2025 Active Benefits Guide.pdf

City of Oklahoma City Employee Benefits Guide

2 - Oklahoma City Employee Benefits Guide

City of Oklahoma City

Important Note: Benefits are subject to Labor negotiations with applicable collective bargaining groups. Benefits and/or rates referenced herein are subject to change. If such change occurs, employees will be notified.

Things to Know for 2025 On-Site Enrollment Location Open Enrollment will be held at the OKC Convention Center (100 Mick Cornett Dr, Oklahoma City, OK 73109) the week of October 28 to November 1, 2024 from 8am to 4pm. Staff will be available to assist in assisting with self-enrollment in One OKC Cloud. Representatives from American Fidelity will be on-site to assist with Accident, Cancer, Long Term Disability, and Individual Life plans. Vendors for medical, dental, life, EAP, and retirement will be on-site to answer any questions. EMBARK will be providing shuttles from the downtown campus. Please check InsideOKC for more information and updates as the event nears.

Beneficiary Update As part of the Oracle Cloud conversion, the decision was made to have employees reload the Group Life beneficiaries. While the City has the prior historical beneficiary record in Peoplesoft, HR is encouraging all employees to designate Group Life beneficiaries in One OKC Cloud self-service as well as periodically review and update their beneficiaries as needed. Beneficiary designations and changes can be completed at anytime throughout the year in One OKC Cloud self-service. Please note Employee Benefits does have access to historical beneficiary information in the event the employee has not updated the beneficiary in One OKC Cloud. Once the employee has made the update in One OKC Cloud, this will become the source of record.

New 457 Vendor We are moving to a single administrator, Voya Financial. This will lower costs for you, provide greater fee transparency, improve services and simplify account management.

MissionSquare and Nationwide are the current recordkeepers for the City of Oklahoma City’s deferred compensation plans. Any account you currently have with either MissionSquare or Nationwide will be transferred automatically to Voya® in December 2024. Refer to pages 42–43 for more information.

One OKC Cloud Every employee should have access to One OKC Cloud and will have access to make their own elections and changes to their benefit selections. In addition, employees are STRONGLY encouraged to check and periodically update their beneficiaries. For more information to enroll or make changes, click on QR code or www.okc.gov/oe.

Dear City of OKC Employee, It is Open Enrollment time! The Total Rewards Team has worked diligently to ensure no increase for medical premiums for active employees for the third straight year!

HR continues to work hard to evaluate and meet the needs of our workforce. The first year of the new EPO medical plan has been a positive change. For 2025, a new 457 and 401a plan administrator, VOYA, will streamline and enhance the offerings provided, while saving employees in fees. Please take time during Open Enrollment to review and invest in your 457 to maximize your overall retirement security.

The Total Rewards Team is here to support you during Open Enrollment in a way that best suits your busy schedule. We are committed to assisting each employee no matter if you prefer self-service via One OKC Cloud or on-site enrollment. If you plan to enroll on-site, please make sure you have your Multi- Factor Authentication (MFA). If you have login or MFA issues, IT will be onsite to assist.

I encourage each of you to take a small amount of time to log in to One OKC Cloud and review your other benefits and beneficiaries to make sure they are still meeting you and your family’s needs.

Additional information and/or changes for Open Enrollment will be communicated through InsideOKC, www.okc.gov/oe, and/or departments.

Let’s keep the momentum going as one of the top 35 organizations to work for in Oklahoma.

Aimee Maddera Chief HR Officer

Oklahoma City Employee Benefits Guide - 3

City Benefits Program Eligibility & Coverage Information

Plan Eligibility Eligibility is determined by the requirements stated in the appropriate plan document or insurance policy. Since the plans are subject to change, eligibility may also change. If you change coverage from one plan to another, you and your dependent(s) must meet the requirements of the new plan selected.

Benefits Information Additional information regarding your benefits can be found at www.okc.

gov/oe. If you need to meet with Employee Benefits, please call 297-2144 to set up an appointment.

Employee and Dependent Eligibility You are eligible to participate in the City’s health and welfare plans if you are classified as a regular, full-time active employee, excluding Fire Fighters, or in one of the following categories: 1) An employee on paid disability leave due to an on-the-job injury or illness who was a regular, full-time active employee on the date the disabling injury or illness occurred;

2) An elected official of the City; 3) The City Auditor or a regular, full-time active employee of the City Auditor’s office; 4) The Municipal Counselor or a regular, full-time active employee of the Municipal Counselor’s office;

or 5) A full-time active Oklahoma City Municipal Judge; or 6) An eligible employee of a participating public trust.

Employees must provide official documentation establishing a legal relationship with dependents in order for the dependents to be eligible for coverage. You and your dependents will not be covered until you complete the appropriate paperwork with the Employee Benefits Division, provide the necessary documents to be enrolled (i.e. birth certificates, marriage license, copy of the social security card, etc.) and pay the required premium(s). Acceptable documentation must be received in the Employee Benefits Division of the Human Resources Department within 31 days of becoming eligible. Refer to the Guide to Qualifying Change in Status in this guide for additional information.

Eligible Dependents Include

• Spouse, including Common Law partner.

• Child(ren), under age 26, (or those who qualify as a dependent under the Internal Revenue Code).

• Child(ren), currently enrolled in coverage, who are physically or mentally incapable of self support on the date coverage would otherwise end at age 26.

About this Guide This benefit guide is a compilation of City sponsored employee benefits. It is intended for informational purposes only. The actual benefits available and the full descriptions of these benefits are governed in all cases by the relevant plan document, insurance contracts, and Ordinances and Resolutions of The City of Oklahoma City, and, where applicable, collective bargaining agreements. If there are discrepancies between the benefit guide and the actual plan documents, insurance contracts, and Ordinances and Resolutions, the documents, contracts, and Ordinances and Resolutions will govern. Please refer to Supplemental Benefits Information and Disclosures for additional information.

