2021 Benefits Guide www.cityoftulsa.org/2021benefits - City of Tulsa
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2021 Benefits Guide www.cityoftulsa.org/2021benefits
Table of Contents
3 Eligibility & Enrollment
4 Medical Benefits
5 CareATC Benefits
Benefits in Hand
Directly access City of Tulsa’s 6 Benefits Value Advisors
benefits information with the
7 Where To Go For Care
Lockton BenefitLink mobile
app. You’ll find benefits contact 8 MDLive - Virtual Medicine
information, Lockton’s digital
Lifestyle Benefits newsletter 9 Health Savings Account
and more!
10 Flexible Spending Accounts
11 Dental Benefits
Username: cityoftulsa
Password: benefits 12 Vision Benefits
13 Survivor Benefits
14 Income Protection
15 Additional/Supplemental Benefits
16 Glossary
We all work together to make City of Tulsa 17 Required Notices
a success, and our teamwork extends
to your benefits. Your health and well- 19 Important Contacts
being are important to us. We provide
benefit options to make you and your
family’s lives better. Together, let’s invest
in you. Read over this guide for details on
your 2021 benefits from A to Z. If you have
questions, your Insurance Section is here
to help.
See page 17 for important information concerning Medicare Part D coverage.
In this Guide, we use the term company to refer to City of Tulsa. This Guide is intended to describe the eligibility requirements, enrollment procedures and coverage effective dates for
the benefits offered by the company. It is not a legal plan document and does not imply a guarantee of employment or a continuation of benefits. While this Guide is a tool to answer most
of your questions, full details of the plans are contained in the Summary Plan Descriptions (SPDs), which govern each plan’s operation. Whenever an interpretation of a plan benefit is
necessary, the actual plan documents will be used.
Eligibility & Enrollment
City of Tulsa offers a variety of benefits to Preparing For Open Enrollment
support you and your family’s needs. Choose You may select any combination of medical, dental and/or
options that cover what’s important to your vision plan coverage. For example, you could select medical
unique lifestyle. coverage for you and your entire family, but select dental
and vision coverage only for yourself. The only requirement
Eligibility is that you, as an eligible employee of City of Tulsa, must
If you are a full‑time employee of City of Tulsa who is elect coverage for yourself in order to elect any dependent
regularly scheduled to work at least 30 hours a week, you coverage.
are eligible to participate in the medical, dental, vision, life
and disability plans and additional benefits. Open Enrollment To-Do
When does coverage begin? Update your personal information.
You are eligible for Basic Life/AD&D on your date of hire. All You will need to verify or enter all your dependents
other elections are effective the first of the month following and beneficiaries into the system. Make sure you
30 days of employment. You won’t be able to change have all your dependents’ and beneficiaries’ full
your benefits until the next enrollment period unless you names, dates of birth and social security numbers.
experience a qualifying life event.
Don’t forget to assign your
Eligible Dependents beneficiary for the Life insurance.
Dependents eligible for coverage in the City of Tulsa benefits Your beneficiary is the person you designate to
plans include: receive your Life insurance benefits in the event
f Your legal spouse (same or opposite gender). of your death. This includes any benefits payable
under Basic and Supplemental Life offered by
f Children up to age 26 (includes birth children, City of Tulsa.
stepchildren, legally adopted children, children placed
for adoption, foster children and children for whom How to Enroll
legal guardianship has been awarded to you or
Go to https://compass.empyreanbenefits.com/COT
your spouse).
f Dependent children 26 or more years old, unmarried
and primarily supported by you and incapable of
self‑sustaining employment by reason of mental or
physical disability which arose while the child was
covered as a dependent under this plan (periodic
certification may be required).
Thoughts & Tips: You cannot
change your benefit selections during the
plan year unless you have a qualifying life
event, such as marriage and/or the birth
or adoption of a child.
3
Medical Benefits
Medical benefits are provided through Blue Cross Blue Shield of Oklahoma (BCBSOK) and CareATC.
Choose the plan option that works best for your life. Consider the physician networks, premiums
and out-of-pocket costs for each plan. Visit www.bcbsok.com or call Customer Service at
800-942-5837 for a current list of BCBSOK network providers.
BCBS WITH CAREATC BCBS WITH HSA
BLUE PREFERRED NETWORK BLUE PREFERRED NETWORK
(INCLUDES HILLCREST, ST. FRANCIS, (INCLUDES HILLCREST, ST. FRANCIS,
ST. JOHN & OSU MEDICAL CENTER) ST. JOHN & OSU MEDICAL CENTER)
BIWEEKLY CONTRIBUTIONS
EMPLOYEE ONLY $6.56 $40.35
EMPLOYEE + SPOUSE $65.70 $102.60
EMPLOYEE + CHILD(REN) $34.17 $70.28
EMPLOYEE + FAMILY $94.33 $133.56
IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK
CALENDAR YEAR DEDUCTIBLE
INDIVIDUAL $3,000 $4,500 $3,000 $4,500
FAMILY $6,000 $9,000 $6,000 $9,000
COINSURANCE (PLAN PAYS) 80% after deductible 60% after deductible 80% after deductible 60% after deductible
CALENDAR YEAR OUT OF POCKET MAXIMUM (INCLUDES DEDUCTIBLE)
INDIVIDUAL $5,000 $8,000 $5,000 $8,000
FAMILY $10,000 $14,000 $10,000 $14,000
COINSURANCE
PREVENTIVE CARE 100%; no deductible 70% after deductible 100%; no deductible 70% after deductible
MDLIVE VIRTUAL VISITS 100%; no deductible Not available 100% after deductible Not available
OFFICE VISITS 80% after deductible 60% after deductible 80% after deductible 60% after deductible
URGENT CARE 80% after deductible 60% after deductible 80% after deductible 60% after deductible
EMERGENCY ROOM 80% after deductible 80% after deductible 80% after deductible 80% after deductible
ALL OTHER COVERED SERVICES 80% after deductible 60% after deductible 80% after deductible 60% after deductible
PRESCRIPTION DRUGS
RETAIL OR MAIL ORDER 80%; no deductible 60%; no deductible 80% after deductible 60% after deductible
IMPORTANT: Deductible applies to all services with the exception of CareATC, preventive visits and preventive prescription drugs.
