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HealthChoice Health Plan Handbook

The information provided in this handbook is a summary of the benefits, conditions, limitations and exclusions of the HealthChoice High, High Alternative, Basic and Basic Alternative Plans and High Deductible Health Plan (referenced herein as plan or plans). It should not be considered an all-inclusive listing. All references to you and your relate to the plan member.

This health handbook replaces and supersedes any health handbook the Office of Management and Enterprise Services Employees Group Insurance Division previously issued. This health handbook will, in turn, be superseded by any subsequent health handbook OMES issues.


PLEASE READ THIS HANDBOOK CAREFULLY

The Office of Management and Enterprise Services Employees Group Insurance Division provides health care benefits to eligible state, education and local government employees, former employees, and their dependents in accordance with the provisions of 74 O.S. § 1301, et seq.The information provided in this handbook is a summary of the benefits, conditions, limitations and exclusions of the HealthChoice High, High Alternative, Basic and Basic Alternative Plans and High Deductible Health Plan (referenced herein as plan or plans). It should not be considered an all-inclusive listing. All references to you and your relate to the plan member.

  • Plan benefits are subject to conditions, limitations and exclusions, which are described and located in Oklahoma statutes, handbooks and Administrative Rules adopted by the plan administrator. You can obtain a copy of the official Administrative Rules from the Office of the Oklahoma Secretary of State. An unofficial copy of the rules is available on the EGID website at omes.ok.gov. In the menu bar under Services, select Employees Group Insurance Division. Under Resources, select About EGID, then select Administrative Rules.
  • A dispute concerning information contained within any plan handbook or any other written materials, including any letters, bulletins, notices, other written document or oral communication, regardless of the source, shall be resolved by a strict application of Administrative Rules or benefit administration procedures and guidelines as adopted by the plan. Erroneous, incorrect, misleading or obsolete language contained within any handbook, other written document or oral communication, regardless of the source, is of no effect under any circumstance.


INFORMATION AVAILABLE ONLINE

healthchoiceconnect.com

This online tool is designed to give you quick and easy access to your benefit information. HealthChoice Connect provides you with member and dependent coverage information, a link to the Tobacco-Free Attestation which includes verification of other insurance coverage for coordination of benefits during the annual Option Period, temporary member health and pharmacy ID cards and claim information. If you haven’t already registered for HealthChoice Connect, create a unique username and password to access your information. Your covered dependents ages 18 and older must register independently for HealthChoice Connect.

HealthChoice app

The HealthChoice app is designed to give you immediate access to all your benefit information on your phone or tablet. You can easily retrieve a digital copy of your health and pharmacy insurance cards. The app also offers live texting capabilities which allow you to chat directly with a Care Guide expert 24/7. These Care Guides can answer all your benefit questions, help you set appointments and direct you to $0 HealthChoice services if you are eligible. Download the HealthChoice app from your favorite app store for Apple and Android devices.

omes.ok.gov

Select Services in the menu bar and choose HealthChoice. This provides more information for HealthChoice members.

Note: Refer to healthchoiceconnect.com for any temporary COVID-19 expanded benefits in 2021.

Customer Care
Medical Benefit Coverage, Claims, Certification Inquiries and Medical Records

HealthChoice Customer Care

800-323-4314

TTY 711
healthchoiceconnect.com

Claims and correspondence
P.O. Box 99011
Lubbock, TX 79490-9011

Appeals and provider inquiries
P.O. Box 3897

Little Rock, AR 72203-3897

Pharmacy benefits
Pharmacy Benefit Manager
CVS Caremark
CVS Customer Care: 877-720-9375
Specialty Pharmacy: 800-237-2767

Pharmacy Prior Authorization: 800-294-5979

TTY 711

Caremark.com

SwiftMD telemedicine service
833-980-1442
SwiftMD.com

Subrogation administrator
McAfee & Taft405-235-9621 or 800-235-9621
Two Leadership Square, 10th Floor
211 N. Robinson Ave.Oklahoma City, OK 73102