Administrative Information Clerical Error/Delay Clerical error or delay will not invalidate coverage or cause coverage to be in force. Coverage is governed solely by terms and provisions of the Plans, and City policy. Additionally, payment or lack of payment of premiums will not cause coverage under a Plan to commence or terminate. However, upon discovery of clerical error or delay, which results in over or under collection of premiums, an adjustment will be made to reflect the correct amount of premiums. The City has the right to collect premiums owed by the employee and conversely, the employee will be reimbursed if an overpayment occurs. Additionally, if a clerical error results in the processing of claims against the Plan, any payments disbursed to providers will be invalidated and payment of services will be the responsibility of the employee.

HIPAA Compliance The Health Insurance Portability and Accountability Act (HIPAA) requires that your health insurance plan limit the release of your health information to the minimum necessary required for your care. If you have questions about your claims, contact your insurance carrier first.

If, after contacting the insurance carrier, you need a representative of the Employee Benefits Division to assist you with any claim issues, you may be required to provide written authorization to release information related to your claim. The City of Oklahoma City advises you that the HIPAA Notice of Privacy Practices is available to you by accessing okc.gov/departments/ personnel/benefits. If you do not have access to the internet and you would like a copy of the HIPAA Notice of Privacy Practice, or if you have any questions, please contact a representative of the Employee Benefits Division at 405-297-2144.

For more information, contact Employee Benefits at eb@okc.gov or 405-297-2144.

IMPORTANT NOTICE: If dependent eligibility changes during the year you must notify the Employee Benefits Division of the Human Resources Department within 31 days of the qualifying event.

4 - Oklahoma City Employee Benefits Guide

Enrollment for Plan Year 2025

Important Dates to Remember Your On-Site Enrollment Dates are:

October 28, 2024 - November 1, 2024 Your Period of Coverage Dates are:

January 1, 2025 - December 31, 2025

Self-Service Online Enrollment:

October 22 - November 4

Open Enrollment Deadlines Online Enrollment Changes Due:

November 8, 2024 Required Open Enrollment Legal Documentation Due:

November 8, 2024

Annual Open Enrollment Each year Open Enrollment provides you an opportunity to change plans and modify dependent coverage. Changes made become effective January 1, 2025, and will remain in effect through the plan year (January 1, 2025 - December 31, 2025).

What You Need to Do During Annual Open Enrollment

1. Review the benefits available and determine which plans best meet your needs.

2. Review the family members you have covered under the Plan. During the annual enrollment period, you are verifying that your dependents meet the City’s benefit eligibility requirement. You may be required to provide supporting documentation.

3. Ensure the City has your correct mailing address on file in the Human Resources Department.

Enrollment Information By taking no enrollment action, you will not have medical coverage for 2025. Your dental, vision, life insurance and voluntary products you are currently enrolled in will remain the same and premiums will automatically adjust to the new rates, with the exception of the Health Flexible Spending Account or Dependent Care Flexible Spending Account.

IMPORTANT NOTICE: The Health Flexible Spending Account and Dependent Care Flexible Spending Account require a new election each year. Any current FSA election from the current plan year will be terminated as of first day of the new plan year.

NOTE: If spouse/dependent child eligibility changes during the year you must notify the Employee Benefits Division of the Human Resources Department within 31 days of the qualifying event.

In addition, coverage will only continue for the next plan year, if all required documents supporting eligibility for benefits have been provided to the Employee Benefits Division.

On-Site and Virtual Enrollment will be held October 28, 2024 - November 1, 2024 from 8:00 a.m. - 4:00 p.m.

Oklahoma City Convention Center 100 Mick Cornett Drive, Hall B

Parking validation will be provided

Appointments are encouraged. To schedule your appointment, visit:

https://americanfidelity.com/okc

COTPA On-Site Enrollment will be held October 23 from 12:00 p.m. – 6:00 p.m.

October 24 from 6:00 a.m. - 9:00 a.m.

2000 S. May www.okc.gov/oe

Remember...

We recommend reviewing your current information, including...

• Updating your beneficiaries.

• Removing ineligible dependents

• If you are divorced, your ex-spouse is no longer eligible for health, dental, and /or vision coverage.

• If a child no longer qualifies for coverage as a dependent (i.e. stepchildren who are no longer eligible due to divorce, loss of guardianship, etc.)

• If you have Spousal Life Insurance coverage, and are divorced, your ex-spouse is no longer eligible for this coverage.

• If you have Child Life Insurance coverage and your children are over the age of 23, your children are no longer eligible for this coverage.

http://americanfidelity.com/okc http://www.okc.gov/oe

Oklahoma City Employee Benefits Guide - 5

Two Easy Ways to Enroll

Enroll Self-Service Enrollment Enroll online from the convenience of your home using your work or home computer with One OKC Cloud Self-Service for Medical, Dental, Vision, and Flexible Spending Accounts. If you wish to enroll in voluntary products or make changes to your voluntary products (Long-Term Disability, Cancer, Accident Only, Individual Term Life, or Permanent Life plans), you will need to attend the on-site enrollment and meet directly with an American Fidelity enroller at the on-site enrollment or schedule a virtual visit. The American Fidelity enroller will not have access to make change to the City’s group plans.

Additional Instructions for online enrollment are available on the Open Enrollment page at www.okc.gov/oe in the Employee Benefits section of www.okc.gov/oe.

Enroll On-Site or Virtual Enrollment Human Resources staff will be present to assist employees with reviewing and making changes in self-service. Employees will need to bring a multi-factor authentication (MFA) to the on-site enrollment to login to the kiosk to review or make election changes. Employees are authorized up to two hours of paid leave to participate in the enrollment process. Please remember that approval from your supervisor is required for use of your authorized two hours of paid leave prior to the OE event. Also, if you add dependent(s), you must provide appropriate documentation (i.e. birth certificate, marriage license, copy of the Social Security card, etc.) to the Employee Benefits division at enrollment before dependent(s) will be added to the City’s plan(s).

