Monthly Premiums for Current Employees

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2 ET EBER UE D DRE etna $ $ $ $ $ $ $ $ ommunityare $ $ $ $,238.9 $ $ $ $ 693. Globalealth $ $ $ $ 82. $ $ 286. $ $ ealthhoice igh and igh lternative $ $ 5.4 $ $ 64.3 $ $ $ $ ealthhoice Basic and Basic lternative $ $ $ $ 55.3 $ $ $ $ 39.6 ealthhoice igh Deductible ealth lan (D) $ $ 32.6 $ $ $ $ 9.8 $ $ DBTY (Employee only) $9. (imited city and county participation only) DET EBER UE D DRE ssurant Freedom referred $ $ 3.26 $ $ 3. $ $ $ $ 6.68 ssurant eritage lus with B (repaid) $ $.4 $ $ 8.86 $ $.6 $ $ 5.2 ssurant eritage ecure (repaid) $ $.2 $ $ 5.98 $ $ 5.2 $ $.38 igna Dental are lan (repaid) $ $ 9.6 $ $ 6. $ $ 4.8 $ $ 9.8 Delta Dental $ $ $ $ $ $ $ $ 4.4 Delta Dental lus remier $ $ $ $ $ $ 38.8 $ $ 98.6 Delta Dental hoice $ $ 5.6 $ $ 34.8 $ $ $ $ 83.6 ealthhoice Dental $ $ 34.3 $ $ 34.3 $ $ 2.4 $ $ 2.64 etife lassic $ $ $ $ $ $ 3.68 $ $ 8.8 etife Value $ $ 2.24 $ $ 2.24 $ $ $ $ 58.2 etife Value D $ $ $ $ $ $ $ $ 62.8 V EBER UE D DRE rimary Vision are ervices (V) $ $ 9.36 $ $ 8. $ $ 8. $ $. uperior Vision $ $.4 $ $.36 $ $ 6.96 $ $ 4.3 Vision are Direct $ $ 5.9 $ $.26 $ $.26 $ $ 22.4 Vision ervice lan (V) $ $ 9.4 $ $ 6.29 $ $ 6.9 $ $ 3.58 FE onthly remiums for urrent Employees lan Year Jan. through Dec. 3, 2 ealthhoice Basic ife ($2,) $4. First $2, of upplemental ife $4. UEET FE ge Rated ost er $2, Unit < $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 39.2 DEEDET FE ow ption $2.6 tandard ption $4.32 remier ption $8.64 pouse $6, of coverage $, of coverage $2, of coverage hild (live birth to age 26) $3, of coverage $ 5, of coverage $, of coverage Dependent ife does not include ccidental Death and Dismemberment (D&D).

3 TBE F TET 2 lan hanges and mportant Reminders General nformation ealth lans Dental lans Vision lans ealthhoice ife nsurance lan ealthhoice Disability lan Enrollment eriods Eligibility Z ode ists omparison of etwork Benefits for ealth lans omparison of Benefits for Dental lans omparison of Benefits for Vision lans ontact nformation This information is only a brief summary of the plans. ll benefits and limitations of these plans are governed in all cases by the relevant plan documents, insurance contracts, handbooks and dministrative Rules of the ffice of anagement and Enterprise ervices. The rules of the klahoma dministrative ode, Title 26, are controlling in all aspects of plan benefits. o oral statement of any person shall modify or otherwise affect the benefits, limitations or exclusions of any plan. fully accessible version of this guide is available at This publication was printed by the ffice of anagement and Enterprise ervices as authorized by Title 62, ection 34.,8 copies have been printed at a cost of $3,44.. copy has been submitted to Documents.K.gov in accordance with the klahoma tate Government pen Documents nitiative ( , 34..3). This work is licensed under a reative ttribution-onommercial-oderivs 3. Unported icense.

4 2 GE D RTT REDER lan changes are indicated by bold text in the comparison of benefits charts. ET etna TEGR and etna t. John etna is expanding its offering in 2 to include etna t. John network for members who live and/or work in Tulsa. etna will continue to offer the etna TEGR network for members who live and/or work in klahoma ity; however, the service area has changed. When you enroll with etna, your network of providers is determined by the Z code in which you live or work. Refer to Z ode ists to determine if you live or work in their area. Blueincs Blueincs is not available for 2. f you have Blueincs, you can choose another health plan. f you do not choose another plan or terminate health coverage, EGD will enroll you in an alternate plan. ommunityare The pharmacy program is being redesigned. hanges are listed in bold text in omparison of etwork Benefits for ealth lans. ealthhoice ealth lans There will be some changes to the list of referred medications. f you are a ealthhoice health plan member who is taking a medication that will no longer be covered in 2, you will be notified by mail. For a complete list of medications that will no longer be covered, please visit The mental health or substance abuse outpatient treatment benefit is increasing to 2 vists per year without certification. ealthhoice elpheck program and ealthhoice U lan are not available for 2. ealthhoice igh, igh lternative, Basic, Basic lternative lans and igh Deductible ealth lan ealthhoice is expanding the ealthhoice elect rogram. These select facilities provide certain services to members that are covered at percent with no out-of-pocket costs to members.* For the most current list of facilities participating in the ealthhoice elect rogram and the most current list of procedures covered, select Find a rovider in the top menu bar of the ealthhoice website at select edical and Dental roviders under ealthhoice rovider istings, and then choose elect etwork from the top menu bar. *D members must meet their before benefits are paid at percent, except for preventive services. ealthhoice igh and igh lternative lans new $ per person pharmacy, with a $3 maximum per family. 2

5 ealthhoice igh and igh lternative lans and igh Deductible ealth lan Emergency room copay is increasing to $2. The ealthhoice reventive edication ist is being implemented for lan Year 2. This is a list of frequently prescribed generic medications and the charges for these medications will not be subject to the igh and igh lternative pharmacy and D combined medical and pharmacy. ealthhoice igh Deductible ealth lan (D) The maximum annual contribution for an individual is increasing from $3,35 to $3,4. DET etife ew for 2 etife is offering three dental plans for 2. For benefit information, refer to the omparison of Benefits for Dental lans or visit their website at the address listed in ontact nformation. V umana Vision are lan umana Vision are lan is not available for 2. f you have umana Vision are lan, you can choose another vision plan or your vison coverage will end Jan.. rimary Vision are ervices rimary Vision are ervices is offering additional discounts on laser vision correction surgery. hanges are listed in bold text in omparison of Benefits for Vision lans. Unitedealthcare Vision Unitedealthcare Vision is not available for 2. f you have Unitedealthcare Vision, you can choose another vision plan or your vision coverage will end Jan.. Vision ervice lan Vision ervice lan is increasing the allowance for frames. hanges are listed in bold text in omparison of Benefits for Vision lans. REDER f you are enrolled in the ealthhoice igh or Basic lan and wish to stay enrolled in that plan, you must complete the online tobacco-free attestation for lan Year 2 available at by ov. 4. The attestation is waived for the first year of enrollment in the igh or Basic lan but is required each year thereafter to remain enrolled. f you are in the process of quitting tobacco, you must be tobacco-free for 9 days prior to the deadline to attest to being tobacco-free. 3

