Benefit details

CommunityCare is pleased to offer the benefits outlined below to OU-Tulsa employees who select the HMO option for their health insurance needs. Please note that the information below is only a summary. For a complete plan description that includes exclusions and limitations, please refer to the benefit plans for medical, mental health and prescription drug coverage.

OU-Tulsa Medical Benefits Summary ▪ Plan Year 2010

Plan Features - CommunityCare HMO Benefit Plan 12A

Individual Deductible		None
Family Deductible		None
Plan Coinsurance		None
Individual Coinsurance Maximum		$2,000
(Out-of-pocket maximum)
Family Coinsurance Maximum		$4,000

Physician Services
PCP Office Visit		$20 copay
Specialist Office Visit		$30 copay
Inpatient Hospital		$100 copay per day (max. $500 copay per admission)
Outpatient Hospital		Included in outpatient surgical facility charge
Urgent Care		$40 copay

Hospital Services
Inpatient		$100 copay per day (max. $500 copay per admission)
Outpatient Surgical Facility		$100 copay per visit
Outpatient Surgery		$20 copay (PCP) / $30 copay (specialist)

Emergency Services
Emergency Room		$100 copay
Ambulance		No copay

Preventive Care Services
Preventive Care Maximum		Not applicable
Routine Physical Exam		$20 copay
Well-Child Care		$20 copay
Routine Ob/Gyn Exam		$20 copay
Routine Mammogram		No additional copay
Routine PSA Test & Digital Rectal Exam		$20 copay
Routine Hearing Exams		$20 copay
Routine Eye Exam		$20 copay

Diagnostic X-ray and Lab
Physician Office		Lab - no copay; outpatient radiology - $30 copay;
		MRI/CT/PET Scans - $100 copay
Outpatient Hospital or Other Facility		Lab - no copay; outpatient radiology - $30 copay;
		MRI/CT/PET Scans - $100 copay

Allergy Treatment
Testing		$20 copay (PCP) / $30 copay (specialist)
Injections in Office		$20 copay (PCP) / $30 copay (specialist)
Serum		50% copayment

Family Planning Services
Voluntary Sterilization		$20 copay (add'l variable copays may apply to some procedures)
Infertility		50% copayment for evaluation
Contraceptives		Oral contraceptives - subject to prescription benefit copays



Maternity
Physician Office		$20 copay for initial maternity care visit only
Hospital		$100 copay per day (max. $500 copay per admission)

Mental Health and Alcohol and Drug Services
Inpatient Mental Health and Alcohol and Drug Services		$100 copay per day (max. of $500 copay per admission)
Partial Hospitalization for Mental Health and Alcohol and Drug Services		$50 copay per day (max. of $250 copay per admission)
Intensive Outpatient Mental Health and Alcohol and Drug Services		$25 copay per day (maximum of $125 copay per admission)
Outpatient Mental Health and Alcohol and Drug Services		$30 copay per visit

Hospice Care Services
Inpatient		$100 copay per day (max. $500 copay per admission)
Outpatient		No copay

Skilled Nursing/Convalescent Facility
Skilled Nursing Facility		$25 copay per day
Maximum		Up to 60 consecutive treatment days per disability

Other Services
Durable Medical Equipment		20% copayment
Home Health Care		No copay
Private Duty Nursing		Not covered
Short-term Rehabilitation		Inpatient - $100 copay/day; Outpatient - $30 copay/visit
Spinal Disorders/Chiropractic Therapies		$30 copay

Prescription Medication Coverage
Retail (30-day supply)
Select Generics		$0
Preferred Generics		$10
Preferred Brand		$35
Non-Preferred Brand or Generics		$60

Mail Order Drug Program
Mail Order Select Generics		$0
Mail Order Preferred Generics		$20
Mail Order Preferred Brand		$70
Mail Order Non-Preferred Brand or Generics		$120
Mail Order Maximum Supply		90-day supply

Diabetic Supplies		20% copayment
Oral Contraceptives		Subject to prescription benefit copays
Viagra		4 tablets per 30-day supply

Questions during open enrollment? Contact Bonnie Martinez at (918) 594-5295 Ext. 6299 or bonnie@ccok.com.