By enrolling on-site you can enroll in:

• Medical • Vision • Accident Only Insurance • 457(b) Savings Plan

• Group Term Life • Long-Term Disability • Cancer Insurance • Fitness Center

• Dental • Individual Term Life • Flexible Spending Accounts • Permanent Life

Documents required for Benefit Enrollment or Changes* Birth Certificate Medicare Card Social Security Card

Dependent Eligibility Form Common Law Marriage Affidavit and Documentation

Legal Guardianship Documents

Marriage License Divorce Decree Adoption Papers

NOTE: You may need to clear your internet cache/cookies.

Remember: FSA enrollment elections do not carry over into 2025. You must re-enroll in the Flexible Spending Account Health and/or Dependent Care Flexible Spending Account EACH YEAR!!

* Current dependents do not require documents if they are on file.

6 - Oklahoma City Employee Benefits Guide

Table of Contents

2025 Benefits Enrollment Rates COVID-19 Update Section 125 Cafeteria Plan Health Plan Benefits Comparison......................................................................... 10-13 Health Plans Employee Medical Center. ....................................................................................... 16-17 Blue Access for Members Dental Plan ..................................................................................................................... 19-21 Vision Plan ...................................................................................................................... 22-23 Fitness Center ................................................................................................................ 24-26 Flexible Spending Accounts ................................................................................... 27-28 Group Term Life Insurance and AD&D (City Employees Only) ................. 29-31 Individual Term Life Insurance Universal Life Insurance Accident Only Insurance Cancer Insurance Long-Term Disability Income Insurance Hospital Indemnity Short Term Disability Insurance (COTPA Employees Only) ........................ 38-39 Group Term Life Insurance and AD&D (COTPA Employees Only) ........... 40-42 IRC 457 Deferred Compensation .......................................................................... 43-45 Employee Assistance Program Guide to Life Events / Change in Status Benefit Highlights for New Employees Employee Payroll Calendar COTPA Payroll Calendar Benefits Resource Directory ........................................................................ Back Cover

Additional information regarding the eligibility, administration, policies, and/or regulations that govern the City of Oklahoma City benefit programs can be found in the Disclosures and

Supplemental Benefit Information Guide. Revisions and updates to the Disclosures and Supplemental Information Guide will be posted on the Benefits page of InsideOKC as well as www.okc.gov/oe.

American Fidelity Benefit Site information can be found by scanning the QR code:

OKC Open Enrollment can be found by scanning the QR code:

http://www.okc.gov/oe

Oklahoma City Employee Benefits Guide - 7

Rates Benefit Plan Total Premium Employer Employee Frequency of Deductions

BlueCross BlueShield PPO Employee Only $416.58 $333.26 $83.32

Employee + Spouse $787.34 $629.87 $157.47

Employee + Child $583.21 $466.57 $116.64

Employee + Children $749.85 $599.88 $149.97

Employee + Family $1,062.28 $849.82 $212.46

BlueCross BlueShield EPO Employee Only $445.95 $379.06 $66.89

Employee + Spouse $1,003.51 $852.98 $150.53

Employee + Child $780.50 $663.43 $117.07

Employee + Children $958.91 $815.07 $143.84

Employee + Family $1,382.62 $1,175.23 $207.39

BlueCross BlueShield Dental Employee Only $12.22 $8.00 $4.22

Low Plan Employee + 1 $24.45 $8.00 $16.45

Employee + 2 or more $39.10 $8.00 $31.10

BlueCross BlueShield Dental Employee Only $18.02 $8.00 $10.02

High Plan Employee + 1 $36.02 $8.00 $28.02

Employee + 2 or more $57.63 $8.00 $49.63

VSP Vision Plan Employee Only $3.50 $3.50

Employee + 1 $6.49 $6.49

Employee + 2 or more $10.44 $10.44

BCBS (formerly Dearborn National) Basic Life Coverage $20,000 $1.10 $1.10

BCBS Basic AD&D Coverage $5,000 $0.08 $0.08

BCBS Voluntary Employee Life Coverage 1/2x, 1x, 2x, or 3x $0.14 ** see formula below

(1,2, or 3 x's annual salary)**

BCBS Voluntary AD&D Coverage $5,000 $0.08 $0.08

Coverage $10,000 $0.16 $0.16

Coverage $15,000 $0.24 $0.24

Coverage $20,000 $0.32 $0.32

BCBS Voluntary Dependent Life - Coverage $10,000 $1.43 $1.43

Spouse Coverage $20,000 $2.85 $2.85

Coverage $40,000 $5.70 $5.70

Coverage $60,000 $8.55 $8.55

Coverage $80,000 $11.40 $11.40

Coverage $100,000 $14.25 $14.25

BCBS Voluntary Dependent Life - Coverage $2,500 $0.27 $0.27

Child Coverage $5,000 $0.53 $0.53

Coverage $7,500 $0.79 $0.79

Coverage $10,000 $1.05 $1.05

* For complete details, see the 2025 payroll calendar on page 61.

** Voluntary Life Calculation: Coverage Amount/$1,000 * rate = Cost

If you are an employee of a participating Trust of the City of Oklahoma City, your premium contribution rates are included on your Benefit Enrollment form.

Twice each month for a total of 24 times annually (1st and 2nd paycheck of the month)*

8 - Oklahoma City Employee Benefits Guide

As we navigate the changes that have occurred since the pandemic began, American Fidelity realizes that the most important priority is the safety and well-being of our employees and yours.

While considering adjustments you must make at your organization, you may be wondering how your partners’ business practices are changing.