6 f you cannot sign the tobacco-free attestation because either you or a covered dependent uses tobacco, you can still qualify for ealthhoice igh or ealthhoice Basic plans if those that use tobacco complete one of the following alternatives: how proof of an attempt to quit using tobacco by enrolling in the quit tobacco program available through the klahoma Tobacco elpline and lere Wellbeing and completing three coaching calls by ov. 4, 26. rovide a letter from your doctor by ov. 4, 26, indicating it is not medically advisable for you or your covered dependents to quit tobacco. f you do not complete the tobacco-free attestation or complete one of the reasonable alternatives, you will automatically be enrolled in the ealthhoice igh lternative or Basic lternative lan effective Jan., and your annual will be $25 higher. GEER FRT The benefits you select will be in effect Jan., or for new employees, the effective date of your coverage, through Dec. 3, 2, or your termination date. fter enrollment, the plans you select will provide more information about your benefits. ontact each plan directly if you have questions about your benefits. t is your responsibility to review your benefits carefully so you know what is covered, as well as the plan s policies and procedures, before you use your benefits. Enrollment in a plan does not guarantee that a provider will remain in your plan s network for the entire year. You enroll with the plan and not the provider. f your provider terminates his or her contract during the plan year, this does not allow you to change your plan carrier. ET There are eight health plans available: etna TEGR and etna t. John ealthhoice igh and igh lternative lans ommunityare ealthhoice Basic and Basic lternative lans Globalealth ealthhoice D Refer to omparison of etwork Benefits for ealth lans on pages 6-23 for benefit information. There are no preexisting condition exclusions or limitations applied to any of the health plans. ll health plans coordinate benefits with other group insurance plans you have in force. You must live or work within an s Z code service area to be eligible. ost office box addresses cannot be used to determine your eligibility. Refer to pages -5 for the Z ode ists. f you select an, you must use the provider network designated by that plan for klahoma. To remain enrolled in the ealthhoice igh or Basic lan for lan Year 2, you must complete the tobacco-free attestation located on the ealthhoice website or a reasonable alternative. ealthhoice contracts with merican Fidelity ealth ervices dministration to make establishing and keeping a health savings account () easier and more convenient for ealthhoice D members. For more information about s, contact merican Fidelity at the number located in ontact nformation at the back of this guide. 4

7 DET There are dental plans available: ssurant Freedom referred Delta Dental hoice ssurant eritage lus with B (repaid) ealthhoice Dental ssurant eritage ecure (repaid) etife lassic G Dental are lan (repaid) etife Value Delta Dental etife Value D Delta Dental lus remier Refer to omparison of Benefits for Dental lans on pages 24-2 for benefit information. You must select a primary care dentist for yourself and each covered dependent when enrolling in a prepaid dental plan. ssurant Freedom referred and ealthhoice have a 2-month waiting period for orthodontic benefits. ome plans may not be available in all areas. V There are four vision plans available: rimary Vision are ervices (V) Vision are Direct uperior Vision Vision ervice lan (V) Refer to omparison of Benefits for Vision lans on pages 28-3 for benefit information. Verify your vision provider participates in a vision plan s network by contacting the plan, visiting the plan s website or calling your provider. ll vision plans have limited coverage for services provided by out-of-network providers. f your provider leaves your health, dental or vision plan, you cannot change plans until the next annual ption eriod; however, you can change providers within your plan s network as needed. ETE FE URE s a new employee, you can elect life insurance coverage within 3 days of your employment or initial eligibility date. You can enroll in Guaranteed ssue, in addition to Basic ife, without a ife nsurance pplication. Guaranteed ssue is two times your annual salary rounded up to the nearest $2,. ll requests for supplemental coverage above Guaranteed ssue require you to submit a ife nsurance pplication for approval. s a current employee, if you did not enroll when first eligible, you can enroll: During the annual ption eriod (enroll in or increase life coverage); or Within 3 days of a midyear qualifying event, such as birth of a child or marriage by submitting a ife nsurance pplication for approval. ife nsurance pplication is available from your insurance coordinator. s a current employee, you can also enroll in life insurance coverage within 3 days of the loss of other group life coverage. You are eligible to enroll in the amount of coverage you lost rounded up to the next $2, unit without submitting a ife nsurance pplication for approval. roof of the loss of other coverage is required. 5

8 Basic ife nsurance... For You Basic ife pays a benefit of $2, to your beneficiary in the event of your death. Basic ife includes ccidental Death and Dismemberment (D&D) benefits, which pays an additional $2, to your beneficiary if your death is due to an accident. t also pays benefits if you lose your sight or a limb due to an accident. upplemental ife nsurance... For You You can enroll in upplemental ife in units of $2,. The maximum amount of upplemental ife coverage available is $5,. You must complete and submit a ife nsurance pplication, which must be approved before coverage begins. The first $2, of upplemental ife provides an additional $2, of D&D benefits. Beneficiary Designation For Basic and upplemental ife benefits, you must name your beneficiary(ies) when you enroll. Your designation can be changed at any time. For a Beneficiary Designation Form or more information, contact your insurance coordinator. This form is also available at ife insurance benefits are paid according to the information on file. Dependent ife nsurance... For Your Eligible Dependents f you are enrolled in Basic ife insurance, you can elect Dependent ife for your spouse and other eligible dependents during your initial enrollment, the annual ption eriod, within 3 days of the loss of other group life insurance or other midyear qualifying event without a ife nsurance pplication. Each eligible dependent must be enrolled in Dependent ife. Regardless of the number of dependents covered, the monthly premium is a flat amount. Benefits are paid only to the member. Below are the three levels of coverage: DEEDET W T TDRD T REER T pouse $ $ 6, of coverage $ $, of coverage $ $ 2, of coverage hild (live birth to age 26) $ $ 3, of coverage $ $ 5, of coverage $ $, of coverage Dependent ife does not include D&D benefits. ETE DBTY (limited city and county participation) The ealthhoice Disability lan provides partial replacement income if you are unable to work due to an illness or injury. Disability coverage is not available to dependents. Eligibility Enrollment in the Disability lan begins the first day of the month following your employment date or the date you become eligible. You become eligible for disability benefits after 3 consecutive days of employment. During that time, you must continuously perform all of the material duties of your regular occupation. ny claim for disability benefits must be filed within one year of the date your disability began. ontact your insurance coordinator for more information. 6

