2022 Mary Jones Personalized just for you - See inside for information about your 2022 health plan
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2022 Mary Jones
Personalized just for you
See inside for information about your 2022 health plan
102233.1021
Your 2022 Health Plan
October 20, 2021
Prepared for: Mary Jones
Member ID number: 012345678
Authorized agent: Taylor Johnson
Your current health plan will be renewed
for 2022, with some changes.
Your Estimated Monthly Payment Amount
Thank you for being a member of Blue Cross and Blue Shield of Oklahoma (BCBSOK). Your
current health plan is Blue Preferred Security PPO 200.
Please note: The name of your plan is changing in 2022. Learn more about your health plan, Blue Preferred Bronze
PPO 206, in this packet created just for you.
2021 2022
Premium $375.50 $433.57
You may be able to lower your monthly payment amount. Please use our Premium Tax Credit Estimator at
StayBlueOK.com to see if you qualify for a 2022 subsidy (also called "premium tax credit").
If you or someone you know is ready to begin planning for Medicare, we are here to help. To learn more, visit
getblueok.com. You can also call 833-620-0824, or contact your independent, authorized Blue Cross and Blue Shield of
Oklahoma agent.
Key Dates
• November 1: Open enrollment begins.
• January 15: Open enrollment ends.
• January 1: The 2022 plan year begins. First payment is due.
See inside back cover for contact information and details about our
Questions? one-on-one assistance in your area.
StayBlueOK.com
Get Ready for 2022
If you do nothing, your health plan will
renew on January 1.
1. You Can Renew or Shop
Renew Your Plan Shop for a Different Plan
• Just keep making your monthly payments and • Visit StayBlueOK.com or call your authorized
you'll be re-enrolled in your current health plan. BCBSOK agent between November 1 and January
15, during open enrollment.
• Some plan benefits, like copays and
coinsurance amounts, may change in 2022. See • If you were enrolled in Auto Bill Pay, you will need
Benefit Changes on the next page. to re-enroll by visiting PayBlueOK.com or by
calling us at 1-866-520-2507.
Please note: The doctors and hospitals in a plan’s network may change.
Visit StayBlueOK.com to confirm your providers are in your plan’s network.
2. Make Your Payment by January 1, 2022
You can pay or enroll in Auto Bill Pay at PayBlueOK.com.
3. Look for Your Member ID Card and Benefit Information
You will receive your 2022 member ID card(s) before
the end of the year.
You will also receive a welcome kit with helpful information about
your plan. Sign up at StayBlueOK.com to receive your welcome kit
electronically instead of by mail.
StayBlueOK.com
Benefit Changes
Review some benefit changes starting
January 1, 2022.
Your Out-of-Pocket Costs
The terms below help explain your out-of-pocket costs.
Deductible • The amount you pay for most covered services before your health plan starts to pay.
• When you go to a provider that is in the plan's network, before you meet the deductible
you pay a discounted amount that has been negotiated with the provider.
• The deductible resets at the beginning of the calendar year or when you enroll in a
new plan.
Copay • The set dollar amount you pay for a covered health care service at the time you
receive care or when you pick up a prescription drug.
Coinsurance • The percentage of the costs of a covered health care service or prescription drug you
pay after you've paid your deductible.
• You pay 100 percent of the full allowed amount until you meet your deductible.
Out of Network • Services are considered out of network when you use a doctor or other provider that
does not have a contract with your health plan.
• Out-of-network services may not be covered or may be covered at a lower level.
• You may be responsible for all or part of an out-of-network provider's bill.
Individual • The most you have to pay for covered services in a plan year.
and Family • After you spend this amount on deductibles, copays and coinsurance, your health plan
Out-of-Pocket pays 100 percent of the costs of covered benefits.
Maximums • For plans that cover more than one person, individual out-of-pocket maximums count toward
the family out-of-pocket maximum. Once the family out-of-pocket maximum is reached, the
plan pays 100 percent of the cost of covered benefits for everyone on your plan.