We are taking a thoughtful approach and continuing to work hard to ensure safety. We will follow CDC guidelines as we approach in-person enrollments.

Here are some changes we will be incorporating:

Greetings Handshakes have been a common practice in the past. Your account manager will no longer offer their hand as a greeting.

Handouts All product and service promotional materials may be provided electronically if requested.

Sanitization Hand sanitizer will be available and account managers will disinfect the area after each session, including cleaning the 10-key pad used for signatures.

Our Game Plan to Keep Your Employees Safe

E M P L O Y E R B E N E F I T S O L U T I O N S F O R Y O U R I N D U S T R Y

Oklahoma City Employee Benefits Guide - 9

Social distancing guidelines are being implemented in most workplaces to reduce the spread of COVID-19.

We understand you will likely have safety protocols in place when your employees return to work. Many of these guidelines will take time to get used to. Please let us know how we can assist with adhering to your standards.

Before entering your building, our account representatives are prepared to do the following:

Our Promise to You

If one of our account representatives receives a positive COVID-19 diagnosis after visiting your location, we will communicate to you as soon as possible so that contact tracing can take place. Additionally, account managers that are traveling by mass transit for work or personal reasons will adhere to a 14-day quarantine before returning to your location.

We are committed to educating your employees about their available benefits and helping them complete their enrollment in as safe of an environment as possible.

Please contact your dedicated American Fidelity account manager to discuss specifics about your upcoming enrollment.

americanfidelity.com

Adhering to Your Guidelines

MKTG-125-0520

American Fidelity Assurance Company americanfidelity.com

Stay home if they are feeling sick and not return to work until authorized by a healthcare provider

Practice social distancing by following signage or limiting capacity in confined spaces

Maintain good hygiene and cleaning practices by cleaning hands often and sanitizing areas as needed

10 - Oklahoma City Employee Benefits Guide

Section 125 Cafeteria Plan Full-time employees are eligible to participate in the City’s Section 125 Cafeteria Plan. The plan allows you to pay your premiums for qualified insurance plans on a pre-tax basis, which can reduce your total taxable income and possibly increase your take-home pay.

Benefits Eligible for Section 125 Cafeteria Plan

• Group Medical Insurance

• Dental Insurance

• Vision Insurance

• Group Term Life Insurance*

• Flex Spending Accounts

* Up to $50,000 face amount for employee only

Section 125 Plan Section 125 Example

Pre-Tax Example After-Tax Example

$2,500.00 Monthly Gross Salary $2,500.00

- $280.00 Pre-Tax Medical Insurance $0.00

- $25.00 Pre-Tax Dental Insurance $0.00

$2,195.00 Adjusted Monthly Gross Salary $2,500.00

- $439.00 Estimated Federal Tax (20%) - $500.00

- $167.92 Estimated FICA (7.65%) - $191.25

$0.00 After-Tax Medical Insurance - $280.00

$0.00 After-Tax Accident Insurance - $25.00

$1,588.08 Take-Home Pay $1,503.75

* Taxes are a sample average of State, Federal and FICA taxes. Your average tax rate may vary.

Health Plan Benefits Comparison The City of Oklahoma City offers employees a choice in major medical plans: (the Preferred Provider Organization (PPO) and Exclusive Provider Organization (EPO) administered by BlueCross and BlueShield of Oklahoma.) Only you can decide the type of major medical plan that is right for you and your family. Additional information and the provider directory can be found at www.bcbsok.com/okc.

PPO Plan The PPO Plan offers a broad network of doctors, allowing you the ability to select almost any doctor or hospital. By selecting a network doctor, lower coinsurance and deductibles are available. However, non-network care is still partially covered. A prescription drug plan (administered by Prime Therapeutics) is provided with the PPO Plan. Prescription drugs must be included on the plan formulary in order to be covered.

Advantages: Choice of doctors and hospitals Disadvantages: Greater out-of-pocket expense during the plan year

EPO Plan If your preferred doctor or specialist is not in the EPO network, you must select another doctor or specialist within the EPO network in order to have your medical visits covered by the EPO plan.

Prescription drugs must be included on the plan formulary in order to be covered.

Advantages: Less out-of-pocket costs during the plan year Disadvantages: More restricted choice in doctors, hospitals, and prescription medications

Comparison The following pages provide a summary of the PPO Plan and the EPO Plan offered by the City of Oklahoma City.

This information is only a summary. If there are discrepancies between the chart and the actual plan documents, insurance contracts, or ordinances and resolutions, the plan documents, contracts, or ordinances and resolutions will govern.

NOTE: All City major medical plans include transition related health care benefits, including gender confirmation surgery, hormone therapy, and mental health counseling among other treatments. Contact your healthcare provider or health insurance provider for more information.

Want to find out what physicians, hospitals, pharmacies and more are covered under your medical plan?

Vendor information is right at your fingertips www.okc.gov/oe or back cover of this guide.

Plan Participation Employee Contribution

The City's Contribution

PPO Plan 20% of the premium 80% of the premium

EPO Plan 15% of the premium 85% of the premium

Oklahoma City Employees Retirement System (OCERS) For employees participating in the Oklahoma City Employees Retirement System (OCERS) - Benefits taken out of your paycheck on a pre-tax basis will lower your average compensation at retirement. The calculation of average compensation is reduced by any benefits elected under Section 125 according to Oklahoma City Municipal Code 40.51.6. For questions, please contact Oklahoma City Employees Retirement System (OCERS) at 405-297-3413 or 405-297-2408.

Oklahoma City Employee Benefits Guide - 11

Health Plan Benefits Comparison

Plan Features PPO Plan Network

PPO Plan Non-Network EPO Plan

Selection of Doctors Member selects from Blue Preferred network of providers

Member selects the provider of choice

Member selects from Blue Preferred network of providers

Network Provider Exceptions

N/A Penalty Applies (higher deductibles, coinsurance, & out-of-pocket maximums)

No benefits outside of network

Deductible

- Person

- Family

$250*

$500

$300*

$900

$0

$0

* Accumulators for network and non-network deductibles are separate. For example, an individual could have a total deductible of $550 ($250 network +

$300 non-network).