NOTE: The BCBS with HSA medical plan pays 100% of certain preventive drugs. For a list of preventive drugs covered at 100%, visit
www.bcbsok.com or call the number on the back of your ID Card.
The individual deductible amount must be met by each member enrolled under your medical coverage. If you have several
covered dependents, all charges used to apply toward a “per individual” deductible amount will also be applied toward the “per
family” deductible amount. When the family deductible amount is reached, no further individual deductibles will have to be met
for the remainder of that plan year. No member may contribute more than the individual deductible amount to the “per family”
deductible amount. The same typically applies for the out‑of‑pocket maximum.
4
CareATC Benefits
CareATC Clinic Highlights
Types of Visits: Unlimited Appointments
f Sick Visits Includes eligible spouses and dependents (ages 2+).
f Allergies
Extended Appointments
f Asthma No rushing in or out.
f Headaches
FREE Prescriptions Included
f Annual Exams
Generic medications (those carried in clinics).
f Well Woman Exams
f Pap Smears Other Services:
f STD Testing/Screening f On-Site X-rays
f Chronic Disease Management f Most Laboratory Testing
w High Blood Pressure FREE Personal Health Assessment (PHA)
w High Cholesterol A PHA is a complete health screening tool to identify your
risk factors such as high blood pressure, high cholesterol,
w Diabetes diabetes, obesity, and much more.
f Minor Injuries Whether you have the HSA Option or CareATC option, you
f Sports Physicals can schedule a Personal Health Assessment at no out-of-
pocket cost to you.
Three Easy Ways to Schedule an Appointment
with CareATC:
1. Call
800-993-8244
2. Go online
Visit patients.careatc.com to log in to your account.
You can schedule an appointment online and also
view your medical records!
3. Mobile App
Download the CareATC app. Log in to your account
to schedule an appointment. Also view your
medical records!
Some same-day appointments available – please call
ahead to check availability.
Please be aware that CareATC is NOT a walk-in clinic.
5
Benefits Value Advisors
Healthcare Cost Transparency Rising Costs of Healthcare
With options like the HSA medical plans and Flexible Spending The cost of healthcare in the U.S. has been steadily growing
Accounts, your healthcare spending is in your control. But with each year. Why? Some of the factors include an aging
so many providers and varying costs for services, how do you population, increased demand for care (resulting in higher
decide where to go? A Benefits Value Advisor (BVA) is available prices for premiums and prescription drugs) and an increase
through your BCBSOK medical plan. A BVA is like a tour guide, in chronic illnesses. The City of Tulsa wants to help
helping to point you in the right direction. You’ll get guidance keep you healthy, so we do what we can to keep your
for benefits such as medical, dental, pharmacy and other healthcare costs reasonable. Make sure you’re informed
available coverage so you only need one call to get support. about your options so you can make the best healthcare
BVAs can also help you: choices for you and your family. Placing an importance on
preventive care, making healthy choices, and managing
f Maximize your benefits costs will help keep your health — and wallet — in control in
f Get cost estimates for various providers the long run.
and procedures
f Help to schedule appointments
f Assist with referrals to clinical staff/programs
f Help with preauthorization
Get the most from your benefits - call Benefits Value
Advisors at 800-942-5837.
Thoughts & Tips: The costs
of an MRI can be between $300 and
$3,000 approximately - even within
your area.
6
Where To Go For Care
You think you may be sick, but your primary care physician is booked through the end of the
month. You have a question about the side effects of a new medication, but the pharmacy is
closed. Instead of immediately choosing an expensive trip to the emergency room or relying on
questionable information from the internet, take a look below at various care centers and resources
and the types of care they provide.
PRIMARY NURSE LINE VIRTUAL
CARE CENTER VISITS
When would I use this? When would I use this? When would I use this?
You need routine care or treatment for a current You need a quick answer to a health issue that You need care for minor illnesses and ailments, but
health issue. Your primary doctor knows you does not require immediate medical treatment would prefer not to leave home. These services are
and your health history, can access your medical or a physician visit. available by phone and online (via webcam).
records, provide routine care, and manage your
What type of care would they What type of care would they provide?*
medications.
provide?* f Cold & flu symptoms
What type of care would they Answers to questions regarding: f Allergies
provide?* f Symptoms f Bronchitis
f Routine checkups f Medications and side effects f Urinary tract infection
f Immunizations f Self‑care home treatments f Sinus problems
f Preventive services f When to seek care What are the costs and time
f Manage your general health
What are the costs and time considerations?**
What are the costs and time considerations?** f If you are enrolled in the CareATC medical
considerations?** f Nurse lines are available 24 hours a day, option, this service is covered at 100%. If you
f Often requires a copay and/or coinsurance 7 days a week. are enrolled in the HSA medical option, it will
f Normally requires an appointment f This service is usually free as part of your be covered at 100% after the deductible.
f Usually little wait time with scheduled medical insurance. f Access to care is usually immediate.
appointment f Some states may not allow for prescriptions
through telemedicine or virtual visits.
DO YOUR
HOMEWORK
What may seem like an urgent
URGENT CARE care center could actually be EMERGENCY
CENTER a standalone ER. These newer ROOM
facilities come with a higher
price tag, so ask for clarification
if the word "emergency"
appears in the company name.
