2025 Retiree Benefits Guide.pdf

City of Oklahoma City Retiree Benefits Guide

About this Guide This benefit guide was developed to provide information about available benefit options, explain the enrollment and change process, and serve as a valuable resource for information about benefits available through the City of Oklahoma City. We recommend reading this guide before attending the annual Open Enrollment and/or completing enrollment forms. If you are married, please share the information in this guide with your spouse or beneficiary.

The guide is merely a compilation of City-sponsored retiree benefits. It is intended for informational purposes only. Actual benefits available and full descriptions of these benefits are governed in all cases by the relevant plan document, insurance company contracts, ordinances, and/or resolutions of The City of Oklahoma City. If there are discrepancies between this benefit guide and actual plan documents, insurance company contracts, ordinances and/or resolutions; the documents, contracts, ordinances and/or resolutions will govern.

Clerical Error/Delay Clerical errors will not invalidate coverage or cause coverage to be in force. Upon discovery of any such error or delay, an adjustment will be made. The City has the right to collect contributions owed by a retiree. Conversely, the retiree will be reimbursed if an overpayment occurs.

Eligibility Eligibility is determined by requirements stated in the appropriate plan document, insurance policy, plan contract, and/or certificate of coverage for the year in question. Since plans are subject to change at any time, eligibility requirements may also change. If you change coverage from one plan to another, you and your dependent must meet the requirements of the plan you have selected. An eligible retiree cannot be a member and a dependent on the same health and/or dental plan.

If any relevant fact has been misstated, whether intentionally or unintentionally, by or on behalf of any person that results in improper coverage under the Plan, the individual is subject to termination from the Plan and other appropriate action. Upon discovery of such misstatement, equitable adjustment of any contributions or benefits paid will be made.

Monthly Premiums Medical, dental, vision, and/or life insurance premiums are automatically deducted from a retiree’s pension check each month (12 times per year). As an example, for the month of May the health, dental and/or life insurance premium is deducted from the pension check issued on the last day of May. When a pension check is less than the premiums due, deductions from the pension check will cease and the retiree is responsible for the monthly payment.

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

Remember:

If you are not making any changes, you do not have to contact us or submit the enclosed election form.

If you are under age 65 and are Medicare eligible, remember to provide a copy of your Medicare card to Employee Benefits.

If you are Medicare eligible, you must enroll in Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance).

Medicare does not allow participants to be enrolled in more than one Medicare Part D prescription plan.

The City sponsored plans include either a Medicare Part D prescription drug plan or credible prescription drug coverage in lieu of Medicare Part D. If you have a non-City sponsored plan with Medicare Part D prescription drug coverage, you will need to decide which plan you wish to continue.

2025 Premium Rates* Exclusive Provider Organization (EPO) Plan Administered by BlueCross BlueShield of OK Medicare Advantage Plan Administered by United Healthcare

BlueCross BlueShield EPO (non-Medicare)

Medicare Advantage Plan (Medicare)

Total City Retiree Total City Retiree

Retiree Only $1,746.24 $873.12 $873.12 $199.78 $ 99.89 $ 99.89 Retiree + Spouse $3,929.02 $1,964.51 $1,964.51 $399.56 $199.78 $199.78 Retiree + Child $3,055.71 $1,527.85 $1,527.86 $399.56 Retiree + Children* $3,754.28 $1,877.14 $1,877.14 Retiree + Family* $5,413.12 $2,706.56 $2,706.56

*For Medicare Advantage Plan maximum covered is 3 individuals; Retiree + 2 Dependents

Group Indemnity Health Plans (PPO) Administered by BlueCross BlueShield (non-Medicare) (Medicare)

Alternate Plan Option Total City Retiree Total City Retiree Retiree Only $1,104.23 $552.11 $552.12 $480.65 $240.32 $240.33 Retiree + Spouse $2,131.16 $1,065.58 $1,065.58 $912.15 $456.07 $456.08 Retiree + Child $1,568.01 $784.00 $784.01 $674.82 $337.41 $337.41 Retiree + Children $2,031.78 $1,015.89 $1,015.89 $868.98 $434.49 $434.49 Retiree + Family $2,904.12 $1,452.06 $1,452.06 $1,236.28 $618.14 $618.14