9 ERET ERD ption eriod Enrollment overage effective Jan., 2 This is the time when eligible employees can: Enroll in coverage; hange plans or drop coverage; ncrease or decrease life coverage; and/or dd or drop eligible dependents from coverage. You can enroll in health, dental, life and/or vision coverage for yourself and/or your dependents during the annual ption eriod, as long as you have not dropped that coverage within the past 2 months. f you have dropped coverage within the past 2 months without a midyear qualifying event, you cannot reinstate that coverage for at least 2 months. nitial Enrollment overage effective the first of the month following your employment date or the date set by your employer This is the time when new employees are eligible to: Enroll in coverage; Enroll eligible dependents; and pply for life insurance coverage above Guaranteed ssue by submitting a ife nsurance pplication for review and approval. s a new employee, you have 3 days from your employment or eligibility date to enroll in coverage. f you do not enroll within 3 days, you cannot enroll until the next annual ption eriod, unless you experience a qualifying event. heck with your insurance coordinator for more information. You have 3 days following your eligibility date to make changes to your original enrollment. pecial Enrollment Rights overage generally effective the first of the month following a qualifying event f you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents other coverage). owever, you must request enrollment within 3 days after your or your dependents other coverage ends (or after the employer stops contributing toward the other coverage). n 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. owever, you must request enrollment within 3 days of the marriage, birth, adoption, or placement for adoption. To request special enrollment or obtain more information, contact your insurance coordinator. idyear hanges overage generally effective the first of the month following a qualifying event idyear plan changes are allowed only when a qualifying event, such as birth, marriage or loss of other group coverage, occurs. You must complete the appropriate form within 3 days of the event. ontact your insurance coordinator for more information.

10 EGBTY embers Your employer must participate in the plans offered through EGD. You must be a current education employee eligible to participate in the klahoma Teachers Retirement ystem working a minimum of four hours per day or 2 hours per week, or a current local government or other eligible employee regularly scheduled to work at least, hours a year, and not classified as temporary or seasonal, or a city employee. You must be enrolled in a group health plan to enroll in dental and/or life insurance. Dependents f one eligible dependent is covered, all eligible dependents must be covered. Exceptions apply (refer to Excluding Dependents from overage in this section). Eligible dependents include: Your legal spouse (including common-law); Your daughter, son, stepdaughter, stepson, eligible foster child, adopted child or child legally placed with you for adoption up to age 26, whether married or unmarried; dependent, regardless of age, who is incapable of self-support due to a disability that was diagnosed prior to age 26. ubject to medical review and approval; and ther unmarried dependent children up to age 26, upon completion and approval of an pplication for overage for ther Dependent hildren. Guardianship papers or a tax return showing dependency can be provided in lieu of the application. f your spouse is enrolled separately in one of the plans offered through EGD, your dependents can be covered under either parent s health, dental and/or vision plan (but not both); however, both parents can cover dependents under Dependent ife. Dependents who are not enrolled within 3 days of your eligibility date cannot be enrolled until the next annual ption eriod, unless a qualifying event such as birth, marriage or loss of other group coverage occurs. Dependent coverage can be dropped midyear with a qualifying event. f you drop dependent coverage without a qualifying event, you cannot reinstate coverage for at least 2 months. Dependents can be enrolled only in the same types of coverage and in the same plans you elect. To enroll your newborn, the appropriate form must be provided to your insurance coordinator within 3 days of the birth. This coverage is effective the first of the birth month. f you do not enroll your newborn during this 3-day period, you cannot do so until the next annual ption eriod. Direct notification to a plan will not enroll your newborn or any other dependents. The newborn s ocial ecurity number is not required at the time of initial enrollment, but must be provided once it is received from ocial ecurity. nsurance premiums for the month the child was born must be paid. Without enrollment: ealthhoice newborn is covered only for the first 48 hours following a vaginal birth or the first 96 hours following a cesarean section birth. Under the ealthhoice lans, a separate and coinsurance apply. etna, ommunityare and Globalealth s newborn is covered for 3 days without an additional premium. Excluding Dependents from overage You can exclude your spouse from health and/or dental coverage while covering other dependents on these benefits. Your spouse must sign the pouse Exclusion ertification section of your enrollment or change form. heck with your insurance coordinator for more information. 8

11 You can exclude dependents who do not reside with you, are married, are not financially dependent on you for support, have other group coverage or are eligible for ndian or military health benefits. ote: Your spouse cannot be excluded from vision coverage if your other dependents are covered unless your spouse has proof of other group vision coverage. You must always provide proof of other group coverage to your insurance coordinator when excluding a dependent for that reason. onfirmation tatements You are mailed a onfirmation tatement () when you enroll or make changes to your coverage. Your lists the coverage you are enrolled in, the effective date of your coverage and the premium amounts. f you are enrolled in Blueincs, you will need to select another health plan for 2. f you do not make a selection or terminate your health coverage, EGD will move you to an alternative health plan to ensure your health coverage does not lapse. f you are enrolled in umana Vision are lan or Unitedealthcare Vision, you can select a vision plan or your vision coverage will end Jan.. lways review your to verify your coverage is correct. orrections to your coverage must be submitted to your insurance coordinator within 6 days of your election. orrections reported after 6 days are effective the first of the month following notification. ection B of your ption eriod Enrollment/hange Form lists your most current coverage. f you don t make changes and you are not automatically enrolled in one of the ealthhoice lternative lans, you will not receive a from EGD. Keep a copy of your ption eriod Enrollment/hange Form as verification of your coverage. Transfer Employee You can keep your coverage continuous when you move from one participating employer to another as long as there is no break in coverage that lasts longer than 3 days. remiums must be paid upon reporting to work. Benefit options vary from employer to employer. hanges to your coverage must be made within the first 3 days of your transfer. ontact your insurance coordinator for more information. Retiring and hanging lans f you are retiring on or before Jan., go to for the appropriate ption eriod materials. elect the ption eriod banner, then select according to your status as of Jan. re-edicare or edicare. Your insurance coordinator can assist you and must also provide you the required pplication for Retiree/Vested/on-Vested/Defer nsurance. f you or your dependents will be edicare eligible by Jan., an additional form will be required to enroll in edicare art D. You can also call EGD ember ervices for assistance. Refer to ontact nformation at the back of this guide. Termination of overage overage will end the last day of the month in which a termination event occurs, such as: oss of employment; Reduction in hours; oss of dependent eligibility; on-payment of premiums; or Death. 9