When would I use this? When would I use this?
You need care quickly, but it is You need immediate treatment for
not a true emergency. Urgent a serious life‑threatening condition.
care centers offer treatment for If a situation seems life threatening,
What are the costs and
non‑life‑threatening injuries or call 911 or your local emergency
time considerations?** What are the costs and
illnesses. number right away.
f Often requires a copay time considerations?**
What type of care would and/or coinsurance that f Often requires a much What type of care would
they provide?* is usually higher than an higher copay and/or they provide?*
f Strains, sprains office visit. coinsurance. f Heavy bleeding
f Minor broken bones f Walk‑in patients welcome, f Open 24/7, but waiting f Chest pain
(e.g., finger) but waiting periods may periods may be longer f Major burns
f Minor infections be longer as patients with because patients with f Spinal injuries
f Minor burns more urgent needs will be life‑threatening emergencies f Severe head injury
f X‑rays treated first. will be treated first. f Broken bones
*This is a sample list of services and may not be all‑inclusive. **Costs and time information represent averages only and are not tied to a specific condition or treatment.
7
MDLive - Virtual Medicine
When you’re sick, the last thing you want to do is leave the cozy comfort of your home.
Or sometimes you’re just too on the go to pop in for a visit. BCBSOK MDLive virtual medicine is a
convenient and easy way to talk to a doctor fast.
Virtual Visits
A virtual visit with MDLive lets you see and talk to a doctor from your phone, tablet or computer without an appointment.
Most visits take about 10‑15 minutes, and doctors can write a prescription (in participating states). Try a virtual visit when your
doctor is not available or you’re traveling.
Doctors can diagnose and treat a wide range of non‑emergency medical conditions, including:
f Allergies f Pink eye f Ear problems (age 12+)
f Asthma f Rash f Nausea
f Cold/flu f Sinus problems f Fever (age 3+)
Behavioral Health
Speak with a licensed counselor, therapist or psychiatrist for support with virtual visits, available by appointment. You can
choose who you want to work with for issues such as anxiety, depression, trauma and loss or relationship problems.
Access Virtual Visits
Visit www.mdlive.com/bcbsok to request a virtual visit. Once you register and request a consult, you will pay your portion
of the service costs according to your medical plan, and then enter a virtual waiting room. During your visit you can talk to
a doctor about your health concerns, symptoms and treatment options.
In order to take advantage of this benefit, activate your account now, before
you need care, so you can schedule a virtual visit immediately at your
time of need. Call MDLIVE at 888-970-4081.
Virtual visits aren’t good for conditions requiring an exam or test,
complex or chronic problems, or emergencies, including
sprains or broken bones.
8
Health Savings Account
An HSA is a personal healthcare bank account How to Enroll
used to pay for qualified health expenses, To enroll in the City of Tulsa‑sponsored HSA, you must elect
funded by you and the City of Tulsa. HSA the HSA option. Complete all HSA enrollment materials and
contributions and withdrawals for qualified designate the amount to contribute on a pre‑tax basis. City
healthcare expenses are tax-free. You must be of Tulsa will establish an HSA account in your name and
enrolled in the HSA Option to participate. send in your contribution once bank account information
has been provided and verified.
Your HSA can be used for qualified expenses for you, your
spouse and/or tax dependent(s), even if they are not Plan. Spend. Save.
covered by your plan.
Contributions to an HSA can be made through payroll
HealthEquity will issue you a debit card, giving you direct deduction on a pre‑tax basis when you open an account
access to your account balance. Use your debit card to with HealthEquity. The money in this account (including
pay for qualified medical expenses, with no need to submit interest and investment earnings) grows tax‑free. When
receipts for reimbursement. You must have a balance in the funds are used for qualified medical expenses, they are
your HSA account to use the card. spent tax‑free.
Eligible expenses include doctors’ visits, eye exams, HSA Funding Limits
prescription expenses, laser eye surgery and more. Check The IRS places an annual limit on the maximum amount
out IRS Publication 502 on www.irs.gov for a complete list that can be contributed to HSAs. For 2021, contributions
of eligible expenses. (which includes City of Tulsa’s contribution) are limited to
the following:
Eligibility
You are eligible to contribute to an HSA if: HSA FUNDING LIMITS
EMPLOYEE $3,600
f You are enrolled in an HSA‑eligible High FAMILY $7,200
Deductible Health Plan — City of Tulsa’s HSA
CATCH ‑UP CONTRIBUTION
medical option qualifies. $1,000
(AGES 55+)
f You are not covered by your spouse’s non‑HDHP If you are enrolling in the HSA medical option, City of Tulsa
health plan. will contribute an annual HSA contribution of $1,500. New
f Your spouse does not have a healthcare Flexible hires will receive City of Tulsa’s HSA contribution on a
Spending Account or Health Reimbursement Account. pro-rated basis according to the employee’s date of hire.
f You are not eligible to be claimed as a dependent on EMPLOYER HSA CONTRIBUTION
someone else’s tax return. EMPLOYEE $1,500
f You are not enrolled in Medicare or TRICARE. FAMILY $1,500
f You have not received Department of Veterans
Affairs medical benefits in the past 90 days for
non‑service‑related care. (Service‑related care will
not be taken into consideration.)