(non-Medicare) (Medicare) Standard Plan Option Total City Retiree Total City Retiree Retiree Only $1,881.89 $940.94 $940.95 $736.73 $368.36 $368.37 Retiree + Spouse $3,632.04 $1,816.02 $1,816.02 $1,398.12 $699.06 $699.06 Retiree + Child $2,672.28 $1,336.14 $1,336.14 $1,034.35 $517.17 $517.18 Retiree + Children $3,462.67 $1,731.33 $1,731.34 $1,331.97 $665.98 $665.99 Retiree + Family $4,949.36 $2,474.68 $2,474.68 $1,894.97 $947.48 $947.49 *For Retirees eligible for subsidy, the City contributes 50% of the total premium for medical in 2025.

For Retirees not eligible for subsidy, the Retiree will be responsible for the "Total" medical premium. Retiree pays total cost for Dental, Vision and Life coverage.

$199.78 $199.78 $599.34 $299.67 $299.67 $599.34 $299.67 $299.67

Dental Plan Administered by BlueCross BlueShield Vision Plan Administered by VSP

High Plan Option Low Plan Option

Retiree Only $36.03 Retiree Only $24.43 Retiree Only $7.00

Retiree + 1 $72.03 Retiree + 1 $48.90 Retiree + 1 $12.98 Retiree + 2 or more $115.25 Retiree + 2 or more $78.19 Retiree + 2 or more $20.88

Group Term Life Insurance Administered by

Basic Life ($10,000) $18.25

For City, Fire, and Police Retirees - COTPA Retirees refer to your enrollment form

Things to Know for 2025

Open Enrollment Site Location Open Enrollment will be held at the Central Maintenance Facility located at 15th and Portland (entrance is off of SW 15th, west of Portland) on October 22nd and 23rd, 2024, from 8 AM to 4 PM. Staff will be available to answer any questions you have.

**Medicare Advantage Plan (MAPD)** For 2025, the rate for the MAPD plan will remain the same. For 2024, the City was able to secure at 50% reduction in the rates for the Medicare Advantage Plan with no change in coverage. This plan has low out-of-pocket costs for covered retirees and spouses. For retiree only coverage, your monthly cost is less than $100 per month. Additional information on the MAPD plan is on Page 10.

**457 Plan**

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 record-keepers 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. Please refer to pages 32-33 for more information.

**Retiree Self-Service Enrollment**

Due to recent IT security updates, Self-Service will be unavailable for Open Enrollment for 2025. Changes may be submitted by completing the enclosed enrollment form or by attending on-site enrollment. Additional forms, including Address Change and Group Life Beneficiary, are located at www.okc.gov/retirees.

**2025 Essential Health Benefits Maximum Out-of-Pocket Limits** (Retirees and Dependents without Medicare) The Affordable Care Act (ACA) establishes a maximum annual out-of-pocket amount for in-network Essential Health Benefits (EHBs). This provision does not apply to the Medicare secondary plan or the Medicare Advantage plan as outlined in the Affordable Care Act. Copays, coinsurance and deductibles for all in-network plan benefits generally apply toward the out-of-pocket limits. For plan year 2025, the maximum essential health benefits in-network out-of-pocket limits for the City of Oklahoma City’s plans are as follows:

BlueCross BlueShield PPO Plans:

Medical and Prescription Benefit combined:

Plan Medical and Prescription Benefit

$9,200 retiree only coverage $18,400 retiree + 1 or more dependent(s)

$9,200 retiree only coverage $18,400 retiree + 1 or more dependent(s)

**Beneficiary Update/Changes for Retiree Group Life** The City recommends that you provide updated beneficiary information at least every five years. Although your beneficiaries and/or designation of proceeds may not have changed, your beneficiaries address and/ or contact information may not be current. Please take this opportunity to complete the Group Life Beneficiary Designation form located on the retiree website: www.okc.gov/retirees

**Dependent Verification** Employee Benefits may periodically request verification to ensure current documentation for dependents enrolled in the City’s medical and dental plans are on file. You may receive a letter requesting documentation for verification of eligibility. You must comply with the request. Failure to do so may result in loss of coverage for your dependent(s). You do not need to contact Employee Benefits to inquire about your file. If your file is selected for verification, you will receive a letter.