12 BR Temporary ontinuation of overage The onsolidated mnibus Budget Reconciliation ct (BR) allows you and/or your covered dependents to continue health, dental and/or vision insurance coverage after your employment terminates or after your dependent loses eligibility. ertain time limits apply to enrollment. ontact your insurance coordinator immediately upon termination of your employment, or when changes to your family status occur, to find out more about your BR rights. Be aware, dropping dependent coverage during ption eriod is not a BR qualifying event. TRVE: K EYEE WE-BEG Thrive is the name and inspiration behind the well-being program. ur vision is for every member s wellbeing to be valued and to empower members to be fearless, valued, and engaged. Thrive does this by standing behind our core pillars of purpose, social, financial, physical, community and emotional well-being. Thrive provides members and their families with information and opportunities to learn, grow and enrich their lives for the better. t s our journey and our promise to help members cultivate excellence and, in short, Thrive. Thrive Well-Being Toolkits Thrive toolkits are monthly well-being initiatives filled with information, suggested activities and promotional materials centered on well-being topics that support Thrive s six elements. The toolkits are available on our website at thrive.ok.gov. You can also contact us with questions at thrive@omes.ok.gov. oming in 2 ew lasses Thrive has several partners that develop well-being classes available to members and their dependents. Visit our website at thrive.ok.gov for the most up-to-date details.

13 etna TEGR Z ode ist etna t. John Z ode ist Z D E Z codes are subject to change by plan T

14 ommunityare Z ode ist 2 Z D E T Z codes are subject to change by plan 2

15 Globalealth Z ode ist Z codes are subject to change by plan continued on next page 3 2 Z D E T

16 Globalealth Z ode ist 2 Z D E T Z codes are subject to change by plan continued on next page 4

17 Globalealth Z ode ist Z D E Z codes are subject to change by plan 5 T

18 2 E T R F ETWRK BEEFT FR ET Your osts for etwork ervices alendar Year Deductible alendar Year ut-of-ocket aximum etna TEGR and etna t. John ommunityare o o o $3, individual $4,5 family ncludes all copays and coinsurance paid on covered services, prescriptions and durable medical equipment $4, individual $8, family ncludes all copays and coinsurance paid on covered services, prescriptions and durable medical equipment Globalealth $3,5 individual $,5 family ncludes all copays and coinsurance paid on covered services, prescriptions and durable medical equipment ffice Visit $25 copay/ $5 copay/specialist $35 copay/ $5 copay/specialist $ copay/ $5 copay/specialist R X-Ray and ab llergy Testing and Treatment $ copay for X-ray and lab $25 copay per R, T, R or ET scan $25 copay/ $5 copay/specialist $ copay for X-ray and lab $2 copay per scan pecialty scans: R, T, R and ET scans $35 copay/ $5 copay/specialist $3 serum and shots including a 6-week supply of antigen $ copay for X-ray and lab $25 copay per scan in a preferred facility $5 copay per scan in a non-preferred facility pecialty scans: R, R, ET, T and nuclear scans $ copay/ $5 copay/specialist $3 serum and shots including a 6-week supply of antigen and administration lan changes are indicated by bold text. This is only a sample of the services covered by each plan. For services that are not listed in this comparison chart, contact each plan. Refer to ontact nformation at the back of this guide. 6

19 R F ETWRK BEEFT FR ET Your osts for etwork ervices alendar Year Deductible alendar Year ut-of-ocket aximum (igh, igh lternative, Basic, and Basic lternative lans have a separate pharmacy out-ofpocket maximum, refer to page 23) ffice Visit X-Ray and ab llergy Testing and Treatment ealthhoice igh and igh lternative lans igh lan $5 individual $,5 family igh lternative lan $5 individual $2,25 family igh lan* opays apply $3,3 etwork individual $8,4 etwork family $3,8 non-etwork individual $9,9 non-etwork family, plus amounts over llowable Fees igh lternative lan* opays apply $3,55 etwork individual $8,4 etwork family $4,5 non-etwork individual $9,9 non-etwork family, plus amounts over llowable Fees $3 copay/physician office visit** $5 copay/specialist office visit 2% of llowable Fees after 2% of llowable Fees after imit of 6 tests every 24 months ealthhoice Basic and Basic lternative lans Basic lan $, individual $,5 family pplies after lan pays first $5 of llowable Fees Basic lternative lan $,25 individual $,5 family pplies after lan pays first $25 of llowable Fees Basic lan $4, individual $9, family Basic lternative lan $4, individual $9, family opays do not apply ll covered services, exceptions, limitations and conditions are identical to the ealthhoice igh lan Basic lan $ of the first $5 of llowable Fees % of the next $, of llowable Fees (). nly llowable Fees count toward the ; 5% of the next $6, of llowable Fees Basic lternative lan $ of the first $25 of llowable Fees % of the next $,25 of llowable Fees (). nly llowable Fees count toward the ; 5% of the next $5,5 of llowable Fees Both Basic lans $ of llowable Fees over the individual or family out-of-pocket maximum You can use non-etwork providers, but it will be more costly ealthhoice D $,5 individual $3, family The individual does not apply if two or more family members are covered The combined medical and pharmacy must be met before benefits are paid $3, individual $6, family harmacy copays apply to the out-of-pocket maximum but non- etwork charges do not apply You pay % of llowable Fees until is met $3/$5** office visit copay applies after 2% of llowable Fees after 2% of llowable Fees after imit of 6 tests every 24 months lan changes are indicated by bold text. *Emergency room and office visit copays apply. oinsurance applies until the out-of-pocket maximum is met. **The $3 copay applies to general practitioners, internal medicine physicians, B/GYs, pediatricians, physician assistants and nurse practitioners. 2 E T R