• The out-of-pocket maximum doesn't include your monthly premium payments or
anything you spend for services your plan doesn't cover.
For the full list of terms, please visit BlueGlossaryOK.com.
StayBlueOK.com
Benefit Changes continued
Here Are Some Plan Changes
2021 Health Plan 2022 Health Plan
Blue Preferred Security PPO Blue Preferred Bronze PPO
Your plan name
200 206
Your Benefits 2021 2022
In-network individual deductible $8,550 $6,000
In-network family deductible $17,100 $17,400
In-network individual out-of-pocket
$8,550 $8,700
maximum
In-network family out-of-pocket maximum $17,100 $17,400
0% coinsurance 50% coinsurance
In-network coinsurance
after deductible is paid after deductible is paid
Coinsurance (%) and Copay ($) Changes
Your Out-of-Pocket Costs for: 2021 2022
40% coinsurance
In-network PCP office visit $20 copay
after deductible is paid
0% coinsurance 50% coinsurance
In-network specialist office visit
after deductible is paid after deductible is paid
0% coinsurance 50% coinsurance
In-network urgent care visit
after deductible is paid after deductible is paid
In-network mental health and substance 0% coinsurance 40% coinsurance
abuse office visit after deductible is paid after deductible is paid
Preferred generic (Tier 1) prescription
0% coinsurance 20% coinsurance
drugs payment when purchasing from a
after deductible is paid after deductible is paid
preferred pharmacy
Non-preferred generic (Tier 2) prescription
0% coinsurance 25% coinsurance
drugs payment when purchasing from a
after deductible is paid after deductible is paid
preferred pharmacy
Preferred brand (Tier 3) prescription
0% coinsurance 30% coinsurance
drugs payment when purchasing from a
after deductible is paid after deductible is paid
preferred pharmacy
Non-preferred brand (Tier 4) prescription
0% coinsurance 35% coinsurance
drugs payment when purchasing from a
after deductible is paid after deductible is paid
preferred pharmacy
Preferred generic (Tier 1) prescription
0% coinsurance 25% coinsurance
drugs payment when purchasing from a
after deductible is paid after deductible is paid
non-preferred pharmacy
StayBlueOK.com
Benefit Changes continued
Coinsurance (%) and Copay ($) Changes
Your Out-of-Pocket Costs for: 2021 2022
Non-preferred generic (Tier 2) prescription
0% coinsurance 30% coinsurance
drugs payment when purchasing from a
after deductible is paid after deductible is paid
non-preferred pharmacy
Preferred brand (Tier 3) prescription drugs
0% coinsurance 35% coinsurance
payment when purchasing from a
after deductible is paid after deductible is paid
non-preferred pharmacy
Non-preferred brand (Tier 4) prescription
0% coinsurance 40% coinsurance
drugs payment when purchasing from a
after deductible is paid after deductible is paid
non-preferred pharmacy
• In 2022, the number of services that need prior authorization may change. Please see your 2022 Benefit Book for
services that need prior authorization.
• Please review the 2022 drug list at BlueRxOK.com to see if the drugs that you take or are prescribed are affected by
any changes. For example, a drug may have moved to a lower or higher drug tier. Please check BlueRxOK.com often
for any changes to the drug list.
This is not a complete list of benefit changes.
For a more complete summary of your benefits, see the enclosed Summary of Benefits and Coverage for 2022, also
available online at BlueBenefitSummaryOK.com/15/.
About Dental Coverage
If you have a separate BCBSOK dental plan: Details about dental coverage, such as your monthly rate and any benefit
changes, may be included in this packet. If you bought your BCBSOK dental coverage through the Health Insurance
Marketplace in Oklahoma, look for a letter in the mail.
StayBlueOK.com
Pharmacy Information
and Prescription Drug
Changes
Changes to your pharmacy benefit
program will start on January 1, 2022.
Visit BlueRxOK.com to see if any of these changes may affect your drugs or coverage. If
you are affected by these changes, talk to your doctor about your treatment options.