Contents:

2025 Premium Rates 4

Things to Know for 2025 5

Important Dates to Remember 7

How To Enroll 8

About Your Coverage 8-9

Plan 4

BlueCross BlueShield PPO Plans 8

Wellness 1

OKCCare Medical Center 22

Dental Plans 24

Vendor Directory

For most current up to date retiree information, please visit www.okc.gov/retirees (QR Code Below).

You will find important plan information and links that will assist you in keeping up to date regarding your benefit elections.

Vision

Back Cover

Notices (including Medicare Part D Disclosure) 4

Retiree Group Term Life

Deferred Compensation Plan

Important Dates to Remember…

Open Enrollment Dates Times Location Coverage Period

October 22, 2024 through

October 23, 2024 a.m. to 4 p.m.

Tuesday-

January 1, 2025 through

December 31, 2025

Open Enrollment will be held at:

Staff will be available October 22- October 23 (see times below) to answer questions and provide assistance. No appointments are necessary.

As a result of the COVID-19 pandemic, there may be limited vendors present this year at the on-site enrollment. This change was necessary to maximize space for social distancing. If you need to reach a vendor, please refer to the back page of this guide.

If you do not make any plan changes, your premiums will automatically adjust to the new rates for the 2025 plan year. Rates are on page 3 of this guide.

Two Ways to Enroll

Enroll On-Site Staff members will be available at the

. See page 6 for dates and times for on-site enrollment.

Enroll by Mail Complete your personalized Enrollment Statement included in your enrollment packet and return by 8, 2024. Additional enrollment instructions are provided on your statement.

If you are not making any changes, it is not necessary to contact us or return your enrollment statement..

How to Enroll in your Benefits:

About Your Coverage

Who is eligible for coverage?

Spouse and eligible child(ren) up to age 26 (disabled children over age 26 incapable of self-support) are eligible for medical, dental, and vision coverage at the time of initial enrollment or eligibility (birth and/or marriage). Elections must be made within 31 days of qualifying event. Retirees are responsible to provide any required supporting documents that estab-lishes eligibility. Retirees and eligible dependents must maintain continuous coverage. Once coverage is waived, coverage cannot be re-elected at a later date.

Surviving spouse may elect coverage at initial enrollment for any child(ren) that were cov-ered at the time of retiree’s death. New spouses and any new dependents are not eligible to be added to a survivor’s elected coverages.

Which medical plan is right for me?

The City offers retirees four health plan options - the plan, Medicare Advantage Plan, the Group Indemnity Alternate Plan, and the Group Indemnity Standard Plan. Each plan offers a large network of providers, prescription drug benefits, and basic medical and preventive care such as office visits and immunizations.

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Which medical plan am I eligible to enroll myself and/or dependents?

Myself and ALL covered dependent(s) are not Medicare eligible Plan

BCBS Group Indemnity Plan (Standard or Alternate option), non-Medicare rate

Myself or at least one covered dependent(s) are Medicare eligible but not ALL covered individuals BCBS Group Indemnity Plan (Standard or Alternate option), Medicare rate

Myself and ALL covered dependent(s) are Medicare eligible UHC Medicare Advantage Plan (MAPD) BCBS Group Indemnity Plan (Standard or Alternate option), Medicare rate

HIPAA Compliance The City of Oklahoma City advises members of the Group Indemnity Health Plan that the HIPAA Notice of Privacy Practices is available to you by accessing the internet. Simply type in the following information in the address field - www.okc.gov and navigate to Careers → Benefits to download a copy of the Notice of Privacy Practices. If you do not have access to the internet and you would like a copy of the HIPAA Notice of Privacy Practices, or if you have any questions, please contact a representative of the Employee Benefits Division at (405)297-2144.

About Your Coverage

UnitedHealthcare® Group Medicare Advantage (PPO) is a Medicare Advantage plan that delivers all the benefits of Original Medicare (Parts A and B), includes prescrip on drug coverage (Part D) and offers addi onal benefits and features. It is not a supplement plan and does not pay secondary to Medicare. All claims are submi ed directly to UnitedHealthcare for payment, not Medicare.

