Page 4 - 2024 FINAL Citizens Bank Benefit Guide

BCBS of Oklahoma:

Medical Plan: Preferred PPO

MOBPF0043

Per Pay Period
Dependent Information
Employee Only $ 40.00
Citizens Bank of Ada offers employees the oppor-
Employee + Spouse $188.37 tunity to cover their spouse and dependent chil-
Employee + Child(ren) $155.70 dren. Children can join or remain on a parent’s
medical plan until age 26.
Employee + Family $253.68

Members Cost
In-Network Out-of-Network
Benefit Overview

Annual Calendar Deductible (CYD) Individual: $1,000 Individual: $1,500
January 1 to December 31 Family: $3,000 Family: $4,500
Member: 20% Member: 40%
Co-Insurance
Insurance Carrier: 80% Insurance Carrier: 60%

Annual Out of Pocket Maximum Individual: $3,000 Individual: $9,000
(Includes, CYD, Co-Pays, Co-Insurance) Family: $9,000 Family: $27,000
Maximum Benefit (some limits apply) Unlimited

Physician Services:
Primary Office Visit $20 Copay 40% After Annual Deductible
Specialist Office Visit $20 Copay 40% After Annual Deductible
Virtual Visit (MDLive) 24/7 $0 Copay Not Covered
Virtual Office Visits (Including Psychiatric) $0 Copay 40% After Annual Deductible
Chiropractic Office Visit (Limits Apply) $20 Copay 40% After Annual Deductible
Acupressure Office Visit (Limits Apply) $20 Copay 40% After Annual Deductible
Preventive Care Covered 100% Not Covered
Labs / X-rays / Tests:

Lab / X-ray (Diagnostic) - See Booklet details Covered 100% 40% After Annual Deductible
Lab (Preventive) Covered 100% 40% After Annual Deductible
X-ray (Preventive) Covered 100% 40% After Annual Deductible
CT, PET, MRI, MRA (Major) 20% After Annual Deductible 40% After Annual Deductible

Urgent Care $50 Copay 40% After Annual Deductible
20% After CYD (Emergency
Emergency Room $100 Copay plus 20% After CYD 40% After CYD (Non-Emergency
Pharmacy Retail 30 Days: Network Pharmacies Non-Network Pharmacies
Pharmacy Deductible NONE NONE
Generic (Preferred/Non-Preferred) $0 - $20 Copay / No Charge—Mail Order $0 - $20 Copay + 50% coinsurance
Brand (Preferred) $35-$55 Copay / $87.50 Copay Mail Order $55 Copay plus 50% coinsurance
Brand (Non-Preferred) $75-$95 Copay / $187.50 Mail Order $55 Copay plus 50% coinsurance
Specialty Drugs (30 Days) $150—$250 $150—$250 plus 50% coinsurance

NOTE: This is only a brief overview. Please see Benefit Summary for more details.
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Website: www.bcbsok.com or Customer Service: 1-800-942-5837