Some Drugs Will Move to a Different Drug Tier
• Your health plan uses drug tiers. In general, the lower the tier,
the lower your out-of-pocket costs.
• Drugs may move to a lower or a higher tier. Please check
BlueRxOK.com often for any changes to the drug list.
• View the drug list at BlueRxOK.com to see your drug's tier.
How to Read Drug Lists
Drug Your The example below from the
Tier
Type Cost
drug list shows a drug that:
6 Non-Preferred Specialty $$$ • Is in tier 5
5 Preferred Specialty (preferred specialty drug)
• Requires prior authorization
4 Non-Preferred Brand
• Has a dispensing limit
3 Preferred Brand
2 Non-Preferred Generic
1 Preferred Generic $
Example drug – for
Some Drugs Have Additional Requirements subcutaneous inj 25 mg
• Some medicines on the drug list may have additional
requirements, such as prior authorization. You can download the drug list
• Check the drug list to see if any drugs you take have these at BlueRxOK.com.
additional requirements.
StayBlueOK.com
Pharmacy Information and
Prescription Drug Changes continued
Changes in Coverage for Commonly Used Drugs
Some drugs may no longer be covered under your plan. For complete lists of drugs that are
newly covered or no longer covered as of January 1, 2022, visit BlueRxOK.com. Please check
BlueRxOK.com often for any changes to the drug list.
Commonly Used Drugs That Will No Longer Be Covered as of January 1, 2022
Generic Brand Specialty
CLINDAMYCIN PHOSPHATE-
HALOBETASOL NO
BENZOYL PEROXIDE GEL INVOKAMET SEGLUROMET
0.05% Ointment CHANGES
1-5% (non-refrigerated)
HYDROCODONE/APAP
CLOTRIMAZOLE-BETAMETHASONE
5-300 Mg, 7.5-300 Mg, 10-300 Mg INVOKAMET XR STEGLATRO
1-0.05% Lotion
Tablets
COLESEVELAM PAK METHYLPHENIDATE TAZORAC
INVOKANA
3.75 Gm 2.5 Mg, 5 Mg, 10 Mg Chew Tablets 0.05%, 0.1% Gel
DESONIDE METRONIDAZOLE LOTION MITIGARE
TRUVADA
0.05% Lotion 0.75% 0.6 Mg Capsules
MORPHINE SULFATE ER
DILTIAZEM ER
10 Mg, 20 Mg, 30 Mg, 50 Mg, 60 QTERN
(Coated Bead Tablets)
Mg, 80 Mg, 100 Mg Capsules
DOXYCYCLINE MONOHYDRATE OXYCODONE
150 Mg Tablets 5 Mg Capsules
EC-NAPROXEN TRETINOIN
375 Mg, 500 Mg Tablets 0.025%, 0.05% Gel
FENOPROFEN
600 Mg Tablets
Please note:
• For commonly used drugs that are no longer covered, a covered generic or brand alternative may be available. Ask
your doctor about therapeutic alternatives.
• Commonly used drugs that are no longer covered may not apply to all strengths/formulations.
• Some benefit plans may have preventive drug benefits. This means you may pay a lower cost, as low as $0, for
preventive care drugs.
• If your plan has these preventive drug benefits, and coverage for your prescription changes, the amount you pay
under the preventive drug benefit may also change.
• Drugs that have not received U.S. Food and Drug Administration (FDA) approval are not covered.
• Some drugs may be covered under your medical plan instead of your pharmacy benefits. These can include drugs
that must be given to you by a health care provider. If you are taking or prescribed a drug that is not on your plan's
drug list, call the number on your member ID card to see if the drug may be covered by your medical plan.
StayBlueOK.com
Pharmacy Information and
Prescription Drug Changes continued
Pharmacy Information
You can save money by using an in-network pharmacy. In-network pharmacies can be either
preferred or non-preferred.