When you join a Medicare Advantage plan, it is considered Part C. Part C is the combined coverage of Medicare Parts A and B with addi onal benefits administered by the plan. Instead of paying for Medicare deduc bles and coinsurance, you pay health plan premiums, co-insurance and co-payments.

This health plan is a rac ve to re rees. Monthly premiums and/or out of pocket expenses can be much less than other plans. This plan is the complete Medicare solu on offered by the City. All par cipants must be eligible for Medicare and maintain enrollment in Part A and B.

To enroll in the Medicare Advantage Plan, you must no fy Employee Benefits a minimum of 31 days prior to the effec ve date of Medicare and/or start of coverage. Addi onal informa on can be found at re ree.uhc.com.

IMPORTANT NOTE: If you enroll in another Medicare Advantage Plan and/or Part D prescrip on drug plan, you will automa cally be disenrolled from the City’s MAPD plan. This is a Medicare rule.

Highlights include:

No Deduc ble - Low Copays for Office Visits and Prescrip ons Na onwide access - You have access to our na onwide coverage. You can see any provider (in-network or out-of-network) at the same cost share, as long as they accept the plan and have not opted out of or been excluded or precluded from the Medicare Program.

Prescrip on drugs - Your Medicare Part D prescrip on drug coverage includes thousands of brand name and generic prescrip on drugs. Check your plan’s drug list to see if your drugs are covered. Prescrip on copays will remain at the same low copay through all phases of Medicare Part D prescrip on coverage program.

Telephonic Nurse Support- Speak to a registered nurse 24/7 about your medical concerns at no addi onal cost to you.

Renew Rewards - Renew by UnitedHealthcare is our health and wellness experience that helps empower you to take charge of your well-being every day. It provides a wide variety of useful resources and ac vi es, including brain games, healthy recipes, learning courses, fitness ac vi es and more. Plus, you may be eligible to earn rewards by comple ng certain health care ac vi es such as your annual physical or wellness visit.

Renew Ac ve® – Renew Ac ve® is the gold standard in Medicare fitness programs for body and mind, available at no addi onal cost. You’ll receive a free gym membership with access to the largest Medicare fitness network of gyms and fitness loca ons. This includes access to many premium gyms, on-demand digital workout videos and live streaming classes, social ac vi es and access to an online Fitbit® Community for Renew Ac ve and access to an online brain health program from AARP® Staying Sharp® (no Fitbit device is needed.)

Virtual Visits - See a doctor or a behavioral health specialist using your computer, tablet or smartphone.

With Virtual Visits, you’re able to live video chat — any me, day or night. You will first need to register and then schedule an appointment.

HouseCalls -With UnitedHealthcare® HouseCalls, you get a yearly in-home visit from one of our health care prac oners at no extra cost. A HouseCalls visit is designed to support, but not take the place of, your regular doctor’s care. Every visit includes tailored recommenda ons based on health care screenings.

Benefit Highlights

CITY OF OKLAHOMA CITY

Effective January 1, 2025 to December 31, 2025

This is a short summary of your plan benefits and costs. See your Summary of Benefits for more information. Or review the Evidence of Coverage for a complete description of benefits, limitations, exclusions and restrictions. Benefit limits and restrictions are combined in- and out-of-network.

Plan costs

In-network and out-of-network

Annual medical deductible No deductible

Annual medical out-of-pocket maximum

(the most you pay in a plan year for covered medical care)

Your plan has an annual combined in-network and out-of-network out-of-pocket maximum of $6,700 for this plan year.

Medical benefits

Medical benefits covered by the plan and Original Medicare

In-network and out-of-network

Doctor’s office visit

Primary care provider (PCP) $5 copay

Specialist $5 copay

Virtual visits $0 copay

Preventive services

Medicare-covered $0 copay

Inpatient hospital care $0 copay per stay

Skilled nursing facility (SNF) $0 copay per day up to 100 days

Outpatient surgery $0 copay

Outpatient rehabilitation

Physical, occupational, or speech/ language therapy

$5 copay

Outpatient mental health

Group therapy $5 copay

Individual therapy $5 copay

Virtual visits $5 copay

Diagnostic radiology services such as MRIs, CT scans

$0 copay

Lab services $0 copay

Medical benefits

Medical benefits covered by the plan and Original Medicare

In-network and out-of-network

Outpatient X-rays $0 copay

Therapeutic radiology services such as radiation treatment for cancer

$0 copay

Ambulance $0 copay

Emergency care $50 copay (worldwide)