Eligibility and enrollment
EGID Member Services
405-717-8780 or 800-752-9475

TTY 711

Plan names
HealthChoice High, High Alternative, Basic, Basic Alternative and High Deductible Health Plan

Plan administrator
Office of Management and Enterprise Services Employees Group Insurance Division
405-717-8780 or 800-752-9475
TTY 711
2401 N. Lincoln Blvd., Ste. 300

Oklahoma City, OK 73105
healthchoiceok.com

You can seek care from a network provider or a non-network provider; however, the amount you are responsible for paying is greatly increased when you use a non-network provider. With a statewide and multistate network of more than 24,000 physicians, hospitals and other health care professionals and facilities, the HealthChoice Provider Network is one of the largest in Oklahoma.

Finding a HealthChoice network provider

You can find a HealthChoice network provider by going to healthchoiceconnect.com.You can also contact Customer Care to find a network provider. A Customer Care member advocate can give you the names of network providers in your area.

If you are unable to locate a HealthChoice network provider in your area, you can nominate a provider for participation by completing the online provider nomination form or contacting EGID Member Services.

Refer to HealthChoice Plan Contact Information.

Importance of selecting a HealthChoice network provider

Network providers are contracted with HealthChoice and have agreed to accept HealthChoice allowable amounts for the services and equipment they provide. Network providers have agreed not to bill you for charges that are greater than allowable amounts. You are still responsible for your plan’s copays, deductibles, coinsurance and charges for non-covered services.

Non-network providers are not contracted with HealthChoice and have not agreed to accept allowable amounts. This means you are responsible for paying the difference between the amount the provider bills and allowable amounts. This process, known as balance billing, can be a large amount of money out of your own pocket. Even after you reach your plan’s out-of- pocket maximum, you are still responsible for all amounts above allowable amounts when you use non-network providers.

HealthChoice Select Program

HealthChoice Select is available to any HealthChoice health plan member and provides specified medical services at no cost to the member. If you have one of the qualifying HealthChoice Select procedures done at a participating HealthChoice Select facility for that procedure, there is no copay, deductible or coinsurance applied. Note: High Deductible Health Plan members must meet their annual deductible before they are eligible to have any costs waived (unless the service is considered preventive). However, since HealthChoice Select facilities accept one consolidated bundled payment for certain procedures at a reduced rate, HDHP members can still save by utilizing a Select facility for one of these procedures.

In addition to offering these services at no cost to you, HealthChoice will also pay you a $100 incentive payment when you have a qualifying colonoscopy or sigmoidoscopy at a Select participating facility. Note: HealthChoice will pay High Deductible Health Plan members who have a qualifying preventive colonoscopy or sigmoidoscopy done at a participating Select facility $100 even if your deductible hasn’t been met.

If HealthChoice is not the primary payer, the Select benefit does not apply.

To find out what other procedures qualify under the HealthChoice Select Program and which network facilities throughout Oklahoma are participating for those procedures, go to healthchoiceconnect.com. HealthChoice Customer Care member advocates are also available to help guide you through the HealthChoice Select process and ensure that all members have a positive, beneficial experience. Refer to HealthChoice Plan Contact Information.

Plan features

If you use the HealthChoice medical or pharmacy provider networks, you are responsible for:

  • Office visit copays.
  • Calendar year deductibles.
  • Coinsurance.
  • Calendar year out-of-pocket maximum.

Calendar year deductible

No member must contribute more than the individual deductible. Once the individual deductible is met, the member shares the cost of services with HealthChoice by paying coinsurance. A family deductible applies when three or more family members are covered and can be met by any combination of the family members. Once the family deductible is met, coinsurance will begin for everyone.

Deductible High vs High Alternative Plan pricing

High Plan
High Alternative Plan
Individual deductible $750 Individual deductible $1,000
Family deductible $2,000 Family deductible $2,750

 

Copayments

Service Copay

General physician office visit (network general practitioners, internal medicine physicians, OB/GYNs, pediatricians, physician assistants and nurse practitioners)

$30

Urgent care (urgent care visits at a network urgent care facility)

$30

Specialist office visit (network specialist providers)

$50

Emergency department (network or non-network visit; waived if the patient is admitted to the hospital or if death occurs prior to admission)

$200

Non-network inpatient admission (non-network hospital/facility admissions; patient is subject to balance billing)

$300

Preventive services (qualified preventive care office visits and services)

$0

*This is the fixed amount you pay for certain services, and they apply before you meet your deductible, but they do not count toward meeting your deductible.