9
Flexible Spending Accounts
Flex your spending power! A Flexible Spending This account covers dependent day care expenses that
Account (FSA) is a special tax-free account you are necessary for you and your spouse to work or attend
put money into to pay for certain out-of-pocket school full time. Examples of eligible dependent care
expenses. expenses include:
f In‑Home Baby‑Sitting Services (not provided by a
Healthcare Flexible Spending Account tax dependent)
You can contribute up to $2,750 annually for qualified
f Care of a Preschool Child by a Licensed Nursery or Day
medical expenses (deductibles, copays and coinsurance)
Care Provider
with pre‑tax dollars, reducing your taxable income and
increasing your take‑home pay. You can even pay for f Before‑ and After‑School Care
eligible expenses with an FSA debit card at the same time f Day Camp
you receive them without waiting for reimbursement.
f In‑House Dependent Day Care
Limited Use Flexible Spending Account
A Limited Use Flexible Spending Account (LUFSA) works
alongside a Health Savings Account (HSA) and allows for
reimbursement of eligible dental and vision expenses. You
must decide how much to set aside for this account. You
may contribute up to $2,750.
Dependent Care
Flexible Spending Account
In addition to the Healthcare FSA, you may opt to participate in
the Dependent Care FSA — whether or not you elect any other
benefits. You can set aside pre‑tax funds into a Dependent
Care FSA for expenses associated with caring for elderly or child
dependents. Unlike the Healthcare FSA, reimbursement from
your Dependent Care FSA is limited to the total amount that is
deposited in your account at that time.
General Rules and Restrictions
f With the Dependent Care FSA, you can set aside up
to $5,000 to pay for child or elder care expenses on a The IRS has the following rules and restrictions for
pre‑tax basis. Healthcare and Dependent Care FSAs:
f Eligible dependents include children under 13 and a f Expenses must be incurred during the 2021 plan year.
spouse or other individual who is physically or mentally f Dollars cannot be transferred between FSAs.
incapable of self‑care and has the principal place of
residence as the employee for more than half the year f You cannot participate in a Dependent Care FSA and
may be a qualifying individual. claim a dependent care tax deduction at the same time.
f Expenses are reimbursable if the provider is not f You must “use it or lose it” — any unused funds will
your dependent. be forfeited.
f You must provide the tax identification number or f Up to $550 may be rolled over to the next plan year at
Social Security number of the party providing care to the end of 2021 for Healthcare FSAs.
be reimbursed. f You cannot change your FSA election in the middle of the
plan year unless you experience a qualifying life event.
10Dental Benefits
Brushing your teeth and flossing are great, but don’t forget to visit the dentist too! City of Tulsa offers
affordable plan options for routine care and beyond. Coverage is available from Blue Cross Blue
Shield of Oklahoma.
Network Dentists
The member’s share of the cost is determined by care being received from a contracting or non-contracting provider. When
you go see a contracting provider, your out-of-pocket cost will generally be the least amount because BlueCare Providers
have contracted to accept a lower Allowable Amount as payment in full for Eligible Dental Expenses. You are not required to
file claim forms and you are not balance billed for costs exceeding the BCBSOK Allowable Amount for BlueCare Dentists.
If you use a dentist who doesn’t participate in your plan’s network, your out-of-pocket costs will be higher, and you are subject
to any charges beyond the Reasonable and Customary (R&C).
To find a network dentist, visit Blue Cross Blue Shield of Oklahoma at www.bcbsok.com (BlueCare Dental network).
Dental Premiums Dental Plan Summary
Premium contributions for dental are deducted from This chart summarizes the 2021 dental coverage provided by
your paycheck on a pre-tax basis. Your tier of coverage Blue Cross Blue Shield of Oklahoma.
determines your biweekly premium.
DENTAL DENTAL DENTAL
LOW PLAN MEDIUM PLAN HIGH PLAN
BIWEEKLY CONTRIBUTIONS
EMPLOYEE ONLY $10.15 $13.91 $20.22
EMPLOYEE + FAMILY $29.01 $40.13 $58.26
IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK
CALENDAR YEAR DEDUCTIBLE
INDIVIDUAL $0 $0 $25 $25 $50 $50
FAMILY $0 $0 $75 $75 $150 $150
CALENDAR YEAR MAXIMUM
PER PARTICIPANT $750 $750 $1,000 $1,000 $2,500 $2,500
COINSURANCE
DIAGNOSTIC & PREVENTIVE (DEDUCTIBLE WAIVED) 100% 100% 100% 100% 100% 100%
BASIC RESTORATIVE DENTAL SERVICES, 80% after 80% after 80% after 80% after 90% after 90% after
NON-SURGICAL EXTRACTIONS, NON-SURGICAL deductible deductible deductible deductible deductible deductible
PERIODONTAL SERVICES, ORAL SURGERY SERVICES
80% after 80% after 90% after 90% after
SURGICAL PERIODONTAL SERVICES 0% 0% deductible deductible deductible deductible
MAJOR RESTORATIVE SERVICES, PROSTHODONTIC 50% after 50% after 60% after 60% after
SERVICES, MISCELLANEOUS RESTORATIVE AND 0% 0% deductible deductible deductible deductible
PROSTHODONTIC SERVICES
"ORTHODONTICS (DEDUCTIBLE WAIVED) Not Covered Not Covered Not Covered Not Covered 50% 50%
(ADULTS & CHILDREN)"
ORTHODONTICS LIFETIME MAXIMUM
PER PARTICIPANT N/A N/A N/A N/A $2,000 $2,000
Thoughts & Tips: Only 60% of adults ages 20 to 64 have been to the dentist
in the past year. Take advantage of your dental coverage to keep your smile healthy.
11Vision Benefits
Don’t wear glasses? Even you shouldn’t skip an annual eye exam! City of Tulsa provides you
and your family access to quality vision care with a comprehensive vision benefit through
Blue Cross Blue Shield of Oklahoma. Vision Network: EyeMed’s Select Network.
Vision Premiums Vision Plan Summary
Premium contributions for vision are deducted from This chart summarizes the 2021 vision coverage provided by
your paycheck on a pre-tax basis. Your tier of coverage Blue Cross Blue Shield of Oklahoma.
determines your biweekly premium.