Urgently needed services $5 copay (worldwide)

Additional benefits and programs not covered by Original Medicare

In-network and out-of-network

Routine physical $0 copay; 1 per plan year*

Chiropractic – routine $5 copay, 12 visits per plan year*

Foot care – routine $5 copay, 6 visits per plan year*

UnitedHealthcare

Healthy at Home post-discharge program $0 copay for 28 meals, 12 rides (one-way), and 6 hours of non-medical personal care up to 30 days following all inpatient and SNF discharges. Referral required.

Hearing – routine exam $0 copay, 1 exam per plan year*

Hearing aids

UnitedHealthcare Hearing

Plan pays a $500 allowance for hearing aids (combined for both ears) every 2 years. Hearing aids purchased outside of UnitedHealthcare Hearing’s nationwide network are not covered.

Vision – routine eye exam $0 copay, 1 exam every 12 months*

Vision – routine eyewear Plan pays $130 for eyeglasses or $175 for contact lenses instead of eyeglasses, every 12 months.*

Fitness program

Renew Active® by UnitedHealthcare $0 copay for a standard gym membership at participating locations

24/7 Nurse Support Receive access to nurse consultations and additional clinical resources at no additional cost.

Personal emergency response system

(PERS)

Lifeline

$0 copay for a personal emergency response system.

Rally Coach™ programs $0 copay for the Rally Coach™ Programs:

Real Appeal® Weight Management, Real Appeal Diabetes Prevention, Wellness Coaching and a tobacco cessation program.

*Refer to your Evidence of Coverage for eligibility requirements.

*Benefits are combined in and out-of-network

Plan inform ation

Prescription drugs Your cost

Initial coverage stage Network pharmacy (30-day retail supply)

Mail service pharmacy (90-day supply)

Tier 1: Preferred Generic $10 copay $20 copay

Tier 2: Preferred Brand 1 $20 copay $40 copay

Tier 3: Non-Preferred Drug 1 $40 copay $80 copay

Tier 4: Specialty Tier 1 $40 copay $80 copay

Coverage gap stage After your total drug costs reach $5,030, the plan continues to pay its share of the cost of your drugs and you pay your share of the cost

Catastrophic coverage stage During this payment stage, the plan pays the full cost for your covered drugs. You pay nothing.

1 You will pay a maximum of $35 for a 1-month supply of each Part D insulin product covered by our plan. Most adult Part D vaccines are covered at no cost to you.

Your plan sponsor offers additional prescription drug coverage. Please see your Additional Drug Coverage list for more information.

Retiree plan prospects must meet the eligibility requirements to enroll for group coverage. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premium and/or copayments/coinsurance may change each plan year.

The Drug List (Formulary), pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

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Plan Features BCBS EPO Plan

Eligibility Retirees and covered dependents NOT Medicare eligible

Selection of Doctors and Hospitals

Member selects from the Blue Preferred network of providers

Network Provider Exceptions No benefits outside of network

Deductible

-Individual $0

-Family $0

Out-of-Pocket Maximums (Does not include premiums)

-Individual $1,500

-Family $3,000

Lifetime Benefit Maximum No lifetime benefit maximum

Contact Information for Additional Questions

BlueCross BlueShield of Oklahoma 1-877-219-4301 www.bcbsok.com/okc

Prescription Plan

Generic Drugs

Preferred Brands

Non-Preferred Brands

90-day Mail Order

$15 (in-network only)*

$30 (in-network only)*

$65 (in-network only)*

2 copayments for up to a 90-day supply

Contact Information for Additional Questions www.myPrime.com

1-877-546-2779

*No benefit for out-of-network providers.