Coinsurance

You must meet the deductible before coinsurance applies. You are responsible for the cost of all non-covered services regardless of your provider’s network or non-network status.

Coinsurance Network
Non-Network
Member Pays
20% of allowable amount 50% of allowable amount*
Healthcare pays
80% of allowable amount 50% of allowable amount

*Plus, you pay the difference between the amount billed by the provider and the allowable amount.

Calendar year out-of-pocket maximum

No member contributes more than the individual maximum. Once the individual maximum is met, HealthChoice then pays 100% of the allowed amount for that person. A family maximum applies when three or more family members are covered and can be met by any combination of the family members. HealthChoice then pays 100% of the allowable amounts for covered services for everyone on the plan.

High Plan
High Alternative Plan
Network individual $3,300 Network individual $3,550
Network family $8,400 Network family $8,400
Non-network individual $3,800 Non-network individual $4,050
Non-network family $9,900 Non-network family $9,900


Charges that do not count toward the out-of-pocket maximum

The following charges do not count toward meeting the out-of-pocket maximum and do not qualify for 100% payment after the out-of-pocket maximum is met:

  • Amounts above HealthChoice allowable amounts.
  • Non-network copays.
  • Non-covered services or charges.
  • Amounts above maximum benefit limitations.

**Some services have an annual cap on the dollar amount or the total number of visits that will be covered. After the annual limit is reached, you must pay all associated health care costs for the remainder of the calendar year.

No lifetime maximum per member.

Plan features

If you use the HealthChoice medical or pharmacy provider networks, you are responsible for:

  • Calendar year deductibles.

  • Coinsurance.

  • Calendar year out-of-pocket maximum.

First dollar coverage

For each enrolled member, this is the initial amount that HealthChoice pays towards allowable amounts for network and/or non-network covered services before anything is owed by you. This includes, but is not limited to, amounts for office visits, lab work, X-rays, surgical procedures, hospital admissions, etc. Expenses for non-covered services and any expense over the allowable amount for non-network services do not qualify for first dollar coverage. Once your first dollar coverage limit is reached, you will be responsible for meeting your deductible.

Basic Plan
Basic Alternative Plan
First dollar coverage $500 First dollar coverage $250


Calendar year deductible

After your first dollar coverage has been met, network and/or non-network allowable amounts for covered services go toward your deductible. No member must contribute more than the individual deductible. Once the individual deductible is met, the member shares the cost of services with HealthChoice by paying coinsurance. A family deductible applies when two or more family members are covered and can be met by any combination of the family members. Once the family deductible is met, coinsurance will begin for everyone.

Basic Plan
Basic Alternative Plan
Individual deductible $1,000 Individual deductible $1,250
Family deductible $1,500 Family deductible $1,750


Copayments

You have no network copays on the Basic and Basic Alternative plans. You only have one non- network copay of $300, which is for a non-network hospital/facility inpatient admission.

Coinsurance

You must meet the deductible before coinsurance applies. You are responsible for the cost of all non-covered services regardless of your provider’s network or non-network status.

COINSURANCE Network
Non-Network
Member pays
50% of allowable amount 50% of allowable amount*
HealthChoice pays
50% of allowable amount 50% of allowable amount

*Plus, you pay the difference between the amount billed by the provider and the allowable amount.

Calendar year out-of-pocket maximum

No member contributes more than the individual maximum. Once the individual maximum is met, HealthChoice then pays 100% of the allowed amount for that person. A family maximum applies when three or more family members are covered and can be met by any combination of the family members. HealthChoice then pays 100% of the allowable amounts for covered services for everyone on the plan.