20 2 R F ETWRK BEEFT FR ET Your osts for etwork ervices reventive ervices etna TEGR and etna t. John ommunityare Globalealth $ copay/ $ copay ( or specialist) $ copay//routine physical exam $5 copay male surgical procedure $ copay well-woman exam and preventive services E T Well hild are mmunizations earing creening and earing id $ copay $ copay $ copay $ copay ages birth through 8 years $ copay ages 9 and older When medically necessary earing screening $ copay imit of one per year earing aids 2% coinsurance for children up to age 8 $ copay birth through age 2 years $ copay ages 2 and older when appropriate following the recommendation of earing screening $ copay when performed by imit of one per year earing aids 2% coinsurance for children up to age 8 $ copay birth through age 8 years $ copay ages 9 and older when appropriate following the recommendation of ffice visit copay may apply earing screening $ copay children imit of one per year earing aids 2% coinsurance For children up to age 8 R ospital npatient ospital utpatient Emergency Room Urgent are $25 copay per day $5 maximum per admission reauthorization required $2 copay per day 5 day maximum ($,) per admission reauthorization required $25 copay per day $5 maximum per admission $25 copay per visit $5 copay per visit $25 copay in a preferred facility $5 copay in a nonpreferred facility $2 copay; waived if admitted $2 copay; waived if admitted $3 copay; waived if admitted $5 copay per visit $5 copay per visit $25 copay per visit lan changes are indicated by bold text. This is only a sample of the services covered by each plan. For services that are not listed in this comparison chart, contact each plan. Refer to ontact nformation at the back of this guide. 8

21 R F ETWRK BEEFT FR ET Your osts for etwork ervices reventive ervices Well hild are mmunizations earing creening and earing id ospital npatient ospital utpatient Emergency Room Urgent are ealthhoice igh and igh lternative lans $ copay for two preventive services office visits per calendar year for members and dependents ages 8 and older ne mammogram per year at no charge for women ages 4 and older $ copay; no applies o charge for well child and adult immunizations and administration $3/$5** office visit copay may apply earing screening $3/$5** copay imit of one per year earing aids overed as durable medical equipment for children up to age 8 ertification required 2% of llowable Fees after dditional $3 copay per non-etwork admission (does not count toward outof-pocket maximum) 2% of llowable Fees after 2% of llowable Fees after dditional $2 ER copay waived if admitted $3/$5** office visit copay may apply 2% of llowable Fees after ealthhoice Basic and Basic lternative lans $ copay for two preventive services office visits per calendar year for members and dependents ages 8 and older ne mammogram per year at no charge for women ages 4 and older o for well child care visit opays do not apply ll covered services, exceptions, limitations and conditions are identical to the ealthhoice igh lan Basic lan $ of the first $5 of llowable Fees % of the next $, of llowable Fees (). nly llowable Fees count toward the ; 5% of the next $6, of llowable Fees Basic lternative lan $ of the first $25 of llowable Fees % of the next $,25 of llowable Fees (). nly llowable Fees count toward the ; 5% of the next $5,5 of llowable Fees Both Basic lans $ of llowable Fees over the individual or family out-ofpocket maximum You can use non-etwork providers, but it will be more costly. ealthhoice D $ copay for two preventive services office visits per calendar year for members and dependents ages 8 and older ne mammogram per year at no charge for women ages 4 and older $ copay; no applies o charge for well child and adult immunizations and administration $3/$5** office visit copay may apply earing screening $3/$5** copay after imit of one per year earing aids overed as durable medical equipment for children up to age 8 ertification required 2% of llowable Fees after dditional $3 copay per non-etwork admission (does not count toward out-of-pocket maximum) 2% of llowable Fees after 2% of llowable Fees after dditional $2 ER copay waived if admitted $3/$5** office visit copay may apply after 2% of llowable Fees after lan changes are indicated by bold text. **The $3 copay applies to general practitioners, internal medicine physicians, B/GYs, pediatricians, physician assistants and nurse practitioners. 9 2 E T R

22 2 E T R R F ETWRK BEEFT FR ET Your osts for etwork ervices aternity re and ost atal are Durable edical Equipment (DE) ental ealth or ubstance buse npatient ental ealth or ubstance buse utpatient ccupational or peech Therapy Visit hysical Therapy or hysical edicine Visit hiropractic and anipulative Therapy Visit etna TEGR and etna t. John $25 copay for initial visit $25 copay per day $5 maximum per admission ommunityare $ copay for prenatal and postnatal care $35 copay initial visit $2 per day, 5 day maximum ($,) per hospital admission reauthorization required Globalealth $ copay for prenatal care $25 copay for delivery and all postnatal care $5 per hospital admission 2% coinsurance 2% coinsurance 2% coinsurance $25 copay per day $5 maximum per admission reauthorization required $2 per day 5 day maximum ($,) per hospital admission reauthorization required $5 copay/specialist $35 copay $ copay o copay inpatient $5 copay outpatient therapy imit of 6 days per illness o copay inpatient $5 copay outpatient therapy imit of 6 days per illness $2 copay imit of 5 visits per year $2 copay per day 5 day maximum ($,) per hospital admission reauthorization required $5 copay per outpatient therapy visit (up to 6 days treatment per disability) $5 copay imit 5 visits per year $25 per day $5 maximum per admission o copay inpatient $5 copay per outpatient therapy imit of 6 visits $25 copay imit 5 visits per year lan changes are indicated by bold text. This is only a sample of the services covered by each plan. For services that are not listed in this comparison chart, contact each plan. Refer to ontact nformation at the back of this guide. 2

23 R F ETWRK BEEFT FR ET Your osts for etwork ervices aternity re and ost atal are Durable edical Equipment (DE) ental ealth or ubstance buse npatient ental ealth or ubstance buse utpatient ccupational or peech Therapy Visit hysical Therapy or hysical edicine Visit hiropractic and anipulative Therapy Visit ealthhoice igh and igh lternative lans 2% of llowable Fees after ncludes one postpartum home visit criteria must be met 2% of llowable Fees after for purchase, rental, repair or replacement 2% of llowable Fees after o limit on the number of days per year 2% of llowable Fees after imit of 2 services per calendar year without certification 2% of llowable Fees after ccupational therapy* imit of 2 visits per year without certification peech therapy* For ages and younger, certification required For ages 8 and older, certification not required *aximum of 6 visits per year 2% of llowable Fees after imit of 2 visits per year without certification aximum of 6 visits per year hiropractic therapy 2% of llowable Fees after imit of 2 visits per year without certification aximum of 6 visits per year anipulative therapy Refer to hysical Therapy/ hysical edicine above ealthhoice Basic and Basic lternative lans opays do not apply ll covered services, exceptions, limitations and conditions are identical to the ealthhoice igh lan Basic lan $ of the first $5 of llowable Fees % of the next $, of llowable Fees (). nly llowable Fees count toward the ; 5% of the next $6, of llowable Fees Basic lternative lan $ of the first $25 of llowable Fees % of the next $,25 of llowable Fees (). nly llowable Fees count toward the ; 5% of the next $5,5 of llowable Fees Both Basic lans $ of llowable Fees over the individual or family outof-pocket maximum You can use non-etwork providers but it will be more costly. ealthhoice D 2% of llowable Fees after ncludes one postpartum home visit criteria must be met 2% of llowable Fees after for purchase, rental, repair or replacement 2% of llowable Fees after o limit on the number of days per year 2% of llowable Fees after imit of 2 services per calendar year without certification 2% of llowable Fees after ccupational therapy* imit of 2 visits per year without certification peech therapy* For ages and younger, certification required For ages 8 and older, certification not required *aximum of 6 visits per year 2% of llowable Fees after imit of 2 visits per year without certification aximum of 6 visits per year hiropractic therapy 2% of llowable Fees after imit of 2 visits per year without certification aximum of 6 visits per year anipulative therapy Refer to hysical Therapy/ hysical edicine above lan changes are indicated by bold text. *The $3 copay applies to general practitioners, internal medicine physicians, B/GYs, pediatricians, physician assistants and nurse practitioners. 2 2 E T R