Common Medical Event

Services You May Need

BCBS EPO Plan

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

Primary care visit to treat an injury or illness $30 copayment per visit

Specialist visit $30 copayment per visit

Screening / Immunization Plan pays 100%

Chiropractic Care $30 copayment

If you have a test Diagnostic test (x-ray, blood work) $0

Imaging (CT/PET scans, MRIs) $0

If you have a hospital stay

Facility fee (e.g. hospital room) $100 copayment per admission

Physician / Surgeon fee $0

If you have outpatient surgery

Facility fee (e.g. ambulatory surgery center) $50 copayment

Physician/surgeon fee $0

If you need immediate medical attention

Emergency medical transportation $0 copayment (prior authorization required except for emergencies)

Emergency Room $50 copayment, waived if admitted

Urgent care $30 copayment

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

Mental/Behavioral health outpatient services $30 copayment per visit

Mental/Behavioral health inpatient services $100 copayment per admission

Substance use disorder outpatient services $30 copayment per visit

Substance use disorder inpatient services $100 copayment per admission

If you have recovery or other special health needs

Home health care $0

Rehabilitation services $100 copayment per admission

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

Durable medical equipment $0 ($5,000 maximum benefit per Calendar Year)

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

Vision Benefit $30 copayment (one visit per year)

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 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 Authoriza on A prior authoriza on is a requirement that the physician obtain approval prior to prescribing a specific medica on. Your physician will be responsible for submi ng the required documenta on.

Step Therapy Some medica ons require that alterna ves be prescribed and determined to be ineffec ve or not appropriate treatment op ons. Your physician will be responsible for submi ng the required documenta on.

Group ID #293447

BlueCross BlueShield of Oklahoma administers the City’s Group EPO health plan. Under this health plan 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 BlueCross BlueShield of Oklahoma PPO providers, visit the account representative on-site during the enrollment period, contact a representative of the Employee Benefits Division or visit the City’s BlueCross BlueShield of Oklahoma web site at www.bcbsok. com/okc.

Prescription Plan

Prime Therapeutics is the pharmacy manager for this Plan. 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 utilizes 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.

Specialty Pharmacy

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 Group Indemnity Healthcare Plan Document.

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.

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

Plan Features BlueCross BlueShield Standard

BlueCross BlueShield Alternate

Eligibility Retirees and dependents Retirees and dependents

Selection of Doctors and Hospitals

Member selects from the Blue Preferred PPO for in-network of providers. For out-of-network benefits, member selects the provider of choice.

Member selects from the Blue Preferred PPO for in-network of providers. For out-of-network benefits, member selects the provider of choice.

Deductible*

-Individual $250 (in-network), $300 (out-of-network) $750 (in-network), $750 (out-of-network)

-Family $500 (in-network), $900 (out-of-network) $2,250 (in-network), $2,250 (out-of-network)

*Accumulators for in-network and out-of-network deductibles are separate. For example, an individual could have a total deductible of $1,500 ($750 in-network + $750 out-of-network)

Coinsurance 10% of eligible charges (in-network)

30% of eligible charges (out-of-network)

20% of eligible charges (in-network)

40% of eligible charges (out-of-network)

Coinsurance Maximum

-Individual $1,000(in-network), $3,300 (out-of-network) $1,750 (in-network), $3,250 (out-of-network)

-Family $3,000(in-network), Individual maximum applies to each family member out-of-network $1,750 (in-network), $3,250 (out-of-network)

Annual Out-of-Pocket Maximums (does not include premiums)

-Individual Deductible + Coinsurance Deductible + Coinsurance

-Family Individual maximums apply for each family member up to family maximum (in-network).

Individual maximums apply for each family member up to family maximum.

Lifetime Benefit Maximum

No lifetime benefit maximum No lifetime benefit maximum

Contact Information for Additional Questions BlueCross BlueShield of Oklahoma

1-877-219-4301 www.bcbsok.com/okc

Prescription Plan

Generic Drugs $15 (in-network only)* $15 (in-network only)* Preferred Brands $30 (in-network only)* $30 (in-network only)*

Non-Preferred Brands $30 (in-network only)* $60 (in-network only)*

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

Contact Information for Additional Questions www.myPrime.com 1-877-546-2779

*No benefit for out-of-network providers.

s

Common Medical Event

Services You May Need

BlueCross BlueShield Alternate

BlueCross BlueShield Standard

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

Primary care visit to treat an injury or illness

$25 copay + deductible + coinsurance

$15 copay + deductible + coinsurance

Specialist visit $25 copay + deductible + coinsurance

$15 copay + deductible + coinsurance

Screening / Immunization Plan pays 100% Plan pays 100%

Chiropractic Care $25 copay + deductible + coinsurance

$15 copay + deductible + coinsurance

If you have a test Diagnostic test (x-ray, blood work)