Coinsurance Maximum

- Individual $1,000 $3,000 N/A

Out-of-Pocket Maximums

- Individual

- Family

Deductible + Coinsurance

$3,500

Deductible + Coinsurance

Individual maximums apply for each family member

$1,500

$3,000

Lifetime Benefit Maximum No lifetime maximum No lifetime maximum No lifetime maximum

Contact Information for Additional Questions

BlueCross BlueShield of Oklahoma 877-219-4301 www.bcbsok.com/okc

How You and Your Insurer Share Costs - PPO Plan Network Example

January 1st - Beginning of Policy Period December 31st - End of Policy Period

Jane’s Plan Deductible: $250 Co-insurance: 10% Out-of-Pocket Limit: $1,250

Jane hasn’t reached her $250 deductible yet.

Her plan does not pay part of the costs.

Office visit costs: $125 Jane pays: $125 Her plan pays: $0

Jane reaches her $250 deductible, co-insurance begins.

Jane has seen a doctor several times and paid $250 in total. Her plan pays some of the costs for her next visit.* Office visit costs: $100 Jane pays: 10% of $100 = $10 Her plan pays: 90% of $100 = $90

Jane reaches her $1,250 out-of-pocket limit.

Jane has seen a doctor often and paid $1,250 in total. Her plan pays the full cost of her covered health care services for the rest of the year.

Office visit costs: $125 Jane pays: $0 * Her plan pays: $125

Jane Pays:

100%

Her Plan Pays:

0%

Jane Pays:

10%

Her Plan Pays:

90%

Jane Pays:

0%

Her Plan Pays:

100% more costs more costs

* Copayments may apply.

12 - Oklahoma City Employee Benefits Guide

Common Medical Event Services You May Need PPO Plan Network PPO Plan Non-Network EPO Plan

If you visit a health care provider’s office or clinic...

Primary care visit to treat an injury or illness

$15 copayment + deductible + 10% of eligible charges

$15 copayment + deductible + 30% of eligible charges

$30 copayment per visit

Specialist visit $15 copayment + deductible + 10% of eligible charges

$15 copayment + deductible + 30% of eligible charges

$30 copayment per visit

Preventative Care/ Screening/Immunization

Plan pays 100% Plan pays 100% Plan pays 100%

Chiropractic Care $15 copayment + deductible + 10% of eligible charges

$15 copayment + deductible + 30% of eligible charges

$30 copayment

Virtual Visit / Telehealth $15 copayment + deductible + 10% of eligible charges

$15 copayment + deductible + 30% of eligible charges

$25 copayment

If you have a test...

Diagnostic Test (x-ray, blood work)

$15 copayment + Deductible + 10% of eligible charges

$15 copayment + Deductible + 30% of eligible charges

$0

Imaging (CT/PET Scans, MRIs)

$50 copayment + Deductible + 10% of eligible charges

$50 copayment + Deductible + 30% of eligible charges

$0

If you need drugs to treat your illness or condition...

Generic Drugs $15 No Benefit $15

Preferred Brand $30 No Benefit $30

Non-Preferred Brand N/A No Benefit $65

90-day Mail Order 2 copayments for up to a 90-day supply

No Benefit 2 copayments for up to a 90-day supply

Website for more information www.myPrime.com

If you become pregnant...

Prenatal and postnatal care $15 copayment + deductible + 10% of eligible charges

$15 copayment + deductible + 30% of eligible charges

$30 copayment first visit

Delivery and all inpatient services

$50 copayment + deductible + 10% of eligible charges

Plan pays 100% for birthing centers and related physician expenses

$50 copayment + deductible + 30% of eligible charges

Plan pays 100% for birthing centers and related physician expenses

$100 copayment per admission

If you need immediate medical attention...

Emergency medical transportation

EMSA paid at 100%, deductible waived.

Non-EMSA providers:

Deductible + 10% of eligible charges

EMSA paid at 100%, deductible waived.

Non-EMSA providers:

Deductible + 30% of eligible charges

$0 copayment (prior authorization required except for emergencies)

Emergency Room $50 copayment + deductible + 10% of eligible charges

$50 copayment + deductible + 30% of eligible charges

$50 copayment, waived if admitted

Urgent Care $15 copayment + deductible + 10% of eligible charges

$15 copayment + deductible + 30% of eligible charges

$30 copayment

Oklahoma City Employee Benefits Guide - 13

The Summary of Benefits and Coverage for each plan is available at the following location:

BlueCross and BlueShield: www.bcbsok.com/okc/coverage

Common Medical Event Services You May Need PPO Plan Network PPO Plan Non-Network EPO Plan

If you have outpatient surgery...

Facility fee (e.g. ambulatory surgery center)

$50 copayment + deductible + 10% of eligible charges

$50 copayment + deductible + 30% of eligible charges

$50 copayment

Physician/Surgeon fee Deductible + 10% of eligible charges

Deductible + 30% of eligible charges

$0 copayment per visit

If you have a hospital stay...

Facility Fee (e.g. hospital room)

$50 copayment + deductible + 10% of eligible charges

$50 copayment + deductible + 30% of eligible charges

$100 copayment per admission

Physician/Surgeon Fee Deductible + 10% of eligible charges

Deductible + 30% of eligible charges

$0

If you have mental health, behavioral health, or substance abuse needs...