24 2 E T R R F ETWRK BEEFT FR ET Your osts for etwork ervices harmacy Benefits etna TEGR and etna t. John Retail elect generic: $4 Generic: $ Brand: $3 on-preferred brand: $6 ail-order elect generic: $8 Generic: $2 Brand: $6 on-preferred brand: $2 pecialty referred: $ on-preferred: $2 ommunityare Retail referred harmacies (Walgreens and Walmart) elect generic: $ referred generic: $5 referred brand: $4* on-preferred brand or generic: $* pecialty: $6* on-referred harmacies (ll other network pharmacies) elect generic: $5 referred generic: $2 referred brand: $5* on-preferred brand or generic: $9* pecialty: $2* ail-order (9-day supply) elect generic: $ referred generic: $45 referred brand: $2* on-preferred brand or generic: $2* ail-rder pecialty (3-day supply) BriovaRx: $6* referred pharmacy copays will apply to prescriptions filled through our mail order service using (Walgreens or ptum) or through BriovaRx for specialty medicines. *f you choose to obtain a brand name drug when a generic equivalent is available, you will pay the applicable copay or coinsurance for the brand name drug, plus the difference in cost between the brand name drug and its generic equivalent. The difference in cost between the brand name drug and its generic equivalent will not count toward your annual outof-pocket maximum. Globalealth Retail elect generic: $5 Generic: $ Brand: $5 on-preferred brand: $5 ail-order elect generic: $ Generic: $2 Brand: $ on-preferred brand: $5 pecialty referred: $ on-preferred: $2 lan changes are indicated by bold text. This is only a sample of the services covered by each plan. For services that are not listed in this comparison chart, contact each plan. Refer to ontact nformation at the back of this guide. 22

25 R F ETWRK BEEFT FR ET Your osts for etwork ervices rescription edications ealthhoice igh, igh lternative, Basic, Basic lternative and D lans 3-Day upply Generic Drugs Up to $ Up to $25 referred Drugs Up to $45 Up to $9 on-referred Drugs Up to $5 Up to $5 pecialty Drugs* Generic $ copay referred drugs $ copay on-referred drugs $2 copay 3- to 9-Day upply opays are for up to a 3-day supply *pecialty medications are covered only when ordered through the V/caremark specialty pharmacy. ETE G D G TERTVE harmacy $ for individual ($3 for family). ETE G D G TERTVE D G DEDUTBE ET ealthhoice reventive edication ist edications not subject to pharmacy. ETE G, G TERTVE, B, D B TERTVE harmacy out-of-pocket maximum $2,5 for individual ($4, for family) using referred products at etwork harmacies, then you pay $ for the rest of the calendar year. ETE D harmacy benefits are available only after the combined medical and pharmacy ($,5 individual/$3, family) has been met. ETE ll lan provisions apply. ome medications are subject to prior authorization and/or quantity limits. f you choose a brand-name medication when a generic is available, you are responsible for the difference in the cost in addition to the copay. ealthhoice covers two 9-day courses of tobacco cessation medications at percent when filled at a etwork harmacy. Visit the Be Tobacco-Free page at for details. D vaccinations, such as for shingles, are covered at percent when using a etwork harmacy. ote: These can also be covered under the health benefit if provided by a recognized etwork health provider, such as a physician or health department. 2 E T R 23

26 2 D E T nnual Deductible Diagnostic and reventive are (cleanings, routine oral exams) llowable Fees pply R F BEEFT FR DET ssurant Employee Benefits Freedom referred $25 per person, waived for in-etwork preventive services etwork: lan pays % of allowable amounts o on-etwork: lan pays % of usual and customary after ssurant Employee Benefits eritage lus and eritage ecure o s o charge for routine cleaning (once every 6 months) o charge for topical fluoride application (up to age 8) o charge for periodic oral evaluations eritage lus: ealant per tooth: $5 copay eritage ecure: ealant per tooth: $22 copay G Dental are lan (repaid) o or plan maximum $5 office copay applies ealant per tooth: $ copay Routine cleaning (once every 6 months): no charge Topical fluoride application (up to age 8): no charge eriodic oral evaluations: no charge Delta Dental n-etwork and ut-of- etwork $25 per person, per year, applies to Basic and ajor are only lan pays % of allowable amounts o applies Topical fluoride covered for children (up to age 9) Delta Dental lus remier n-etwork and ut-of- etwork $5 per person, per year, applies to Diagnostic, reventive, Basic and ajor are lan pays % of allowable amounts after Topical fluoride covered for children (up to age 9) R Basic are (extractions, oral surgery) llowable Fees pply etwork: lan pays 85% of allowable amounts after on-etwork: lan pays % of usual and customary after Fillings inor oral surgery eritage lus: malgam, one surface, permanent teeth: $25 copay eritage ecure: malgam, one surface, permanent teeth: $32 copay 24 malgam: ne surface, permanent teeth $23 copay lan pays 85% of allowable amounts after lan changes are indicated by bold text. This is only a sample of the services covered by each plan. For services that are not listed in this comparison chart, contact each plan. Refer to ontact nformation at the back of this guide. ome plans may not be available in all areas. lan pays % of allowable amounts after