$ Preferred In-Network Pharmacies
Generally, your out-of-pocket costs are lowest at a preferred pharmacy. Preferred pharmacies may change in the
future.
Reminder: You can fill up to a 90-day supply of most covered drugs in store at a preferred pharmacy or through
home delivery.
$$ Non-Preferred In-Network Pharmacies
Your out-of-pocket costs are generally higher at a non-preferred pharmacy than at a preferred pharmacy.
Visit myprime.com to find preferred and non-preferred in-network pharmacies.
$$$ Out-of-Network Pharmacies
• Your out-of-pocket costs are highest when you use an out-of-network pharmacy.
• Your plan may not provide out-of-network pharmacy benefits. If so, you may pay the full cost if you use
an out-of-network pharmacy.
Coverage is based on the limits and terms noted in your plan materials. For some medicines, members must meet certain criteria before prescription
drug benefit coverage may be approved. See your plan materials for details. As always, treatment decisions are between you and your doctor.
A “preferred“ or “participating” pharmacy has a contract with BCBSOK or BCBSOK’s pharmacy benefit manager (Prime Therapeutics) to provide
pharmacy services at a negotiated rate. The terms preferred and “participating” should not be construed as a recommendation, referral or any other
statement as to the ability or quality of such pharmacy.
Prime Therapeutics LLC is a separate pharmacy benefit management company contracted by Blue Cross and Blue Shield of Oklahoma (BCBSOK) to
provide pharmacy benefit management and other related services. In addition, contracting pharmacies are contracted through Prime Therapeutics. The
relationship between BCBSOK and contracting pharmacies is that of independent contractors. BCBSOK, as well as several independent Blue Cross and
Blue Shield Plans, has an ownership interest in Prime Therapeutics.
Myprime.com is an online resource offered by Prime Therapeutics LLC.
StayBlueOK.com
Your Dental Plan
October 20, 2021
Your dental plan from Blue Cross and
Blue Shield of Oklahoma will renew in 2022.
Changes to Your 2022 Dental Plan
• Your coverage is: BlueCare Dental 4 Kids 1B. This plan is being renewed for 2022.
• Your new dental monthly payment amount will be $0.00. Your rate adjustment will take effect January 1, 2022.
• Beginning January 1, 2022, your pediatric out-of-pocket maximum will change from $350 to $375 for one child or
from $700 to $750 for two or more children.
• You may continue to use your coverage as long as you keep your payments up to date.
Review Your Information and Make Any Changes Needed
Also, if you purchase a dental plan through another carrier or the Health Insurance Marketplace and no longer need
dental coverage from BCBSOK, please contact us at the number below to remove your dental coverage.
Still have questions?
If you have questions, contact your authorized BCBSOK agent, Taylor Johnson, or
call 855-414-6185.
StayBlueOK.comGovernment-Required Notice
October 20, 2021
Important: It’s time to review your health coverage. Take action by December 15, 2021, or you’ll be
automatically re-enrolled in the same or similar coverage. This may change some of your costs and
coverage, so review your options carefully.
Thank you for choosing Blue Cross and Blue Shield of Oklahoma (BCBSOK) for your health care needs. We’re here
to help you prepare for Open Enrollment.
Why am I getting this letter?
Your health coverage is still being offered in 2022, but some details may have changed. Read this letter carefully and
decide if you want to keep this plan or choose another one. Unless you take action by December 15, you’ll be
automatically re-enrolled in this plan for 2022.
Important: This isn’t an Exchange plan. This means you won’t get any financial help lowering your
monthly premium or out-of-pocket costs (like deductibles, copayments, and coinsurance) if you remain
enrolled in this plan. To see if you qualify for these savings and to enroll in an Exchange plan, visit
healthcare.gov by January 15. If you don’t, any financial help you currently get will end in December. If you
don’t enroll in an Exchange plan by January 15, you may not be able to switch to one for 2022, even if your
finances change.
Changes you’ll see to your plan in 2022
Your new premium
• Your 2021 monthly premium is $375.50.