Mental/Behavioral Health Outpatient Services

$15 copayment + deductible + 10% of eligible charges

$15 copayment + deductible + 30% of eligible charges

$30 copayment per visit

Mental/Behavioral Health Inpatient Services

$50 copayment + deductible + 10% of eligible charges

$50 copayment + deductible + 30% of eligible charges

$100 copayment per admission

Substance Use Disorder Outpatient Services

$15 copayment + deductible + 10% of eligible charges

$15 copayment + deductible + 30% of eligible charges

$30 copayment per visit

Substance Use Disorder Inpatient Services

$50 copayment + deductible + 10% of eligible charges

$50 copayment + deductible + 30% of eligible charges

$100 copayment per admission

If you have recovery or other special health needs...

Home Health Care Deductible + 10% of eligible charges

(Maximum of 120 days)

Deductible + 30% of eligible charges

(Maximum of 120 days)

$0

Rehabilitation Services Deductible + 10% of eligible charges

Deductible + 30% of eligible charges

$100 copayment per admission

Skilled Nursing Care Deductible + 10% of eligible charges

(Limited to 120 days)

Deductible + 30% of eligible charges

(Limited to 120 days)

$0 (Limited to 100 consecutive Inpatient days per disability)

Durable Medical Equipment

Deductible + 10% of eligible charges

Deductible + 30% of eligible charges

$0 ($5,000 maximum benefit per

Calendar Year)

Hearing Services (Adult) $500 Benefit for Hearing Aid every 24 months

$500 Benefit for Hearing Aid every 24 months

$0 copayment (Limited to one hearing aid every 3 years)

If your child needs dental, eye care, or hearing services...

Eye Exam No benefit No benefit $30 copayment (One visit per year)

Glasses No benefit No benefit No benefit

Dental Check-up No benefit No benefit No benefit

Hearing Services Deductible + 10% of eligible charges on hearing aids for children age 17 and under

Deductible + 30% of eligible charges on hearing aids for children age 17 and under

No copayment on hearing aids for children age 17 and under

14 - Oklahoma City Employee Benefits Guide

Health Benefit Plans BlueCross BlueShield of Oklahoma

Prime Therapeutics

BlueCross BlueShield of Oklahoma administers the City’s Group EPO and PPO health plans. Under these health plans you may go to any physician.

However, it is to your advantage to go to a network provider to maximize your health plan’s benefits and lower out-of-pocket expenses. For questions regarding the plan or a list of Blue Cross Blue Shield of Oklahoma providers, visit the account representative on-site during the enrollment period, contact a representative of the Employee Benefits Division or visit the City’s Blue Cross Blue Shield of Oklahoma web site at www.bcbsok.

com/okc.

Prescription Plan Prime Therapeutics is the pharmacy manager for these plans. For questions, regarding your pharmacy benefits please contact the 1-877-546-2779.

Please visit, www.myPrime.com, or download the MyBlueRxOK app to compare drug costs, prescription refill reminders, search for in-network pharmacies, find drug costs, coverage information and any additional self-help inquires. The City of Oklahoma employees utilize the Basic drug list for medications approved for use and/or covered by the plan.

The Advantage network does not include CVS pharmacies. If you have prescriptions with CVS, you must transfer your prescriptions to an in-network pharmacy in order to receive benefits.

Mail Order If you are taking a covered, maintenance (or long-term) medicine, consider using the home delivery pharmacy service, Express Scripts® Pharmacy.

With home delivery, you enjoy the ease of having your maintenance drugs delivered anywhere in the U.S. You could also save time and possibly money.

To start using the home delivery pharmacy service visit express-scripts.

com/rx. Click on “Register Now” or “Get Started” to create an account using your Member ID and follow the steps, or you can call (833) 715-0942. Your doctor can send a new prescription electronically to EXPRESS SCRIPTS HOME DELIVERY, or by phone or fax.

Specialty Pharmacy Specialty medicines are used to treat conditions like multiple sclerosis, hepatitis C and rheumatoid arthritis. These prescriptions that are approved for self-administration (like oral capsules or injections you can give yourself) must be filled through an in-network specialty pharmacy to avoid paying higher out-of-pocket costs. Your drug list may have a mark for specialty drugs, and if it requires prior authorization.

Prior Authorization A prior authorization is a requirement that the physician obtain approval prior to prescribing a specific medication. Your physician will be responsible for submitting the required documentation.

Step Therapy Some medications require that alternatives be prescribed and determined to be ineffective or not appropriate treatment options. Your physician will be responsible for submitting the required documentation.

The BlueCard Program The BlueCard Program allows you to use a BlueCross BlueShield of Oklahoma EPO/PPO Physician or Hospital outside the state of Oklahoma and to receive the advantages of EPO/PPO benefits and savings.

Health Plan Provisions Coverage is provided only for a service or supply, which is “necessary for diagnosis, care or treatment of a physical or mental condition involved.”

Only that part of a charge that is “reasonable and customary” is payable.

Pre-Certification is required for inpatient hospital services, skilled nursing facility services, services received in a Coordinated Home Care Program, and private duty nursing services, at least one day prior to the scheduling of the admission.

Private room limit is the Institution’s semi-private rate. If the institution does not offer a semi-private rate, a semi-search rate will be utilized for coverage.

Medical or dental benefits paid by “other plans” will be taken into account when determining benefits under this Plan. Medicare benefits will be calculated before the medical benefits of this Plan are determined.

Claims Claims must be filed with the Claims Administrator within twelve (12) months of the date of service. Claims received after twelve (12) months will be denied.

The Claims Administrator will have discretionary authority to construe and interpret the Plans and determine whether a particular claim is covered.

BlueCross BlueShield of Oklahoma has established a process to review your dissatisfactions, complaints and/or appeals. If you have a question or complaint, an initial attempt should be made to resolve the problem by directly communicating with a BlueCross BlueShield of Oklahoma Service Representative. In most cases, a Customer Service Representative will be able to provide you with a satisfactory solution to your problem.

However if a resolution cannot be reached in an informal exchange, you may request an administrative review of the problem through the appeal process described in the Oklahoma City Medical Plan Document.