$25 copay + deductible + coinsurance

$15 copay + deductible + coinsurance

Imaging (CT/PET scans, MRIs) $50 copay + deductible + coinsurance

$50 copay + deductible + coinsurance

If you have a hospital stay

Facility fee (e.g. hospital room) $100 copay + deductible + coinsurance

$50 copay + deductible + coinsurance

Physician / Surgeon fee Deductible + coinsurance Deductible + coinsurance

If you have outpatient facility services

Facility fee (e.g. ambulatory surgery center)

$50 copay + deductible + coinsurance

$50 copay + deductible + coinsurance

Physician/surgeon fee Deductible + coinsurance Deductible + coinsurance

If you need immediate medical attention

Emergency medical transportation

EMSA paid at 100%, deductible waived.

Other providers: deductible + coinsurance

EMSA paid at 100%, deductible waived.

Other providers: deductible + coinsurance

Emergency Room $50 copay + deductible + coinsurance

$50 copay + deductible + coinsurance

Urgent care $25 copay + deductible + coinsurance

$15 copay + deductible + coinsurance

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

Mental/Behavioral health outpatient services (office visit)

$25 copay + deductible + coinsurance

$15 copay + deductible + coinsurance

Mental/Behavioral health inpatient services

$100 copay + deductible + coinsurance

$50 copay + deductible + coinsurance

Substance use disorder outpatient services (office visit)

$25 copay + deductible + coinsurance

$15 copay + deductible + coinsurance

Substance use disorder inpatient services

$100 copay + deductible + coinsurance

$50 copay + deductible + coinsurance

If you have recovery or other special health needs

Home health care Deductible + coinsurance (Maximum of 120 days)

Deductible + coinsurance (Maximum of 120 days)

Rehabilitation services Deductible + coinsurance Deductible + coinsurance

Skilled nursing care Deductible + coinsurance (Limit 120 days)

Deductible + coinsurance (Limit 120 days)

Durable medical equipment Deductible + coinsurance Deductible + coinsurance

Vision Benefit No benefit No benefit

*Not available to COTPA retirees s *Not available to COTPA retirees

Group ID #019574

BlueCross BlueShield of Oklahoma administers the City’s Group PPO health plan. Under this health plan 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 ques ons regarding the plan or a list of BlueCross BlueShield of Oklahoma PPO providers, visit the account representa ve on-site during the enrollment period, contact a representa ve of the Employee Benefits Division or visit the City’s BlueCross BlueShield of Oklahoma web site at www.bcbsok. com/okc.

Two PPO Plan Op ons

There are two plan op ons available: Alternate Plan and Standard Plan. Summary charts are available on the previous pages to iden fy the differences.

Medicare

The plan offers re rees and covered dependents to be split par cipants under one plan. Split par cipant coverage is when one or more individual(s) is Medicare eligible and the other covered individual(s) are not Medicare eligible. Premiums reduce to the Medicare rate upon the first individual reaching Medicare eligibility. No further reduc ons in rate occurs for subsequent covered inindividual(s) becoming Medicare eligible.

Once a par cipant becomes Medicare Eligible, Medicare becomes the primary payer. BCBS will process claims and payments based on enrollment in Part A and B. Failure to maintain enrollment in Part A and/or Part B will result in you being responsible for payment of services that would have been covered under Medicare.

Prescrip on Plan

Prime Therapeutics is the pharmacy manager for this Plan. 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 utilizes 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/Home Delivery 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 Authoriza on A prior authoriza on is a requirement that the physician obtain approval prior to prescribing a specific medica on. Your physician will be responsible for submi ng the required documenta on.

• Step Therapy Some medica ons require that alterna ves be prescribed and determined to be ineffec ve or not appropriate treatment op ons. Your physician will be responsible for submi ng the required documenta on.

Fitness and Fun!

at Willa D. Johnson Recreation Center

909 Frederick Douglass Ave., Oklahoma City, OK 73117 405-297-1435

Weekdays: 7 a.m. to 8 p.m.

Saturday: 9 a.m. to 6 p.m.