27 R F BEEFT FR DET Delta Dental hoice etwork ealthhoice Dental etife lassic etife Value etife Value D 2 nnual Deductible Diagnostic and reventive are (cleanings, routine oral exams) llowable Fees pply $ per person, per year, applies to ajor are only (evel 4) chedule of covered services and copays Topical fluoride covered for children only opay examples: Routine cleaning $5 eriodic oral evaluation $5 Topical fluoride application (up to age 9) $5 etwork: $25 Basic and ajor services combined on-etwork: $25 reventive, Basic and ajor services combined plus amounts above llowable Fees You pay etwork: $ on-etwork: $ of llowable Fees after $25 per person $5 per family Basic and ajor are etwork: lan pays % of negotiated fee schedule on-etwork: lan pays % of reasonable and customary Routine exams and cleanings: two every 2 months Fluoride: two every 2 months (up to age 6) $25 per person $5 per family Basic and ajor are etwork: lan pays % of negotiated fee schedule on-etwork: lan pays % of reasonable and customary Routine exams and cleanings: two every 2 months Fluoride: two every 2 months (up to age 6) $25 per person $5 per family Basic and ajor are etwork: lan pays % of negotiated fee schedule on-etwork: lan pays % of reasonable and customary Routine exams and cleanings: two every 2 months Fluoride: two every 2 months (up to age 6) D E T Basic are (extractions, oral surgery) llowable Fees pply chedule of covered services and copays opay example: malgam - one surface, primary or permanent tooth $2 You pay etwork: 5% on-etwork: 3% plus amounts above llowable Fees Deductible applies etwork: lan pays 85% of negotiated fee schedule on-etwork: lan pays 85% of reasonable and customary etwork and non-etwork: Root canal: one per tooth per lifetime 25 etwork: lan pays 85% of negotiated fee schedule on-etwork: lan pays % of reasonable and customary etwork and non-etwork: Root canal: one per tooth per lifetime lan changes are indicated by bold text. This is only a sample of the services covered by each plan. For services that are not listed in this comparison chart, contact each plan. Refer to ontact nformation at the back of this guide. ome plans may not be available in all areas. etwork: lan pays 85% of negotiated fee schedule on-etwork: lan pays % of reasonable and customary etwork and non-etwork: Root canal: one per tooth per lifetime R

28 2 D E T R ajor are (dentures, bridge work) llowable Fees pply rthodontic are llowable Fees pply lan Year aximum Filing laims R F BEEFT FR DET ssurant Employee Benefits Freedom referred etwork: lan pays 6% of allowable amounts after on-etwork: lan pays 5% of usual and customary after etwork: lan pays 6% on-etwork: lan pays 5% Up to lifetime maximum of $2, for dependents under age 9 $2, per person, per policy year ember/provider must file claims ssurant Employee Benefits eritage lus and eritage ecure eritage lus: Root canal anterior: $65 copay eriodontal/ caling/root planing -3 teeth, per quadrant: $36 copay pecialty rider pays specialist at set copays eritage ecure: Root canal anterior: $5 copay eriodontal/ caling/root planing -3 teeth, per quadrant: $54 copay Endodontist: 5% discount 25% discount dults and children o annual maximum, per policy year G Dental are lan (repaid) Root canal, anterior: $35 copay eriodontal: caling/root planing -3 teeth (per quadrant): $5 copay $2,42 outof-pocket for children $3,384 out-ofpocket for adults 24-month treatment excludes orthodontic treatment plan and banding o plan year dollar maximum Delta Dental n-etwork and ut-of- etwork lan pays 6% of allowable amounts after lan pays 6% of allowable amounts, up to $2, lifetime maximum per person rthodontic benefits are available to eligible employee, spouse and dependent children $2,5 per person/year for Diagnostic, reventive, Basic and ajor are o claims to file o claims to file laims are filed by participating dentists lan changes are indicated by bold text. This is only a sample of the services covered by each plan. For services that are not listed in this comparison chart, contact each plan. Refer to ontact nformation at the back of this guide. ome plans may not be available in all areas. 26 Delta Dental lus remier n-etwork and ut-of- etwork lan pays 5% of allowable amounts after lan pays 6% of allowable amounts, up to $2, lifetime maximum per person rthodontic benefits are available to eligible employee, spouse and dependent children $3, per person/year for Diagnostic, reventive, Basic and ajor are laims are filed by participating dentists

29 R F BEEFT FR DET Delta Dental hoice etwork ealthhoice Dental etife lassic etife Value etife Value D 2 ajor are (dentures, bridge work) llowable Fees pply rthodontic are llowable Fees pply lan Year aximum Filing laims chedule of covered services and copays opay examples: rown - porcelain/ceramic substrate $24 omplete denture maxillary $32 You pay charges in excess of $5 per month ifetime maximum up to $,8 per person rthodontic benefits are available to eligible employee, spouse and dependent children $2, per person/year for Diagnostic, reventive, Basic and ajor are laims are filed by participating dentists You pay etwork: 4% on-etwork: 5% plus amounts above llowable Fees Deductible applies You pay etwork: 5% on-etwork: 5% plus amounts above llowable Fees 2-month waiting period applies o lifetime maximum overed for members under age 9 and members ages 9 and older with TD etwork and non-etwork: $2,5 per person, per year etwork: o claims to file on-etwork: You file claims etwork: lan pays 6% of negotiated fee schedule on-etwork: lan pays 6% of reasonable and customary etwork and non-etwork: Dentures: one every five years Fixed bridges/ inlays/onlays: one every five years mplants: one per tooth every five years etwork: lan pays 6% of negotiated fee schedule on-etwork: lan pays 6% of reasonable and customary $2, lifetime maximum $5,, applies to reventive, Basic and ajor are laims are filed by etwork and non-etwork dentists etwork: lan pays 6% of negotiated fee schedule on-etwork: lan pays 5% of reasonable and customary etwork and non-etwork: Dentures: one every years Fixed bridges/ inlays/onlays: one every years mplants: one per tooth every years etwork: lan pays 6% of negotiated fee schedule on-etwork: lan pays 5% of reasonable and customary $2, lifetime maximum $2,5, applies to reventive, Basic and ajor are laims are filed by etwork and non-etwork dentists lan changes are indicated by bold text. This is only a sample of the services covered by each plan. For services that are not listed in this comparison chart, contact each plan. Refer to ontact nformation at the back of this guide. ome plans may not be available in all areas. 2 etwork: lan pays 6% of negotiated fee schedule on-etwork: lan pays 5% of reasonable and customary etwork and non-etwork: Dentures: one every years Fixed bridges/ inlays/onlays: one every years mplants: one per tooth every years etwork: lan pays 6% of negotiated fee schedule on-etwork: lan pays 5% of reasonable and customary $2, lifetime maximum $2,5, applies to reventive, Basic and ajor are laims are filed by etwork and non-etwork dentists D E T R

