Page 4 - 2023 ANS Benefit Guide - 2-1-23
P. 4
Medical Option: Dependent Information
Our company offers employees the opportunity to cover their
dependent children. Children can join or remain on a
BCBS of Oklahoma parent’s medical plan until age 26. When a child turns 26,
Rates Per Pay Period
Coverage Tier 24 (BASE) 26 (Base) 24 (Buy-Up) 26 (Buy-Up)
Employee Only $ 67.14 $ 61.97 $103.58 $ 95.61
Employee + Spouse $194.27 $179.33 $267.16 $246.61
Employee + Child(ren) $194.27 $179.33 $267.16 $246.61
Employee + Family $336.41 $310.53 $445.74 $411.45
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G7
G746ADT (Base - PPO) PFR (Buy-Up - PPO)
In-Network Benefits Gold—Blue Advantage PPO Gold—Blue Preferred PPO
Summary **Smaller & Most Affordable Network** **Largest Network of contracted Doctors**
In and Out of Network Benefits Covered In and Out of Network Benefits Covered
Blue Advantage (in OK) Blue Preferred (in OK)
Provider Network
Blue Choice (out of OK) Blue Choice (out of OK)
Calendar Year Deductible CYD) Individual: $2,000 / Family: $6,000 Individual: $2,000 / Family: $6,000
Coinsurance after CYD Carrier 80% / Member 20% Carrier 80% / Member 20%
Annual Out-of-Pocket Max. Individual: $6,000 / Family: $17,100 Individual: $6,000 / Family: $17,100
(OOP)
Office Visit Copay:
- PCP / Specialist $30 Copay - PCP / $50 Copay -SPEC $30 Copay - PCP / $50 Copay -SPEC
Virtual Visits $30 Copay; No CYD $30 Copay; No CYD
Diagnostic X-Ray/Lab tests 20% after CYD 20% after CYD
Preventive Care (see Pg. 6) Covered 100% Covered 100%
Urgent Care $50 Copay; No CYD $50 Copay; No CYD
Emergency Room $400 Copay + 20% after CYD $400 Copay + 20% after CYD
Basic Lab/X-Ray 20% after CYD 20% after CYD
Imaging (CT/PET scans, MRI’s) 20% after CYD 20% after CYD
Hospital Inpatient/Outpatient $250 / $200 Copay + 20% After CYD $250 / $200 Copay + 20% After CYD
IN-NETWORK
Participating Pharmacies & Non Participating / Non Participating Participating / Non Participating
Participating Pref Generic: $0 / $10 Pref Generic: $0 / $10
Prescription Drugs: Non-Pref Generic: $10 / $20 Non-Pref Generic: $10 / $20
30 Day Supply or Mail order 90 Pref Name Brand: $50 / $70 Pref Name Brand: $50 / $70
Day Supply = 3 x retail copay Non-Pref Brand: $100 / $120 Non-Pref Brand: $100 / $120
Specialty Pref: $150 Specialty Pref: $150
Specialty Non Pref: $250 Specialty Non Pref: $250
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