VISION 2 YEARS LOW VISION 2 YEARS HIGH VISION ANNUAL LOW VISION ANNUAL HIGH
BIWEEKLY CONTRIBUTIONS
EMPLOYEE ONLY $2.39 $2.90 $3.37 $4.45
EMPLOYEE + FAMILY $5.59 $6.80 $7.92 $9.85
IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK IN-NETWORK OUT-OF-NETWORK
MEMBER COST REIMBURSEMENT MEMBER COST REIMBURSEMENT MEMBER COST REIMBURSEMENT MEMBER COST REIMBURSEMENT
EYE EXAM
COPAY $20 copay $45 $10 copay $45 $10 copay $45 $5 copay $45
FREQUENCY
EXAMINATION Once every 12 months Once every 12 months Once every 12 months Once every 12 months
LENSES OR CONTACTS Once every 12 months Once every 12 months Once every 12 months Once every 12 months
FRAMES Once every 24 months Once every 24 months Once every 12 months Once every 12 months
LENSES
SINGLE VISION $20 copay $30 $25 copay $30 $25 copay $30 $10 copay $30
BIFOCAL $20 copay $50 $25 copay $50 $25 copay $50 $10 copay $50
TRIFOCAL $20 copay $65 $25 copay $65 $25 copay $65 $10 copay $65
LENTICULAR $20 copay $100 $25 copay $100 $25 copay $100 $10 copay $100
CONTACTS (IN LIEU OF LENSES AND FRAMES)
$0 copay, $0 copay, $0 copay, $0 copay,
CONVENTIONAL $80 $105 $105 $105
$100 allowance $130 allowance $130 allowance $150 allowance
$0 copay, $0 copay, $0 copay, $0 copay,
DISPOSABLE $80 $105 $105 $105
$100 allowance $130 allowance $130 allowance $150 allowance
FRAMES
$0 copay, $0 copay, $0 copay, $0 copay,
COPAY/ALLOWANCE $55 $70 $70 $70
$100 allowance $130 allowance $130 allowance $150 allowance
FRAMES
15% off 15% off 15% off 15% off
LASIK N/A N/A N/A N/A
Retail Price Retail Price Retail Price Retail Price
Thoughts & Tips: More than 150 million Americans
use corrective eyewear to compensate for refractive errors.
12Survivor Benefits
It’s difficult to think about what would happen if something ever happened to you, but it’s important
to have a plan in place to make sure your family is provided for. Survivor benefits provide financial
protection and security in the event of an absence or unexpected event. Securing life insurance now
ensures your family will be protected for the future.
Basic Life and Accidental Death and Dismemberment (AD&D) Insurance
For your peace of mind and the financial protection of your family, City of Tulsa provides you with a company-paid Basic
Life/AD&D insurance amount that equals two times your basic annual earnings, up to a maximum benefit of $500,000.
The benefit will be rounded to the next highest $1,000 and paid to your beneficiary in the event of your death. If you are a
full‑time employee, you automatically receive Life and AD&D insurance effective on your date of hire, even if you elect to
waive other coverage.
Supplemental Life and AD&D Insurance
Life and AD&D benefits are an important part of your family’s financial security. The basic benefits provided to you by City of
Tulsa may not be enough to cover expenses in a time of need. Therefore, extra coverage is available to protect you and your
family. Eligible employees may purchase additional Supplemental Life and AD&D insurance. Premiums are paid through
payroll deductions.
SUPPLEMENTAL EMPLOYEE LIFE/AD&D
COVERAGE AMOUNT Increments of $10,000
WHO PAYS Employee
MAXIMUM BENEFIT The lesser of 5 times basic annual earnings or $500,000
EVIDENCE OF INSURABILITY (EOI) REQUIRED Yes, when making elections greater than $200,000 or for any amount if a late entrant
SUPPLEMENTAL SPOUSE LIFE/AD&D
COVERAGE AMOUNT Increments of $5,000
WHO PAYS Employee
MAXIMUM BENEFIT The lesser of 50% of the employee’s covered supplemental benefit or $100,000
EVIDENCE OF INSURABILITY (EOI) REQUIRED Yes, required for any increase
SUPPLEMENTAL CHILD LIFE/AD&D
COVERAGE AMOUNT Increments of $1,000
WHO PAYS Employee
MAXIMUM BENEFIT $10,000
EVIDENCE OF INSURABILITY (EOI) REQUIRED Not Required
Note: Employee must be covered for Supplemental Life/AD&D to insure dependents. No eligible
person may be covered more than once under the Policy. If a person is covered as an Employee, he/
she cannot be covered as a Spouse or Dependent Child of another Employee. If both parents are
covered as insured Employees under the Policy, only one may enroll for life insurance coverage on
Dependent Children.
13Income Protection
Maintaining your quality of life counts on your income. City of Tulsa offers voluntary disability
coverage available for purchase through Blue Cross Blue Shield of Oklahoma to protect you
financially in the event you cannot work as a result of a debilitating injury. A portion of your income is
protected until you can return to work or until you reach retirement age.
Short Term Disability (STD) Insurance
Short Term Disability (STD) benefits are available for purchase on a voluntary basis. You have three different plan
options to choose from:
f 40% of your basic annual earnings to a maximum of $750 weekly
f 50% of your basic annual earnings to a maximum of $1,000 weekly
f 60% of your basic annual earnings to a maximum of $1,250 weekly
WEEKLY MINIMUM BENEFIT $25
ELIMINATION PERIOD 7 days for both injury and sickness
MAXIMUM BENEFIT PERIOD 26 weeks
Certain exclusions, along with pre‑existing condition limitations, may apply. See your plan document for details.