• Starting in January, your estimated monthly premium will be $433.57. Important: This is only an estimate
based on current information we have. It doesn’t reflect any changes to your enrollment, such as adding additional
members to your coverage. You’ll see your new monthly payment amount when you get your January bill.
Other changes
• Please see the enclosed Benefit Changes section.
• You can review more details about your plan at StayBlueOK.com and in your 2022 Summary of Benefits and
Coverage.
StayBlueOK.comGovernment-Required Notice continued
What you need to do
Decide if you want to enroll in this plan or choose another one.
I want to enroll in this plan.
Pay the new monthly premium by January 1, 2022, and you’ll be automatically enrolled.
I want to pick a different plan.
You can choose a different plan between November 1, 2021, and January 15, 2022. Enroll by
December 15, for coverage to start January 1.
Here are some ways to look at other plans and enroll:
• Check with BCBSOK to see what other plans may be available. Remember, you won’t get financial help
unless you qualify and enroll through the Exchange.
• Visit healthcare.gov to see Exchange plans. Consumers who shop can save hundreds of dollars per year
and can find a plan that best meets their needs and budget.
We’re here to help
• Call BCBSOK at 1-866-520-2507 or visit bcbsok.com.
• Visit healthcare.gov, or call 1-800-318-2596 (TTY: 1-855-889-4325) to learn more about the Exchange and to see if
you qualify for lower costs.
• Find in-person help from an assister, agent, or broker in your community at LocalHelp.Healthcare.gov.
• Contact an agent or broker you've worked with before like Taylor Johnson. Call 855-414-6185.
• Call 1-800-318-2596 (TTY: 1-855-889-4325) for a reasonable accommodation to get this information in an
accessible format, like large print, Braille, or audio, at no cost to you.
StayBlueOK.comSummary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 01/01/2022 – 12/31/2022
: Blue Preferred Bronze PPOSM 206 Coverage for: Individual/Family | Plan Type: PPO
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would
share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.
This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.bcbsok.com/bb/ind/bb-
bpsh32eppioko-ok-2022.pdf or by calling 1-866-520-2507. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment,
deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call 1-855-756-4448 to request a copy.
Important Questions Answers Why This Matters:
Network: Generally, you must pay all of the costs from providers up to the deductible amount before this plan
What is the overall $6,000 Individual/$17,400 Family begins to pay. If you have other family members on the plan, each family member must meet their
deductible? Out-of-Network: own individual deductible until the total amount of deductible expenses paid by all family members
$18,000 Individual/$52,200 Family meets the overall family deductible.
This plan covers some items and services even if you haven’t yet met the deductible amount. But a
Are there services covered
Yes. In-Network Preventive Health is copayment or coinsurance may apply. For example, this plan covers certain preventive services
before you meet your
covered before you meet your deductible. without cost-sharing and before you meet your deductible. See a list of covered preventive services
deductible?
at www.healthcare.gov/coverage/preventive-care-benefits/.
Are there other deductibles
No. You don’t have to meet deductibles for specific services.
for specific services?
Network:
The out-of-pocket limit is the most you could pay in a year for covered services. If you have other
What is the out-of-pocket $8,700 Individual/$17,400 Family
family members in this plan, they have to meet their own out-of-pocket limits until the overall family
limit for this plan? Out-of-Network:
out-of-pocket limit has been met.
Unlimited Individual/Unlimited Family
What is not included in Premiums, balance-billed charges, and
Even though you pay these expenses, they don't count toward the out-of-pocket limit.
the out-of-pocket limit? health care this plan doesn't cover.
This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You
Yes. See www.bcbsok.com or will pay the most if you use an out-of-network provider, and you might receive a bill from a provider
Will you pay less if you use
call 1-800-942-5837 for a list of network for the difference between the provider’s charge and what your plan pays (balance billing). Be
a network provider?
providers. aware, your network provider might use an out-of-network provider for some services (such as lab
work). Check with your provider before you get services.