30 2 V overed ervices Eye Exams enses er air R F BEEFT FR V rimary Vision are ervices n-etwork ut-of- etwork $ copay o limit to frequency You pay wholesale cost o limit to number of pairs lan pays up to $4 imit one exam You pay normal doctor s fees, reimbursed up to $6 for one set of lenses and frames annually uperior Vision n-etwork ut-of- etwork $ copay lan pays: $34 phthalmologist $26 ptometrist $25 copay tandard rogressive: $25 copay Refer to Vision lan otes after this chart lan pays: ingle up to $26 Bifocals up to $39 Trifocals up to $49 enticular up to $8 tandard rogressive: Up to $49 R Frames ontact enses aser Vision orrection You pay wholesale cost o limit to number of frames You pay wholesale cost for annual supply of contacts Discount at njoy Vision Extra savings between June - ept. 3, 2 You pay normal doctor s fees, reimbursed up to $6 for one set of lenses and frames per year imit of one set annually in lieu of eyeglasses You pay normal doctor s fees reimbursed up to $6 o benefit lan changes are indicated by bold text. For more information or details, contact each vision plan directly. 28 $25 copay then plan pays up to $25 retail lan pays up to $2 all contacts edically necessary contacts covered in full (ontact lens fit copay: tandard $25, after copay, covered in full; specialty $25, after copay, plan pays up to $5) 5-5% discount off surgical fees lan pays up to $68 lan pays up to $ all contacts; $2 medically necessary (ontact lens fit copay: tandard not covered; specialty not covered) o benefit

31 overed ervices Eye Exams enses er air R F BEEFT FR V n-etwork $5 copay for full comprehensive exam including dilation $5 copay ingle, bifocals, trifocals and no-line progressive lenses covered in full nti-reflective, UV and poly-carbonate lenses are covered in full Vision are Direct ut-of- etwork n-etwork Vision ervice lan (V) ut-of- etwork lan pays up to $4 $ copay $ copay then plan pays up to $35 lan pays up to: $3 single $45 bifocals $55 trifocals $5 lenticular $25 copay applies to lenses or frame ingle vision, lined bifocal and trifocal lenses covered in full verage 35-4% discount on lens options $25 copay then plan pays: ingle up to $25 Bifocals up to $4 Trifocals up to $55 enticular up to $8 2 V Frames ontact enses aser Vision orrection $ copay $3 frame allowance each year $3 allowance for conventional and disposable lenses $25 allowance for medically necessary contacts lan pays up to $35 $8 allowance for conventional, disposable and medically necessary contacts 29 $25 copay then plan pays up to $5 lan pays up to $2 conventional or disposable; edically necessary contacts covered in full Up to $, off o benefit 5% average off usual and customary price or 5% off the laser center s promotional price lan changes are indicated by bold text. For more information or details, contact each vision plan directly. $25 copay then plan pays up to $45 lan pays up to $5 conventional or disposable; $2 medically necessary contacts o benefit R

32 Vision lan otes V: The only klahoma owned and operated vision care plan with unlimited in-network services. ember must select either in-network or out-of-network for entire year. n-network services are unlimited. ut-of-network services (one eye exam, one set of eyeglasses or contacts) are limited to once annually. $5 service fee applies to soft contact lens fittings; a $5 service fee applies to rigid or gas permeable contact lens fittings; and a $5 service fee applies to hybrid contact lens fittings. imple replacements are not assessed with these fees. imitations/exclusions include the following: ) edical eye care, 2) Vision therapy, 3) on-routine vision services and tests, 4) uxury frames 5) remium prescription lenses, and 6) onprescription eyewear. For more information or detail, call uperior Vision: aterials copay applies to lenses and/or frames. Discounts for lens add-ons will be given by contracted providers with a D in their listing. nline, in-network contact lens materials available at www. svcontacts.com. Exams, lenses and frames are provided once per calendar year. rogressive lenses (no-line bifocals) you pay the difference between the retail price of the selected progressive lens and the retail price of the lined trifocal. The difference may also be subject to a discount. tandard contact lens fitting applies to an existing contact lens user who wears disposable, daily wear or extended wear lenses only. The specialty contact lens fitting applies to new contact lens wearers and/or members who wear toric, gas permeable or multifocal lenses. Vision are Direct: plan that will cost you less money overall. With the VD plan, you can get your exam, frames and lenses (upgraded to polycarbonate, premium anti-reflective coatings and UV coatings) for $3, even if you wear progressive no-line lenses. We are not an insurance company and our focus is on delivering the very best patient care with quality materials at a very affordable price. ther plans may offer discounts for extra services, but we include the extras the doctor wants you to have, like polycarbonate lenses that are thinner, lighter and safer. We also include premium anti-reflection and UV coatings on our lenses because it s better for you and the doctor wants you to have it. hoose one of our 9 private line frames and you ll pay no more out of pocket than $3 for single vision lenses or no-line progressives. f you want a brand-name frame, no problem; you simply pay a small $4 unbundling fee and can choose any frame you want up to $3. What would normally cost you over $3 for progressive lenses will cost you much less with VD. Visit for more information, inclusions and limitations. For our provider list, visit and enter your Z code, be sure to look for the VD lus logo. For more information, call or text V: Exam, lenses and frame benefit provided annually. The $25 materials copay applies to lenses or frames, but not to both. opays/prices listed are for standard lens options. remium lens options will vary. f you choose a frame valued at more than your allowance, you ll save 2 percent on your out-of-pocket costs when you use a V doctor. ember s receive an extra $2 towards their frame allowance when selecting a archon frame. ontact lenses are in lieu of spectacle lenses and frame. The $2 in-network allowance applies to the contact lenses. With a V provider, the contact lens exam (fitting and evaluation) is covered in full after a copay up to $6. The $5 out-ofnetwork allowance applies to the contacts and contact lens exam. Your contact lens exam is performed in addition to your routine eye exam to check for eye health risks associated with improper wearing or fitting of contacts. rescription glasses 3 percent off additional complete pairs of glasses and sunglasses, including lens options, from the same V doctor on the same day as your WellVision Exam, or get 2 percent off from any V doctor within 2 months from your last WellVision Exam. ontact V or visit vsp.com to learn more. 3

33 ontact nformation lans etna TEGR and etna t. John ommunityare or TDD state.ccok.com Globalealth, nc or TDD ealthhoice ember ervices/rovider Directory or TDD or ealth, Dental and ife laims, Benefits,Eligibility and D ards or TDD or harmacy laims, Formulary and D ards or TDD merican Fidelity ealth ervices dministration or Dental lans ssurant nc. Dental Freedom referred repaid eritage lans G repaid Dental earing mpaired Relay Delta Dental or etife Vision lans rimary Vision are ervices (V) or TDD uperior Vision or TDD Vision are Direct or TDD Vision ervice lan (V) or TDD

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36 over image: Wichita ountains