Long Term Disability (LTD) Insurance
Long Term Disability (LTD) benefits are available for purchase on a voluntary basis. You have three different plan
options to choose from:
f 40% of your basic annual earnings to a maximum of $10,000 monthly
f 50% of your basic annual earnings to a maximum of $10,000 monthly
f 60% of your basic annual earnings to a maximum of $10,000 monthly
MONTHLY MINIMUM BENEFIT $100
ELIMINATION PERIOD 180 days
Payments will last for as long as you are disabled
or until you reach your Social Security Normal
MAXIMUM BENEFIT PERIOD Retirement Age, whichever is sooner. However, if you
become disabled after age 60, benefits are payable
according to an age‑based schedule.
Evidence of Insurability is required if you do not elect LTD coverage when initially eligible. Benefit may be reduced by other
sources of income and disability earnings.
Certain exclusions, along with pre‑existing condition limitations, may apply. See your plan document for details.
14Additional/Supplemental Benefits
City of Tulsa cares about you and wants you to
succeed in all aspects of life, so we offer a variety
of additional benefits to help make your day-to-
day easier.
Hospital Indemnity* - Voya
This benefit provides payments for inpatient admissions,
each day of inpatient stay, inpatient rehabilitation
and family hotel if 50 miles from home. It also includes
a Wellness Benefit. This provides an annual benefit
payment if you complete a health screening test — you
and your covered spouse can get $50 to $100 depending
on the plan you select.
Accident* – Voya
A benefit that provides direct payment for non-work related
accidents. The amount paid depends on the type of injury
and care received. It also includes a Wellness Benefit. This
provides an annual benefit payment if you complete a
health screening test — $100 per adult and $50 per child. *Certain exclusions, along with pre‑existing condition
limitations, may apply. See your plan document for details.
Critical Illness* – Voya
This benefit provides a lump sum payment based on your
Travel Resource Services –
election from $5,000 to $30,000 for certain critical illnesses Blue Cross Blue Shield of Oklahoma
(heart attack, stroke, cancer, etc.). It also includes a Wellness Provides medical and travel assistance at no cost for you
Benefit. This provides an annual benefit payment if you and your family traveling for business or pleasure 100 or
complete a health screening test — $100 per adult and more miles from home (includes travel within United States).
$50 per child. Services include but are not limited to:
Legal Plan – LegalShield f Medical evacuation
This plan provides a variety of legal services, involving wills, f Monitoring of medical condition
trusts, contracts, divorce and routine traffic tickets. This plan f Travel companion assistance
does not cover criminal cases or drunk driving offenses.
Eligible dependent children can be covered up to age 26. f Replacement of medicine/eyeglasses
Identity Theft – Norton LifeLock
Identity theft protection is available on a voluntary basis.
In today’s online world, there is a new identity fraud victim
every two seconds. Protect yourself with LifeLock. LifeLock
monitors millions of transactions every second, alerting
you to suspicious activity by text, phone or email. Includes
Norton Security.
15Glossary
Balance Billing – When you are billed by a provider for the Health Savings Account (HSA) – A personal healthcare
difference between the provider’s charge and the allowed bank account funded by your and the City of Tulsa’s tax‑free
amount. For example, if the provider’s charge is $100 dollars to pay for qualified health expenses. You must be
and the allowed amount is $60, you may be billed by the enrolled in the HSA option to open an HSA. Funds contributed
provider for the remaining $40. to an HSA roll over from year to year and the account is
portable, so if you change jobs your account goes with you.
Coinsurance – Your share of the cost of a covered
healthcare service, calculated as a percent of the allowed High Deductible Health Plan (HDHP) – A plan option
amount for the service, typically after you meet your that provides choice, flexibility and control when it comes
deductible. to healthcare spending. Most preventive care is covered at
100% with in‑network providers, there are no copays and all
Copay – The fixed amount, as determined by your qualified employee‑paid medical expenses count toward
insurance plan, you pay for healthcare services received. your deductible and your out‑of‑pocket maximum.
Deductible – The amount you owe for healthcare services Network – A group of physicians, hospitals and other
before your health insurance begins to pay its portion. For healthcare providers that have agreed to provide
example, if your deductible is $1,000, your plan does not medical services to a health insurance plan’s members at
pay anything until you’ve paid $1,000 for covered services. discounted costs.
This deductible may not apply to all services, including
preventive care. f In‑Network – Providers that contract with your
insurance company to provide healthcare services at
Explanation of Benefits (EOB) – A statement from your the negotiated carrier discounted rates.
insurance carrier that explains which services were provided,
their cost, what portion of the claim was paid by the plan, f Out‑of‑Network – Providers that are not contracted
and what portion is your liability, in addition to how you can with your insurance company. If you choose an
appeal the insurer’s decision. out‑of‑network provider, services will not be covered at
Healthcare Cost Transparency – Also known as market the in‑network negotiated carrier discounted rates.
transparency or medical transparency. Online cost Open Enrollment – The period set by City of Tulsa during
transparency tools, available through health insurance which employees and dependents may enroll for coverage,
carriers, allow you to search an extensive national database make changes or decline coverage.
to compare varying costs for services.
Out‑of‑Pocket Maximum – The most you pay during a
policy period (usually a 12‑month period) before your health
insurance begins to pay 100% of the allowed amount. This does
not include your premium, charges beyond the Reasonable &
Customary, or healthcare your plan doesn’t cover.
Prescription Medications – Medications prescribed by
a doctor. Cost of these medications is determined by their
assigned tier: generic, preferred, non‑preferred or specialty.
Reasonable and Customary Allowance (R&C) – The
amount paid for a medical service in a geographic area
based on what providers in the area usually charge for the
same or similar medical service.
Summary of Benefits and Coverage (SBC) – Mandated
by healthcare reform, your insurance carrier provides you
with a summary of your benefits and plan coverage.
