Bronze Health Coverage
Current & Former Employee Coverage & Rates for the 2020/21 Plan Year, effective 7/1/2020 through 6/30/2021

Contents
 》Resources
 》Rates
 Medical
 》Zero Out-of-Pocket Procedures
 》Vendor
 》In-Network Coverage
 》Out-of-Network Coverage
 》Enhancements
 》Preventive Coverage
 Prescription
 》Vendor
 》Coverage
 》Co-Pays
 》Specialty Co-Pays
 》Enahncements
 》Management Programs

Resources
 》Bronze Brochure PDF
 》20 in 20 - Making Healthy Cheaper Brochure PDF
 》Side-By-Side Health Options Brochure PDF
 》Benefit Book PDF
 》SBC PDF
 》Medical Provider Search Tool Link
 》Rx Formulary Search Tool Link
 》Bronze Health Video Link
 》Additional Medical Coverage Video Link
 》HIPAA Privacy Notice PDF
Top of Page

Medical Coverage
Zero Out-of-Pocket Procedures
 》Members pay nothing Out-of-Pocket for care received in the following areas from BlueDistinction network providers.
 》Free Cancer Care
 》Free Transplants
 》Free Cardiac Care
 》Free Spinal Surgeries
 》Free Complex Pregnancies
 》Free Hip & Knee Replacements
Top of Page

Vendor
 》BlueCross BlueShield
 》BluePreferred Network
 》800.672.2567
 》http://www.bcbsok.com Link
Top of Page

In-Network Coverage
The following Out-of-Pocket costs apply to covered benefits received from BluePreferred network providers.
$4,500 Deductible - Individual
$8,500 Deductible - Family
$5,000 Maximum Out-of-Pocket - Individual
$10,000 Maximum Out-of-Pocket - Family
50% Co-Insurance
$20 Primary Care Office Visit Co-Pay
$20 Urgent Care Office Visit Co-Pay
$50 Specialist Office Visit Co-Pay
$50 ER Co-Pay
   Only for Non-Emergencies
Office Visit Co-Pays only apply to the Office Visit charge
Additional charges received during an Office Visit are subject to Deductible & Co-Insurance
Top of Page

Out-of-Network Coverage
The following Out-of-Pocket costs apply to services and procedures received at Out-of-Network network providers.
$6,000 Deductible - Individual
$12,000 Deductible - Family
$10,000 Maximum Out-of-Pocket - Individual
$20,000 Maximum Out-of-Pocket - Family
50% Co-Insurance
100% of Balance Billing Amounts in Excess of Allowable Cost is Members Responsibilty
$1,000 In-Patient Pre-Authorization Penalty Deductible
   Per admission when using an Out-of-Network Provider and Pre-Authorization is not obtained, as required
   Waived if admission is Pre-Authorized by the Claims Administrator
   Does not apply towards the Maximum Out-of-Pocket
   Amounts paid towards Out-of-Network Deductible and Maximum Out-of-Pocket do not count towards In-Network amounts and vice versa
Top of Page

Enhancements
 》Free vitalssmartshopper Cash Rewards - Learn more
 》Free MDLIVE Primary & Pediatric Care - Learn more
 》Free MDLIVE Psychiatry & Counseling Services - Learn more
 》Free ConnectDME Home Medical Equipment & Supplies - Learn more
 》Free ConnectDME Home Sleep Studies - Learn more
 》Free Omada Hypertension & High Cholesterol Program - Learn more
 》Free Livongo Diabetes Program - Learn more
 》Free Hinge Physical Therapy Program - Learn more
 》Free Ovia Fertility, Pregnancy & Parenting Support - Learn more
 》Free Well onTarget Health & Wellness Program - Learn more
 》Free Naturally Slim Weight Loss Program - Learn more
 》50% Child Deductible Reimbursement - Learn more
 》$500 Child Accident Reimbursement - Learn more
Top of Page

Prescription
Vendor
 》Express Scripts
 》National Preferred Formulary
 》855.315.2460
 》800.803.2523 Specialty
 》http://www.express-scripts.com Link
Top of Page

Coverage
The following Out-of-Pocket costs apply to prescription medications received from In-Network pharmacies
$500 Deductible - Individual
$2,500 Maximum Out-of-Pocket - Individual
$5,000 Maximum Out-of-Pocket - Individual
Top of Page

Co-Pays
Co-Pays shown are for a 30-Day Supply. For 90-Day Supply Co-Pays, Multiple by 2.5
50% up to $20 Generics
30% up to $100 Preferred Brands
50% up to $150 Non-Preferred Brands
Top of Page

Specialty Co-Pays
Only 30-Day Supply. Only available through Mail Order
20% up to $50 Generics
30% up to $80 Preferred Brands
50% up to $120 Non-Preferred Brands
Co-Pays for certain Specialty medications may be set to the greater of the current plan design or any available manufacturer-funded Co-Pay Assistance, any amount known to be paid by any sources of Patient Assistance will not be considered as true Out-of-Pocket for members and may not apply to Deductible and Maximum Out-of-Pocket amounts.
Top of Page

Enhancements
 》Free Contraceptives & Contraceptive Devices
 》Free Smoking Cessation Medications
 》Free GERD & Acid Reflux Over the Counter Medications
  》Includes Nexium, Prevacid, Prilosec, Protonix, Omeprazole & Zegerid
 》$5 Diabetics Generic Oral Medications
 》$5 Antihistamines Over the Counter Medications
  》Includes Alavert, Claritin, Flonase, Mucinex, Nasacort, Nasonex & Zyrtec
 》$25 Insulin - Preferred Brand Names
Top of Page

Management Programs
 》Quantity & Age Limitations
 》Clinical Prior Authorizations (CPA's)
 》Step Therapies
 》Exclusions
Top of Page

Rates
Current & Former Employee Rates for the 2020/21 Plan Year, effective 7/1/2020 through 6/30/2021
 》469.00 Member
 》228.56 Child
 》372.08 Children
 》559.34 Spouse
 》787.90 Spouse & Child
 》931.42 Spouse & Children
Top of Page