Basic Plan
Basic Alternative Plan
Individual deductible $1,000 Individual deductible $1,250
Family deductible $1,500 Family deductible $1,750


Charges that do not count toward the out-of-pocket maximum

The following charges do not count toward meeting the out-of-pocket maximum and do not qualify for 100% payment after the out-of-pocket maximum is met:

  • Amounts above HealthChoice allowable amounts.
  • Non-network copays.
  • Non-covered services or charges.
  • Amounts above maximum benefit limitations.

**Some services have an annual cap on the dollar amount or the total number of visits that will be covered. After the annual limit is reached, you must pay all associated health care costs for the remainder of the calendar year.No lifetime maximum per member.

Plan features

If you use the HealthChoice medical and pharmacy provider networks, you are responsible for:

  • Calendar year deductible.
  • Office visit copays.
  • Coinsurance.
  • Calendar year out-of-pocket maximum.

Calendar year deductible

Both pharmacy and medical expenses apply toward the combined deductible in the HDHP only. There is not a separate pharmacy deductible with HDHP as there is in the High and Basic Option plans.For families of two or more, the family deductible must be met before benefits for any member will be paid by the plan. The deductible can be met by one individual or any combination of covered family members. Once the family deductible is met by any combination of covered family members, coinsurance and copayments will begin for everyone.

Individual
Family
Deductible $1,750 Deductible $3,500


CopaymentsThis is the fixed amount you pay for certain services, and most copays only apply after you meet your deductible.

 

Service
Copay
General physician office visit (network general practitioners, internal medicine physicians, OB/GYNs, pediatricians, physician assistants and nurse practitioners) $30*
Urgent care (urgent care visits at a network urgent care facility) $30*
Specialist office visit (network specialist providers) $50*
Emergency department (network or non-network visit; waived if the patient is admitted to the hospital or if death occurs prior to admission) $200
Non-network inpatient admission (non-network hospital/facility admissions; patient is subject to balance billing) $300
Preventive services (qualified preventive care office visits and services) $0


*Applies after deductible is met.


Coinsurance

You must meet the deductible before coinsurance applies. You are responsible for the cost of all non-covered services regardless of your provider’s network or non-network status.

Coinsurance Network Non-Network
Member pays 20% of allowable amount 50% of allowable amount*
HealthChoice pays 80% of allowable amount 50% of allowable amount

*Plus, you pay the difference between the amount billed by the provider and the allowable amount.


Calendar year out-of-pocket network maximum

No member contributes more than the individual maximum. Once the individual maximum is met, HealthChoice then pays 100% of the allowed amount for that person. A family maximum applies when two or more family members are covered and can be met by any combination of the family members. HealthChoice then pays 100% of the allowable amounts for covered services for everyone on the plan.

Network Individual
Network Family
$6,000 calendar year maximum $12,000 calendar year maximum


Charges that do not count toward the out-of-pocket maximum

The following charges do not count toward meeting the out-of-pocket maximum and do not qualify for 100% payment by HealthChoice after the out-of-pocket maximum is met:

All non-network expenses, including:

  • Non-network covered services up to the allowable amount.
  • Non-network expenses above the HealthChoice allowable amount.
  • Non-network pharmacy charges.
  • Non-network pharmacy expenses.
  • Non-covered services or charges.
  • Amounts above maximum benefit limitations.

**Some services have an annual cap on the dollar amount or the total number of visits that will be covered. After the annual limit is reached, you must pay all associated health care costs for the remainder of the calendar year.

No lifetime maximum per member

 

 

 


Covered services, supplies and equipment are based on use of network or non-network providers and are subject to plan provisions and criteria for coverage. Covered services through a non-network provider are subject to balance billing. Some services are covered only through network providers. Refer to HealthChoice High and High Alternative Plans, HealthChoice Basic and Basic Alternative Plans or HealthChoice High Deductible Health Plan.

This is not a comprehensive list. Some services may have limited coverage and/or require certification of medical necessity for coverage; refer to Plan Exclusions or Certification for additional information. For questions or information benefits or coverage, contact HealthChoice Customer Care. Refer to HealthChoice Plan Contact Information.

Acupuncture

  • Covered only as alternative to anesthesia for surgery.