Do you need a referral to
No. You can see the specialist you choose without a referral.
see a specialist?
Blue Cross and Blue Shield of Oklahoma, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue
Cross and Blue Shield Association Page 1 of 6All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
What You Will Pay
Common Services You May Need Limitations, Exceptions, & Other Important
Medical Event Network Provider Out-of-Network Provider Information
(You will pay the least) (You will pay the most)
Primary care visit to treat an 40% coinsurance 50% coinsurance Virtual Visits are available. See your benefit
injury or illness booklet* for details.
If you visit a health Specialist visit 50% coinsurance 50% coinsurance None
care provider’s office You may have to pay for services that aren't
or clinic Preventive care/screening/ No Charge; deductible does not preventive. Ask your provider if the services
immunization apply 30% coinsurance needed are preventive. Then check what your
plan will pay for.
Diagnostic test (x-ray, blood Freestanding Facility: 40%
work) coinsurance 50% coinsurance None
Hospital: 50% coinsurance
If you have a test
Imaging (CT/PET scans, Freestanding Facility: 40% Preauthorization is required; see your benefit
MRIs) coinsurance 50% coinsurance booklet* for details.
Hospital: 50% coinsurance
*For more information about limitations and exceptions, see the plan or policy document at www.bcbsok.com/bb/ind/bb-bpsh32eppioko-ok-2022.pdf. Page 2 of 6What You Will Pay
Common Services You May Need Limitations, Exceptions, & Other Important
Medical Event Network Provider Out-of-Network Provider Information
(You will pay the least) (You will pay the most)
Retail – Preferred Participating – Retail – 25% coinsurance plus 50%
Preferred generic drugs 20% coinsurance additional charge
Participating – 25% coinsurance
Retail – Preferred Participating – Limited to a 30-day supply at retail (or a 90-
Non-preferred generic 25% coinsurance Retail – 30% coinsurance plus 50% day supply at a network of select retail
If you need drugs to drugs Participating – 30% coinsurance additional charge pharmacies). Up to a 90-day supply at mail
treat your illness or order. Specialty drugs limited to a 30-day
condition Preferred Participating – 30% Retail – 35% coinsurance plus 50% supply. Payment of the difference between the
Preferred brand drugs coinsurance additional charge cost of a brand name drug and a generic may
More information about Participating – 35% coinsurance also be required if a generic drug is available.
prescription drug Preferred Participating – 35% Additional out-of-network charge will not apply
coverage is available at Non-preferred brand drugs coinsurance Retail – 40% coinsurance plus 50% to any deductible or out-of-pocket amounts.
www.bcbsok.com/rx22 Participating – 40% coinsurance additional charge Your cost for a covered insulin drug will not
exceed $30 per 30-day supply or $90 per 90-
Preferred specialty drugs 45% coinsurance 45% coinsurance plus 50% day supply.
additional charge
Non-preferred specialty 50% coinsurance 50% coinsurance plus 50%
drugs additional charge
Freestanding Facility: $300/visit
Facility fee (e.g., plus 40% coinsurance $2,000/visit plus 50% coinsurance Preauthorization is required.
If you have outpatient ambulatory surgery center) Hospital: $300/visit plus 50% For Outpatient Infusion Therapy, see your
surgery coinsurance benefit booklet* for details.
Physician/surgeon fees $200/visit plus 50% coinsurance 50% coinsurance
Emergency room care $950/visit plus 50% coinsurance $950/visit plus 50% coinsurance Copayment waived if admitted.
If you need immediate Emergency medical 50% coinsurance 50% coinsurance None
medical attention transportation
Urgent care 50% coinsurance 50% coinsurance None
Facility fee (e.g., hospital $400/visit plus 50% coinsurance $2,000/visit plus 50% coinsurance Preauthorization is required. Facility:
If you have a hospital room) Preauthorization penalty: $500. See your
stay benefit booklet* for details.
