ca prit a temporary ID card ad order a replacemet card by loggig i to Blue Access for Members (BAM) at bcbsok.com/ou.

19 15 Experiece. Welless. Everywhere. Biometric screeigs will cotiue to be available to all OU employees i Please watch your ad employee bulleti boards for more iformatio o dates ad locatios. I additio to the cofidetial Health Risk Assessmet o the Persoal Health Maager (located o Blue Access for Members at bcbsok.com/ou), a biometric screeig provides a detailed assessmet of your basic health idicators, icludig blood pressure, body mass idex (calculated from height ad weight), cholesterol (HDL ad LDL) ad blood glucose. This screeig will give you a awareess of potetial health coditios. Blue Care Coectio Persoal Health Maager & Olie Resources Through the Blue Care Coectio program, you ll fid tools ad services that iform, support ad motivate you o your jourey to welless. Our olie health resources are available through Blue Access for Members (BAM) at bcbsok.com/ou, the select Persoal Health Maager. Set goals toward a healthier lifestyle, uderstad ad maage a health coditio, ad keep track of your health care. Iteractive tools ad extesive iformatio cover all aspects of health ad welless, icludig utritio, fitess, work-life balace, medical coditios ad more. Use the Persoal Health Maager to: Assess Your Health: Lear about your health status ad possible health risks by completig the cofidetial Health Risk Assessmet. After you complete ad submit your Health Risk Assessmet, you will immediately receive iformatio o your overall health status ad recommedatios for makig healthy chages. You may also receive olie messages or outreach phoe calls from Blue Care Advisors to help you take actio to reduce your health risks ad improve your health. Before startig the Health Risk Assessmet, it s helpful but ot essetial to kow your most recet: Height ad weight Blood pressure Total cholesterol level Ask A Professioal: Get health ad welless questios aswered by Blue Care Advisor urses ad other health care professioals via secure . Ask registered urses (Blue Care Advisors) your healthrelated questios with the Ask A Nurse feature. Request fitess ad weight loss advice from a team of persoal traiers with Ask A Traier. Ask registered dietitias for utritio advice with Ask A Dietitia. Receive help o maagig stress, workplace coflicts ad other similar issues with Ask A Life Coach. Track & Motivate Healthy Behaviors: Adopt healthier behaviors ad stay motivated usig the iteractive Get Fit, Eat Right ad Live Well tools i the For Your Health sectio. Fid iformatio o fitess, utritio ad lifestyle issues that ca be customized to meet your eeds. Plus, you ca keep track of your activities ad results olie to keep you motivated. Educate: Lear more about health coditios ad medical procedures to help you maage your care or prepare for diagostic testig or treatmets by searchig the health ecyclopedia. Maage Health Iformatio: Set up a persoal health record to keep track of ad maage your family s health iformatio withi oe secure locatio. Usig trackig tools, you ca also track your progress by eterig values such as cholesterol, blood pressure ad blood glucose levels, ad view a graph showig how you are doig over a time period. Reward Yourself with Blue Poits SM At Blue Cross ad Blue Shield of Oklahoma, we uderstad how hard it ca be to chage habits ad maitai a healthy lifestyle. That s why Blue Care Coectio builds i a reward program to keep you motivated ad support you alog the way. Every time you use the Persoal Health Maager to track a fitess workout, report a meal, ad participate i For Your Health iteractive programs, you automatically ear Blue Poits. Redeem your Blue Poits for health-related products at the Blue Poits Redemptio Ceter, accessed through the Persoal Health Maager. HDL cholesterol level Blood glucose level Please review the Blue Poits Program Rules listed o the Persoal Health Maager for complete iformatio o the program. Program rules are subject to chage without prior otice.

20 16 Weight Maagemet Support for a slimmer, healthier you The program offers guidace ad support through behavioral ad motivatioal coachig, persoalized goal settig with a actio pla, olie tools ad discouts to welless-related products ad services. To get started, go to the Persoal Health Maager available through Blue Access for Members at bcbsok.com/ou ad click the Weight Loss butto or call BCBSOK customer service. Fitess Program Joi a etwork of gyms Take advatage of a gym membership to a atiowide etwork of fitess ceters. To get started, go to the Persoal Health Maager available through Blue Access for Members at bcbsok.com/ou ad click o Fitess Program or call BCBSOK customer service. Tobacco Cessatio Support for tobacco users who wat to quit The program provides persoal coachig, olie tools ad discouts for welless-related products ad services. To participate, go to the Persoal Health Maager ad click the Stop Smokig butto or call BCBSOK customer service. There is also a tobacco cessatio beefit described o the pla compariso chart. 24/7 Nurselie Health cocers do t always follow a 9-to-5 schedule. Fortuately, you ca call the toll-free 24/7 Nurselie 24 hours a day, seve days a week to get the iformatio you eed whe you eed it. The 24/7 Nurselie is staffed by registered urses who ca aswer your geeral health questios, direct you to your doctor or ecourage you to seek emergecy services if ecessary. A urse ca help idetify optios ad provide iformatio to help you choose the appropriate care for your cocers. Plus, whe you call, you also have the optio to access a audio library of more tha 1,000 health topics. Call the 24/7 Nurselie toll free at (800) Special Begiigs Materity Program If you are expectig, this preatal program ca help guide you through your pregacy ad postpartum care. The program provides support ad educatio, pregacy risk assessmet ad ogoig attetio/moitorig. Erolled members receive frequet, persoal cotact from obstetrical urses who ca help them better uderstad ad maage their pregacies. Educatioal materials promote healthy behaviors, prevetive care, ad idetify warig sigs of complicatios. Topics also iclude utritio, fetal developmet ad ewbor care. Additioally, members ca call a 24-hour toll-free BabyLie staffed by materity urses. For more iformatio or to eroll i Special Begiigs, call (877) Blue Care Advisors If you have certai chroic health coditios or are at risk for medical complicatios, a Blue Care Advisor may cotact you to offer health couselig, coachig ad support. Workig with you through regularly scheduled telephoe calls, these registered urses ad other health care professioals ca help you lear to maage your coditio more successfully, idetify behaviors that may be barriers to better health, set goals for improvig your health ad help you adopt healthier habits. Case Maagers I the evet that you or a covered family member experieces multiple or complex medical problems, our case maagemet urses registered urses with specialized traiig ad cliical experiece ca work with you. At a time that s usually stressful, case maagers ca be your advocate by: Helpig to explai your medical problem(s) ad treatmet pla(s) Facilitatig commuicatio amog your may health care providers Coordiatig a treatmet pla(s) Explaiig your health care beefits ad how to get the most out of them Helpig you access the right resources ad services Assistig with trasitios from oe health care settig to aother

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