Allergy serum, treatment and testing

  • Limited to one battery of 60 tests every 24 months; excludes testing of the home environment.

Ambulance

  • Air and ground services.
  • Refer to Emergency Care Coverage for additional information.

Anesthesia

  • Eligible services for covered illness or surgery.

Autism spectrum disorders

  • Screening and diagnosis services provided by a licensed physician or a licensed doctoral-level psychologist.
  • Specific to applied behavior analysis:
    • Treatment services provided by a Board Certified Behavior Analyst (BCBA), a licensed physician or psychologist, Board Certified Assistant Behavior Analyst (BCaBA) or a Registered Behavior Technician who is under the direction and close supervision of the BCBA, BCaBA, physician or psychologist for up to eight years.
    • Proposed treatment plan with script is required upon receipt of the first claim each rolling year from a medical doctor or clinical psychologist.Services are limited to 25 hours per week and no more than $25,000 per calendar year.
    • Other calendar year benefit limitations do not apply for treatment (e.g., limits of 60 per calendar year); other plan provisions apply.
  • Refer to Preventive Services for additional information.


Bariatric surgery

  • Must be age 18 or older and HealthChoice must be patient’s primary insurance.
  • Must be covered by HealthChoice for 12 consecutive months prior to surgery
  • Must be performed at a network bariatric facility.

Birthing center

  • Must be associated with an inpatient obstetrical and neonatal facility.

Blood and blood products

  • Processing, storage and administration of blood and blood products in inpatient and outpatient settings, including collection and storage of autologous blood.

Breast pumps

  • Refer to Preventive Services for additional information.

Chelation therapy

  • Covered only for heavy metal poisoning.

Chemotherapy

  • Home, outpatient or inpatient services when medically necessary.
  • Refer to Pharmacy Benefits for medication coverage.

Chiropractic therapy

  • Limited to 20 visits per calendar year without certification; maximum of 60 visits per year.
  • Includes manipulative therapy.

Clinical trials

  • Must be registered with the U.S. National Library of Medicine at clinicaltrials.gov or with the National Cancer Institute at cancer.gov.
  • Routine medical care services required for the provision of the item or service associated with the clinical trial.Includes standard lab work, MRI, CT and PET scans.

Cochlear implant device

  • Analysis, implant and related services/supplies
Continuous positive airway pressure (CPAP)/bilevel positive airway pressure (BiPAP)
 
  • Covered as durable medical equipment/supplies.
  • Unit covered as rent-to-purchase once every five years when medically necessary.
  • Unit supplies limited to once every 90 days, no more than four times per calendar year.
Contraceptive services
 
  • Implantable contraceptives (e.g., Implanon).
  • Diaphragm or cervical cap.
  • Depo Provera injections.
  • Elective sterilization – tubal ligation, vasectomy.
  • IUD insertion, surgical removal and equipment.
  • Refer to Preventive Services and Pharmacy Benefits for additional information.
Corrective lenses
 
  • Eyeglasses one time following cataract surgery.
  • Contact lenses for the diagnosis of keratoconus when medically necessary, limited to one set per calendar year.
Dental accident
 
  • Medically necessary treatment for the repair of traumatic injury to sound natural teeth or gums, provided the accident and treatment occur while the individual is a member under the health plan and the treatment is performed within 12 months following the date of the accident.
Diabetic services
 
  • Equipment and supplies covered as durable medical equipment/supplies.
    • Continuous glucose monitor.
    • Insulin pumps and related supplies.
  • Education services limited to 10 visits per calendar year.
  • Refer to Pharmacy Benefits for additional information.
Durable medical equipment and supplies
 
  • Purchase, rental, repair and/or replacement when medically necessary.
Emergency department treatment
 
  • Refer to Emergency Care Coverage.
Foot orthotics
 
  • Covered as durable medical equipment/supplies with a diagnosis of diabetes.
  • Limit of one pair of therapeutic shoes and three inserts per foot per calendar year.
Fundus photography
 
  • Coverage includes diabetes, glaucoma and macular degeneration.
Gynecological examinations
 