Physician/surgeon fees 50% coinsurance 50% coinsurance
Outpatient services 40% coinsurance 50% coinsurance Preauthorization is required; see your benefit
If you need mental booklet* for details.
health, behavioral
health, or substance Preauthorization is required, see your benefit
abuse services Inpatient services $400/visit plus 50% coinsurance $2,000/visit plus 50% coinsurance booklet* for details. Preauthorization penalty:
$500.
*For more information about limitations and exceptions, see the plan or policy document at www.bcbsok.com/bb/ind/bb-bpsh32eppioko-ok-2022.pdf. Page 3 of 6What You Will Pay
Common Services You May Need Limitations, Exceptions, & Other Important
Medical Event Network Provider Out-of-Network Provider Information
(You will pay the least) (You will pay the most)
Office visits Primary Care: 40% coinsurance 50% coinsurance Cost-sharing does not apply for certain
Specialist: 50% coinsurance preventive services. Depending on the type of
If you are pregnant Childbirth/delivery 50% coinsurance 50% coinsurance services, deductible or coinsurance may apply.
professional services Maternity care may include tests and services
Childbirth/delivery facility described elsewhere in the SBC (i.e.,
services $400/visit plus 50% coinsurance $2,000/visit plus 50% coinsurance ultrasound).
Home health care 50% coinsurance 50% coinsurance 30 visits/year. Preauthorization is required.
Rehabilitation services 50% coinsurance 50% coinsurance Outpatient: Separate 25 visit limit per benefit
period for Rehabilitation and Habilitation
services, which includes physical, speech,
occupational therapy, and muscle
Habilitation services 50% coinsurance 50% coinsurance manipulation. Inpatient: Separate 30-day
If you need help maximum for Rehabilitation and Habilitation
recovering or have services per benefit period. Preauthorization is
other special health required. Preauthorization penalty: $500.
needs 30 days/year. Preauthorization is required.
Skilled nursing care 50% coinsurance 50% coinsurance Inpatient Preauthorization penalty: $500.
Durable medical equipment 50% coinsurance 50% coinsurance None
Inpatient: $400/visit plus 50% Inpatient: $2,000/visit plus 50% Preauthorization is required. Inpatient
Hospice services coinsurance coinsurance Preauthorization penalty: $500.
Outpatient: 50% coinsurance Outpatient: 50% coinsurance
Up to a $30 reimbursement is One visit per year. Out-of-network
Children’s eye exam No Charge; deductible does not available; deductible does not reimbursement will not exceed the retail cost.
apply apply See your benefit booklet* (Pediatric Vision
Care Benefits) for details.
If your child needs One pair of glasses per year. Reimbursement
dental or eye care No Charge; deductible does not Reimbursement is available; for frames, lenses, and lens options purchased
Children’s glasses apply deductible does not apply Out-of-network is available (not to exceed the
retail cost). See your benefit booklet*
(Pediatric Vision Care Benefits) for details.
Children’s dental check-up Not Covered Not Covered None
*For more information about limitations and exceptions, see the plan or policy document at www.bcbsok.com/bb/ind/bb-bpsh32eppioko-ok-2022.pdf. Page 4 of 6Excluded Services & Other Covered Services:
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
• Abortion (unless the life of the mother is endangered) • Dental care (Adult and Child) • Routine eye care (Adult)
• Acupuncture • Infertility treatment • Routine foot care (due to systemic disease and in
• Bariatric surgery (for treatment of obesity/weight • Long-term care connection with diabetes)
reduction) • Non-emergency care when traveling outside the U.S. • Weight loss programs
• Cosmetic surgery (except accidental injury repair and
some instances for physiological functioning
improvement of a malformed body member)
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
• Chiropractic care (Chiropractic and Osteopathic • Hearing aids (limited to one each ear every 48 • Private-duty nursing (limited to 85 visits per year)
manipulation combined with outpatient therapies months)
limited to 25 visits per calendar year)
Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: the
plan at Blue Cross and Blue Shield of Oklahoma at 1-866-520-2507 or visit www.bcbsok.com. You may also contact you state insurance department at 1-800-522-0071 or
the, Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/agencies/ebsa/about-ebsa/ask-a-question/ask-ebsa. Other
coverage options may be available to you, too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the
Marketplace, visit www.HealthCare.gov or call 1-800-318-2596, or state health insurance marketplace or SHOP.
Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a
grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide
complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact:
Oklahoma Department of Insurance, Consumer Protection at 1-405-521-2991 or www.oid.ok.gov.
Does this plan provide Minimum Essential Coverage? Yes
Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP,
TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.
Does this plan meet the Minimum Value Standards? Not Applicable
If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.
Language Access Services:
Spanish (Español): Para obtener asistencia en Español, llame al 1-866-520-2507.
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-866-520-2507.
Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-866-520-2507.
Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-866-520-2507.
To see examples of how this plan might cover costs for a sample medical situation, see the next section.
Page 5 of 6About these Coverage Examples:
This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be
different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost-sharing
amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of
costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.
Peg is Having a Baby Managing Joe’s Type 2 Diabetes Mia’s Simple Fracture
(9 months of in-network pre-natal care and a (a year of routine in-network care of a well- (in-network emergency room visit and follow
hospital delivery) controlled condition) up care)
◼ The plan’s overall deductible $6,000 ◼ The plan’s overall deductible $6,000 ◼ The plan’s overall deductible $6,000
◼ Specialist coinsurance 50% ◼ Specialist coinsurance 50% ◼ Specialist coinsurance 50%
◼ Hospital (facility) copay/coins $400+50% ◼ Hospital (facility) copay/coins $400+50% ◼ Hospital (facility) copay/coins $400+50%
◼ Other coinsurance 50% ◼ Other coinsurance 50% ◼ Other coinsurance 50%
This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like:
Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medical supplies)
Childbirth/Delivery Professional Services disease education) Diagnostic test (x-ray)
Childbirth/Delivery Facility Services Diagnostic tests (blood work) Durable medical equipment (crutches)
Diagnostic tests (ultrasounds and blood work) Prescription drugs Rehabilitation services (physical therapy)
Specialist visit (anesthesia) Durable medical equipment (glucose meter)
Total Example Cost $12,700 Total Example Cost $5,600 Total Example Cost $2,800
In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay:
Cost Sharing Cost Sharing Cost Sharing
Deductibles $6,000 Deductibles $5,400 Deductibles $2,400
Copayments $400 Copayments $0 Copayments $400
Coinsurance $2,300 Coinsurance $0 Coinsurance $0
What isn’t covered What isn’t covered What isn’t covered
Limits or exclusions $60 Limits or exclusions $20 Limits or exclusions $0
The total Peg would pay is $8,760 The total Joe would pay is $5,420 The total Mia would pay is $2,800
The plan would be responsible for the other costs of these EXAMPLE covered services. Page 6 of 6. .
Notes
StayBlueOK.comNotes
StayBlueOK.comHelp is Available
Visit StayBlueOK.com to:
• Find in-network doctors and hospitals.
• Sign up to get your health plan information electronically instead of by mail.
• Review other health plan options and connect to our online shopping experience.
• Download the mobile app to access all these features and more.
Still have questions?
If you have questions, contact your authorized BCBSOK agent, Taylor Johnson, or
call 855-414-6185. We are available:
• Monday through Friday: 8 a.m. to 8 p.m. CT
• Saturday: 8 a.m. to 6 p.m. CT
• Sunday: 10 a.m. to 2 p.m. CT
Expect longer wait times closer to January 15, when open enrollment ends.
We're visiting local communities now through January 15, 2022, to
help Oklahomans like you get answers to their coverage questions.
Visit StayBlueOK.com to find out when we'll be in your neighborhood.
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Blue Cross and Blue Shield of Oklahoma, a Division of Health Care Service Corporation, a Mutual Legal
Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield AssociationYou can also read