Summary Plan Description (SPD) ‑ The document(s) that
outline the rights, obligations, and material provisions of the
plan(s) to all participants and their beneficiaries.
16Required Notices When Will You Pay A Higher Premium (Penalty) To Join A
Medicare Drug Plan?
Important Notice from City of Tulsa About Your You should also know that if you drop or lose your current coverage with
City of Tulsa and don’t join a Medicare drug plan within 63 continuous days after
Prescription Drug Coverage and Medicare under the your current coverage ends, you may pay a higher premium (a penalty) to join a
Blue Cross Blue Shield of Oklahoma Plan(s) Medicare drug plan later.
Please read this notice carefully and keep it where you can find it. This notice has If you go 63 continuous days or longer without creditable prescription drug
information about your current prescription drug coverage with City of Tulsa and coverage, your monthly premium may go up by at least 1% of the Medicare
about your options under Medicare’s prescription drug coverage. This information base beneficiary premium per month for every month that you did not have that
can help you decide whether or not you want to join a Medicare drug plan. If you coverage. For example, if you go nineteen months without creditable coverage,
are considering joining, you should compare your current coverage, including your premium may consistently be at least 19% higher than the Medicare base
which drugs are covered at what cost, with the coverage and costs of the plans beneficiary premium. You may have to pay this higher premium (a penalty) as long
offering Medicare prescription drug coverage in your area. Information about as you have Medicare prescription drug coverage. In addition, you may have to wait
where you can get help to make decisions about your prescription drug coverage until the following October to join.
is at the end of this notice.
There are two important things you need to know about your current coverage For More Information about This Notice or Your Current
and Medicare’s prescription drug coverage: Prescription Drug Coverage…
1. Medicare prescription drug coverage became available in 2006 to Contact the person listed at the end of these notices for further information.
everyone with Medicare. You can get this coverage if you join a Medicare NOTE: You’ll get this notice each year. You will also get it before the next period
Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO you can join a Medicare drug plan, and if this coverage through City of Tulsa
or PPO) that offers prescription drug coverage. All Medicare drug plans changes. You also may request a copy of this notice at any time.
provide at least a standard level of coverage set by Medicare. Some plans
may also offer more coverage for a higher monthly premium. For More Information about Your Options under Medicare
2. City of Tulsa has determined that the prescription drug coverage offered Prescription Drug Coverage…
by the Blue Cross Blue Shield of Oklahoma plan(s) is, on average for all More detailed information about Medicare plans that offer prescription drug
plan participants, expected to pay out as much as standard Medicare coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in
prescription drug coverage pays and is therefore considered Creditable the mail every year from Medicare. You may also be contacted directly by Medicare
Coverage. Because your existing coverage is Creditable Coverage, you drug plans.
can keep this coverage and not pay a higher premium (a penalty) if you
later decide to join a Medicare drug plan. For more information about Medicare prescription drug coverage:
» Visit www.medicare.gov
When Can You Join A Medicare Drug Plan? » Call your State Health Insurance Assistance Program (see the inside back
You can join a Medicare drug plan when you first become eligible for Medicare cover of your copy of the “Medicare & You” handbook for their telephone
during a seven-month initial enrollment period. That period begins three months number) for personalized help
prior to your 65th birthday, includes the month you turn 65, and continues for the » Call 1-800-MEDICARE (1-800-633-4227).
ensuing three months. You may also enroll each year from October 15th through TTY users should call 1-877-486-2048
December 7th. If you have limited income and resources, extra help paying for Medicare
prescription drug coverage is available. For information about this extra help, visit
However, if you lose your current creditable prescription drug coverage, through Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-
no fault of your own, you will also be eligible for a two (2) month Special 1213 (TTY 1-800-325-0778).
Enrollment Period (SEP) to join a Medicare drug plan.
Remember: Keep this Medicare Part D notice. If you decide to join one
What Happens To Your Current Coverage If You Decide to Join of the Medicare drug plans, you may be required to provide a copy of
A Medicare Drug Plan? this notice when you join to show whether or not you have maintained
creditable coverage and, therefore, whether or not you are required to
If you decide to join a Medicare drug plan, your current City of Tulsa coverage pay a higher premium (a penalty).
will not be affected. For most persons covered under the Plan, the Plan will
pay prescription drug benefits first, and Medicare will determine its payments
second. For more information about this issue of what program pays first and Date: January 1, 2021
what program pays second, see the Plan’s summary plan description or contact Name of Entity/Sender: City of Tulsa
Medicare at the telephone number or web address listed herein.
Contact—Position/Office: Insurance Section
If you do decide to join a Medicare drug plan and drop your current City of Tulsa Address: 175 East 2nd St., Suite 1450
coverage, be aware that you and your dependents will not be able to get this Tulsa, OK 74103
coverage back.
Phone Number: 918-596-7445
17Women’s Health and Cancer Rights Act HIPAA Special Enrollment Rights
The If you have had or are going to have a mastectomy, you may be entitled If you are declining enrollment for yourself or your dependents (including your
to certain benefits under the Women’s Health and Cancer Rights Act of 1998 spouse) because of other health insurance or group health plan coverage, you
(WHCRA). For individuals receiving mastectomy-related benefits, coverage will be may be able to later enroll yourself and your dependents in this plan if you or
provided in a manner determined in consultation with the attending physician and your dependents lose eligibility for that other coverage (or if the employer stops
the patient, for: contributing towards your or your dependents’ other coverage).