Oklahoma City Employee Benefits Guide - 15

PPO Plan – Group ID# 019574 Coinsurance Patient’s responsibility of 10 percent or 30 percent applies to coinsurance annual maximum of $1,000 network and $3,000 non-network per individual.

Prescription Plan Retail Copay (up to a 34-day supply)

Generic: $15 Name Brand: $30

Mail Order Copay (up to a 90-day supply)

Generic: $30 Name Brand: $60

EPO Plan – Group ID# 293447 In order to have medical visits covered by the plan, the provider must be included in the BlueCross BlueShield Preferred Network of Providers.

Services received from a non-network provided are not covered by the plan.

Prescription Plan Retail Copay (up to a 34-day supply)

Generic: $15 Name Brand: $30 Non-Preferred Brand: $65

Mail Order Copay (up to a 90-day supply)

Generic: $30 Name Brand: $60 Non-Preferred Brand: $130

Plan Modification and Amendment The Mayor and City Council may modify or amend the Plans from time to time at its sole discretion and such amendments or modifications may affect Covered Persons, which could include elimination of any Plan.

Right of Subrogation In the event you are injured in an accident caused by the negligence of a third party, (i.e. automobile accident, supermarket slip and fall, etc.), the Plans will pay eligible claims. However, the Plans reserve the right to recover expenses paid on your or your dependent’s behalf, from the negligent third party or from you if you receive a monetary settlement.

You are required to notify the Plan Administrator of all such injuries.

BlueCross BlueShield of Oklahoma Prime Therapeutics

Health Benefit Plans

16 - Oklahoma City Employee Benefits Guide

Employee Medical Center OKCCare Employee Medical Center

Activate your account.

[Call (XXX) XXX-XXXX to get started.]

Activate your account.

My Premise Health app | mypremisehealth.com

© 2022 Premise Health. All rights reserved.

My Premise Health is your secure patient portal that you can access online at mypremisehealth.com or through the My Premise Health app. It provides you with convenient access to your providers, health records, vital history, test results and more.

Convenience

• Schedule appointments

• Conduct virtual visits

• Get appointment confirmations and reminders

• Complete forms before your visit

Health management

• View lab results

• Manage medications

• Pay your bill

• View your visit history

The My Premise Health App is powered by MyChart® licensed from Epic Systems Corporation, © 1999 – 2022.

Get, stay and be connected.

OKC Care Employee Medical Center

424 Colcord Drive, Ste A, Oklahoma City, OK

73102 Monday – Friday, 7:30 a.m. – 4:30 p.m.

(405) 276-2030

Oklahoma City Employee Benefits Guide - 17

Employee Medical Center OKCCare Employee Medical Center

How to activate your account:

Download the My Premise Health app or visit mypremisehealth.com.

Select “Sign up now.”

For assistance, call your wellness center or email mypremisehealthsupport@ premisehealth.com. You can also visit mypremisehealth.com and click

“Contact Support.”

Helpful resources

• Find directions, hours and contact information

• Access to health and wellness education

Secure communication

• Exchange private, secure messages with your providers

• Ask a question, get advice, confirm a result or get an update on your condition

Virtual health

• Online and mobile visits allow you to engage your providers remotely

• eVisits offer treatment for common conditions via secure messaging – without the need for a face-to-face encounter

Managing your healthcare just got easier.

Schedule appointments

Conduct virtual visits

View lab results

Message your providers

Manage medications

Complete forms

Pay your bill

And more

© 2022 Premise Health. All rights reserved.

Who can use these services?

Eligible to all employees, retirees and dependents on the health plan.

18 - Oklahoma City Employee Benefits Guide

Your health at your fingertips Get information about the cost of procedures, find a doctor or request an ID card.

You can do it all – simply and securely – on Blue Access for MembersSM (BAMSM).

With BAM, you can:

• Find in-network doctors and hospitals.

• Once registered, view, print or download your member ID card.

• Review your benefits and dependent coverage.

• Covered dependents age 18 and over can have their own BAM accounts.

Scan this QR code to visit bcbsok.com.

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

Let’s get started

1. Go to bcbsok.com.

2. Log in or sign up using your member ID card to complete your registration.

Blue Access for Members BlueCross BlueShield of OklahomaOnline Access for Medical and Dental Plans

Oklahoma City Employee Benefits Guide - 19

Dental Plan BlueCross BlueShield of Oklahoma

Group ID# K19574 Employee Information This is a general summary of your benefit design. Please refer to your dental benefit booklet for other details and for limitations and exclusions.

Eligibility The following eligibility provisions apply:

• Dependent children are covered to age 26. Disabled dependent children can be covered beyond age 26.

• Retirees are eligible for coverage.

Pre-Existing Condition A pre-existing condition exclusion will apply to expenses involving the replacement of teeth that were missing prior to the effective date of the dental contract. This exclusion will not apply to:

• Any participant who becomes eligible on the dental contract date who was covered under a previous group dental care contract by the Employer.

• Any participant who has been continuously covered for 24 months under a group dental care contract with BlueCross BlueShield of Oklahoma, which included prosthetic benefits.

Limitations When the course of treatment will be in excess of $300, a predetermination request should be submitted to BlueCross BlueShield of Oklahoma in advance of treatment. It is the covered persons responsibility to ensure the request is submitted.

Freedom of Choice The dental plan allows you the freedom to choose any dentist you wish. Below highlights the differences between choosing a Contracting Network Dentist and a Non-Contracting Dentist, who is not part of BlueCross BlueShield of Oklahoma’s Dental network

Contracting Network Dentist Regardless of which plan you are enrolled in (Low Plan Option or High Plan Option), when you receive services from a Contracting Network Dentist, you receive the following advantages:

• Reduced out-of-pocket costs due to the provider accepting a negotiated (discounted) allowed amount;

• No balance billing for amounts over the allowed amount. However, you are still responsible for your co-insurance amount;

• No referral needed for specialty dentists;

• Contracting network dentists will submit claims for you.