  • Routine and diagnostic services.
  • Refer to Preventive Services for additional information.
Hearing aids
 
  • Limit of one per impaired ear every 48 months up to the age of 18 when medically necessary.
  • Limit of four additional ear molds per calendar year for children up to age of 2.
  • Must be prescribed, filled and dispensed by a licensed audiologist.
Hearing exams and tests
 
  • Limit of one hearing screening and one hearing test per calendar year.
  • Refer to Preventive Services for additional information.
Home health care and medications
 
  • Limited to 100 visits per calendar year when medically necessary.
    • Home visit/nursing care.
    • Home health aide.
    • Administration of medication and injections.
    • Occupational, physical and speech therapy.
Hospice
 
  • Inpatient services when medically necessary.
  • Hospice services in the home or in a long-term care facility when medically necessary.
    • Requires a physician’s statement of life expectancy of six months or less.
Hospital services
 
  • Inpatient – Requires admission to a health care facility (i.e., hospitals, skilled or long- term acute care facilities).
    • Includes observation stays 48 hours or more.
  • Outpatient – Does not require admission to a health care facility (i.e., hospitals or surgical centers).
    • Includes observation stays less than 48 hours.
Infertility services
 
  • Diagnostic testing – Includes hysteroscopy, lab tests, ultrasounds and hysterosalpingograms.
  • Treatment is limited to prescription coverage only.
Infusion therapy
 
  • Home services when medically necessary.
    • Not subject to home health care limitations.
  • Outpatient or inpatient services when medically necessary.
Mammogram
 
  • Routine and diagnostic services.
  • Refer to Preventive Services for additional information.
Maternity care
 
  • Prenatal and postnatal care; including office visits, lab work and ultrasound.
  • Hospital facility and physician services for delivery.
  • One skilled nurse home health visit if the delivery is at home or in a birthing center.
  • Refer to Preventive Services for additional information.
Mental health treatment
 
  • Inpatient, outpatient, intensive outpatient, residential and partial hospital services when medically necessary.
  • Outpatient services limited to 20 visits per calendar year without certification; maximum 60 visits per calendar year.
  • Refer to Autism spectrum disorder in this section for specific coverage details and ABA services.
  • Refer to Preventive Services for additional information.
Nurse midwife services
 
  • Provider must be a certified nurse midwife and licensed by the state in which services are provided.
Occupational therapy
 
  • Home, inpatient and outpatient services.
  • Outpatient services limited to 20 visits per calendar year without certification; maximum 60 visits per calendar year.
Office visits
 
  • Routine and diagnostic.
  • Refer to Preventive Services for additional information.
Oral surgery
 
  • Inpatient and outpatient services when medically necessary.
  • Includes removal of tumors or cysts, osteotomies, arthroplasties and mandibular/ maxillary reconstruction
Organ transplants
 
  • Non-experimental transplant of (human origin) bone marrow, peripheral stem cells, cornea and the following solid organs: kidney, liver, pancreas, kidney/pancreas, heart, lung, heart/lung and/or intestine when medically necessary.
  • Procurement and harvesting.
    • Donor charges covered if recipient is covered by HealthChoice; limited to 90 days following transplant.
Ostomy supplies
  • Supplies covered as durable medical equipment/supplies.
  • Education services are limited to three visits per calendar year.
  • Refer to Pharmacy Benefits for additional information.
 
Oxygen and respiratory equipment
 
  • Covered as durable medical equipment/supplies.
Physical therapy/physical medicine
 
  • Home, inpatient and outpatient services.
  • Outpatient services limited to 20 visits per calendar year without certification; maximum 60 visits per calendar year.
  • Includes manipulative therapy services.
Preventive services
 
  • Refer to Preventive Services.
 