» All stages of reconstruction of the breast on which the mastectomy was
performed; Loss of eligibility includes but is not limited to:
» Surgery and reconstruction of the other breast to produce a symmetrical » Loss of eligibility for coverage as a result of ceasing to meet the plan’s
appearance; eligibility requirements (i.e. legal separation, divorce, cessation of
» Prostheses; and dependent status, death of an employee, termination of employment,
» Treatment of physical complications of the mastectomy, including reduction in the number of hours of employment);
lymphedema. » Loss of HMO coverage because the person no longer resides or works in
These benefits will be provided subject to the same deductibles and coinsurance the HMO service area and no other coverage option is available through
applicable to other medical and surgical benefits provided under this plan. For the HMO plan sponsor;
deductibles and coinsurance information applicable to the plan in which you enroll, » Elimination of the coverage option a person was enrolled in, and another
please refer to the summary plan description. If you would like more information on option is not offered in its place;
WHCRA benefits, please contact Insurance Section at 918-596-7445. » Failing to return from an FMLA leave of absence; and
» Loss of coverage under Medicaid or the Children’s Health Insurance
Program (CHIP).
HIPAA Privacy and Security
Unless the event giving rise to your special enrollment right is a loss of coverage
The Health Insurance Portability and Accountability Act of 1996 deals with how an
under Medicaid or CHIP, you must request enrollment within 30 days after your
employer can enforce eligibility and enrollment for health care benefits, as well as
or your dependent’s(s’) other coverage ends (or after the employer that sponsors
ensuring that protected health information which identifies you is kept private. You
that coverage stops contributing toward the coverage).
have the right to inspect and copy protected health information that is maintained
by and for the plan for enrollment, payment, claims and case management. If you If the event giving rise to your special enrollment right is a loss of coverage under
feel that protected health information about you is incorrect or incomplete, you Medicaid or the CHIP, you may request enrollment under this plan within 60 days
may ask your benefits administrator to amend the information. For a full copy of of the date you or your dependent(s) lose such coverage under Medicaid or CHIP.
the Notice of Privacy Practices, describing how protected health information about Similarly, if you or your dependent(s) become eligible for a state-granted premium
you may be used and disclosed and how you can get access to the information, subsidy towards this plan, you may request enrollment under this plan within
contact Insurance Section at 918-596-7445. 60 days after the date Medicaid or CHIP determine that you or the dependent(s)
qualify for the subsidy.
In addition, if you have a new dependent as a result of marriage, birth, adoption,
or placement for adoption, you may be able to enroll yourself and your
dependents. However, you must request enrollment within 30 days after the
marriage, birth, adoption, or placement for adoption.
To request special enrollment or obtain more information, contact
Insurance Section at 918-596-7445.
18Important Contacts
MEDICAL CRITICAL ILLNESS DISABILITY
Blue Cross Blue Shield of Oklahoma Voya Blue Cross Blue Shield of Oklahoma
800-942-5837 Customer Service: 877-236-7564 888-381-9727
www.bcbsok.com Claims: 888-238-4840 DisabilityClaimsOK@bcbsok.com
Policy #: 197386 Online Claims Center: https://claimscenter. Policy #: F024608
voya.com/static/claimscenter/
Care ATC Policy #: 69519-0CCI EMPLOYEE ASSISTANCE
800-993-8244 PROGRAM (EAP)
www.careatc.com/patients HEALTH SAVINGS Community Care EAP
PHARMACY ACCOUNT In Tulsa: 918-594-5232
HealthEquity Toll Free Outside of Tulsa: 800-221-3976
Blue Cross Blue Shield of Oklahoma 866-346-5800 www.cook.com/EAP
877-546-2779 www.healthequity.com
www.bcbsok.com CITY OF TULSA
Policy #: 197386 FLEXIBLE SPENDING INSURANCE SECTION
NURSELINE ACCOUNTS 175 East 2nd St., Suite 1450
HealthEquity/WageWorks Tulsa, OK 74103
Blue Cross Blue Shield of Oklahoma 877-924-3967 insurance@cityoftulsa.org
800-581-0407 www.wageworks.com
www.bcbsok.com SECURITY FOR AFTER HOURS
Policy #: 197386 LIFE AND AD&D DRUG/ALCOHOL TESTING
Blue Cross Blue Shield of Oklahoma 918-596-9100
VIRTUAL VISITS 888-381-9727
MDLive AncillaryQuestionsOK@bcbsok.com CITY MEDICAL
888-970-4081 Policy #: F024608 918-596-7075
www.mdlive.com/bcbsok
DENTAL TRAVEL RESOURCE
Blue Cross Blue Shield of Oklahoma
SERVICES
Blue Cross Blue Shield of Oklahoma
888-381-9727 In the US and Canada: 877-715-2593
www.bcbsok.com Other locations (call collect):
(BlueCare Dental PPO network) +1 202-659-7807
Policy #: 197386 ops@us.generaliglobalassistance.com
VISION
Blue Cross Blue Shield of Oklahoma
855-856-4402
www.eyemedvisioncare.com/bcbsokvis
(EyeMed Select Network)
Policy #: F024608
LEGAL PLAN
LegalShield
Benefits in Hand
800-654-7757
benefits.legalshield.com/cityoftulsa Directly access City of Tulsa’s
Policy #: 302017 benefits information with the
IDENTITY THEFT Lockton BenefitLink mobile
Norton LifeLock app. You’ll find benefits contact
800-607-9174
www.lifelock.com information, Lockton’s digital
Policy #: E0001607 Lifestyle Benefits newsletter
HOSPITAL INDEMNITY and more!
Voya
Customer Service: 877-236-7564
Claims: 888-238-4840
Online Claims Center: https://
claimscenter.voya.com/static/ Username: cityoftulsa
claimscenter/
Policy #: 69519 Password: benefits
ACCIDENT
Voya
Customer Service: 877-236-7564
Claims: 888-238-4840
Online Claims Center: https://
claimscenter.voya.com/static/
claimscenter/
Policy #: 69519-0CAC
19You can also read