When you receive services from a Non-Contracting Dentist, your out– of-pocket cost will be greater, as Non-Contracting Dentists do not accept any negotiated (discounted) fees. Therefore, the dentist will be reimbursed based on the Allowed Amount, as determined by the plan, and you are balanced billed for costs exceeding the BlueCross BlueShield of Oklahoma Maximum Allowable Amount.

Please note, there is a difference on how Non-Contracting Dentists are reimbursed, based on the plan you may be enrolled in:

• Low Plan Option:

Claims will be reimbursed at the Maximum Allowable Charge (MAC).

This is where the plan will pay a set dollar amount for each procedure, regardless of the actual billed charge. You will be balance billed for the difference between BlueCross BlueShield of Oklahoma MAC and the total billed charge. You are required to file claim forms.

• High Plan Option:

Claims will be reimbursed at a Usual and Customary (U&C) Allowed Amount, which is based on the geographic location of the rending dentist. The U&C Allowed Amount may be higher or lower than what your dentist charged, so you may be balanced billed for the costs exceeding the BlueCross BlueShield of Oklahoma U&C Allowable Amount.

Please note that our dental plan is a “freestanding” product and can be purchased separately from the health product (i.e., an employee can elect employee only coverage for health, but elect dental for the family).

Find out what Dentists are on your dental plan.

Visit www.bcbsok.com/okc/ coverage to find a provider or review the plan document.

20 - Oklahoma City Employee Benefits Guide20 - Oklahoma City Employee Benefits Guide Oklahoma City Employee Benefits Guide - 21

Dental High Plan BlueCross BlueShield of Oklahoma

PPO

Program Basics N o n - C o n t r a c t i n g P r o v i d e r * MAC

P r o g r a m B a s i c s Benefit Period Maximum: Calendar Year

S e r v i c e s

50%

$1,200

Effective 01/01/2024

City of Oklahoma City – High Plan The following is a listing of common services available through your BlueCare Dental PPO network. The member’s share of the cost is determined by whether care is received from a contracting or non- contracting provider.

This information only provides highlights of this program. Please refer to the BlueCare Dental Certificate for additional benefit information.

D E N T A L B E N E F I T H I G H L I G H T S

C o n t r a c t i n g P r o v i d e r

$1,500 $1,500

Deductible: Calendar Year $50 Individual $1 50 Family

$50 Individual $1 50 Family

Three Month Deductible Carryover Applies Prior Carrier Deductible Credit Applies

Yes ☒ No☐ Yes ☒ No☐

Yes ☒ No☐ Yes ☒ No☐

Diagnostic & Preventive Services (Deductible does not apply) Dental exams and Cleanings; Bitewing X-rays; Full mouth & Panoramic X-rays; Fluoride treatment

100% 100%

Miscellaneous Services (Deductible applies) Sealants; Space maintainers; Labs & tests; Emergency Care (treatment for the relief of pain)

100% 100%

Restorative Services (Deductible applies) Routine fillings (amalgams and resins); Pin retention;

Simple extractions

80% 80%

General Services (Deductible applies) Intravenous sedation; General anesthesia; Stainless steel crowns

80% 80%

80% 80%Oral Surgery Services (Deductible applies) Surgical extractions; Alveoloplasty Vestibuloplasty

Endodontic Services (Deductible applies) Root canals; Pulp caps;Apicoectomy / apexification

80% 80%

Periodontic Services (Deductible applies) Scaling & root planning; Gingivectomy / gingivoplasty;Osseous surgery; Periodontal

80% 80%

50% 50%

Prosthodontic Services (Deductible applies) Bridges and dentures; Reline / rebase of dentures;

Addition of tooth or clasp; Repair of bridges and dentures

50% 50%

Crowns, Inlay / Onlay Services (Deductible applies) Crown, Inlays / onlays; Prefabricated posts and cores;

Repair and recementation of crown, inlays / onlays

Orthodontics

Deductible Waived (standard) Orthodontic Diagnostic Procedures and Treatment:

50%

Adults eligible: ☐ No ☒ Yes Dependent Children eligible: ☐ No ☒ Yes If yes age limitation: 26

$1,200 Lifetime Maximum Benefit per Participant

Oklahoma City Employee Benefits Guide - 2120 - Oklahoma City Employee Benefits Guide Oklahoma City Employee Benefits Guide - 21

Dental Low Plan BlueCross BlueShield of Oklahoma

PPO

Program Basics N o n - C o n t r a c t i n g P r o v i d e r * MAC

P r o g r a m B a s i c s Benefit Period Maximum: Calendar Year

S e r v i c e s

50%

$1,000

Effective 01/01/2024

Orthodontics

Deductible Waived (standard) Orthodontic Diagnostic Procedures and Treatment:

30%

Adults eligible: ☐ No ☒ Yes Dependent Children eligible: ☐ No ☒ Yes If yes age limitation: 26

$1,000 Lifetime Maximum Benefit per Participant

50% 30%

Prosthodontic Services (Deductible applies) Bridges and dentures; Reline / rebase of dentures;

Addition of tooth or clasp; Repair of bridges and dentures

50% 30%

Crowns, Inlay / Onlay Services (Deductible applies) Crown, Inlays / onlays; Prefabricated posts and cores;

Repair and recementation of crown, inlays / onlays

50% 30%Oral Surgery Services (Deductible applies) Surgical extractions; Alveoloplasty Vestibuloplasty

Endodontic Services (Deductible applies) Root canals; Pulp caps;Apicoectomy / apexification

50% 30%

Periodontic Services (Deductible applies) Scaling & root planning; Gingivectomy /…