Child Watch: $2/hour for up to two hours

Premium Programming Available:

Camps • Leagues • Swim Lessons • Lap Lane Rentals • Facility Rentals

Pr og ra m s

Monthly Memberships

GOLD SILVER DAY PASS

Family $45 - - Adult $25 $15 $6

Youth* $15 $10 $5 Fitness Center

Open Gym

Open Swim

Gaming Lounge

Computer Stations

Passive Spaces

Child Watch

Cooking

Social

Sports

Games

Art

* $5/month youth discount available through scholarship endowment

Frequently Asked Questions OKC Care Employee Medical Center

© 2023 Premise Health. All rights reserved.

Who can use the center?

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

What services are provided at the center?

• Annual physicals

• Preventive exams

• Chronic condition management

• Pediatric Care

• Lab services

• Flu shots

• Vaccinations

• Acute and urgent care

• Women’s health

What are the center’s hours?

Where is the center located?

How do I make an appointment?

Monday - Friday, 7:30 a.m. 4:30 p.m.

OKC Care Employee Medical Center is conveniently located on/near City of

Oklahoma City campus at 424 Colcord Drive, Oklahoma City, OK 73102.

To schedule an appointment, you can call OKC Care directly at 405-276-2030 or make an appointment online. Download the My Premise Health app, or visit mypremisehealth.com to register for a portal account and schedule an appointment.

Follow these steps to schedule your appointment using the My Premise Health app or online at mypremisehealth.com.

Select a provider, date and time for your visit.

provide any information you’d like your provider to know, such as questions or symptoms you scheduling through the portal, Your appointment is your wellness center at your scheduled time. eCheck-In is not required for in-person complete the process if you would like.

Select your desired appointment type select “Schedule an Appointment.”

account with your username and password. If you don’t have an account, you can create one using the “Sign Up Now” option.

For support, call your wellness center, email mypremisehealthsupport@ premisehealth.com or visit mypremisehealth.com and click “Contact Support” for assistance.

Choose your location (if 1

Get started today.

Log in or sign up for your account mypremisehealth.com.

© 2023 Premise Health. All rights reserved.

How to schedule an appointment at OKC Care Employee Medical Center.

OKC Care Employee Medical Center

(405) 276-2030 | mypremisehealth.com

The My Premise Health App is powered by MyChart® licensed from

Epic Systems Corporation, © 1999 – 2023.

Group ID# K19574 Employee Information This is a general summary of your benefit d esign. P lease refer t o 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).

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 / gingivoplasty;Osseous surgery; Periodontal

50% 30%

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

Simple extractions

80% 60%

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

80% 60%

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%

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

City of Oklahoma City – Low 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

$1,000 $1,000

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

Enroll in VSP® Vision Care to get access to savings and personalized vision care from a VSP network doctor for you and your family.

Value and savings you love.

Save on eyewear and eye care when you see a VSP network doctor. Plus, take advantage of Exclusive Member Extras which provide offers from VSP and leading industry brands totaling over $3,000 in savings.

Provider choices you want.

With private practice doctors and Visionworks retail locations to choose from nationwide, getting the most out of your benefits is easy at a VSP Premier EdgeTM location.

Quality vision care you need.

You’ll get great care from a VSP network doctor, including a WellVision Exam®. An annual eye exam not only helps you see well, but helps a doctor detect signs of eye conditions and health conditions, like diabetes and high blood pressure.

Using your benefit is easy!

Create an account on vsp.com to view your in-network coverage, find the VSP network doctor who’s right for you, and discover savings with Exclusive Member Extras. At your appointment, just tell them you have VSP.

More Ways to Save

Extra

$20 to spend on

Featured Frame Brands† and more

See all brands and offers at vsp.com/offers.

Up to

40% Savings on lens enhancements‡

A Look at Your VSP Vision Coverage With VSP and CITY OF OKLAHOMA CITY, your health comes first.

Enroll through your employer today.

Contact us: 800.877.7195 or vsp.com

Your VSP Vision Benefits Summary CITY OF OKLAHOMA CITY and VSP provide you with an affordable vision plan.

FREQUENCYCOPAYDESCRIPTIONBENEFIT

Your Coverage with a VSP Provider

Every calendar year$10WELLVISION EXAM Focuses on your…