Prostheses/orthopedic appliances

  • Covered as durable medical equipment/supplies.
Radiology
 
  • Routine and diagnostic.
  • Includes X-rays, ultrasounds, mammograms, imaging scans (MRI, CT, PET).
  • Refer to Preventive Services for routine coverage information.
Rehabilitation
 
  • Inpatient and outpatient services when medically necessary.
  • Refer to Physical therapy/physical medicine, Occupational therapy, Speech therapy and Mental health treatment.
Skilled nursing facility
 
  • Limit of 100 days per calendar year when medically necessary.
Speech therapy
 
  • Home, inpatient and outpatient services.
  • Outpatient services limited to 60 visits per calendar year.
  • For members under 18 years of age, coverage is limited to restoring existing speech loss due to disease or injury when medically necessary.
    • Therapy must be expected to restore the level of speech the member had before the disease or injury.
Standby services
 
  • Surgeon, assistant surgeon, perfusionist and anesthesiologist, when medically necessary and in attendance during the surgery.
  • Standby services must be documented in the patient’s medical record and include time in attendance.
Substance use disorder
 
  • Inpatient, outpatient, intensive outpatient, residential and partial hospital services when medically necessary.
Telemedicine/telehealth services
 
  • Refer to Telemedicine/Telehealth Services.
Ultrasound
 
  • Routine and diagnostic services.
Ultraviolet treatment – actinotherapy
 
  • Covered only for psoriasis.
Vaccinations/immunizations for adults and children
 
  • Covered in accordance with the current Centers for Disease Control and Prevention guidelines.
  • Refer to Preventive Services for additional information.
Wigs and scalp prostheses
 
  • Covered as durable medical equipment/supplies.
  • Limited to one wig or one scalp prosthesis per calendar year for individuals who experience hair loss due to radiation or chemotherapy treatment resulting from a covered medical condition.
  • Must be obtained from a licensed cosmetologist or durable medical equipment provider.

Certification is a review process used to determine if services are medically necessary according to HealthChoice guidelines. Certification is also referred to as prior authorization, precertification or preauthorization. All HealthChoice plans require certification for coverage of specified services. Certification approval does not guarantee benefits. Clinical editing and other plan policies, provisions and criteria apply.

Guidelines

Providers are responsible for obtaining certification. To request certification, your provider must contact Customer Care or go online to healthchoiceconnect.com to complete the online request form. For non-urgent services, certification requests must be initiated within three working days prior to the scheduled service. For urgent services, certification must be initiated within one day following the service. Services rendered in an emergency department and/or ambulance are not subject to certification requirements. For more information on the difference between emergency and urgent services, refer to Plan Definitions.

If certification approval is not obtained for services that require it and/or if certification is denied either before or after the services are provided, claims for those services will be denied. For certifications approved after services are provided, a 10% penalty deduction on the allowable amounts may be applied. Network providers are not allowed to impose certification penalties on members or their covered dependents. If you use a non-network provider, you should ensure that the provider obtains certification prior to receiving services. Otherwise, you may be held responsible for paying the full amount (if certification is denied) or the 10% penalty (if applied because of late certification), as well as any billed amounts over allowable amounts (balance billing).For more detailed information on certification, contact Customer Care. Refer to HealthChoice Plan Contact Information.

Medical services that require certification

  • Bariatric surgery (eligibility criteria also required).
  • Chiropractic therapy.
    • Required only after initial 20 visits per calendar year.
    • Visits are limited to 60 total per calendar year (some exceptions apply).
  • Drugs and medical injectables (some exceptions apply).
    • Required for specified medications covered under the HealthChoice medical benefit; this is not inclusive of requirements under the HealthChoice pharmacy benefit.
    • Required for Botox Injections that are non-cosmetic and rendered in the physician’s office.
  • Durable medical equipment.
  • Enteral feeding.
  • Foot orthotics.
  • Genetic testing.
  • Glucose monitors: continuous.
  • Hearing aids.
  • Home health care (visits limited to 100 per calendar year).
    • Home intravenous therapy (not subject to home health care limits).
  • Hyperbaric oxygen therapy (outpatient).
  • Inpatient admissions.
  • Maternity care.
    • Required if patient and baby are not discharged within 48 hours of vaginal delivery or within 96 hours of C-section delivery.
  • Mental health treatment.
    • Inpatient, residential and partial hospitalization.
    • Required for outpatient services after initial 20 visits per calendar year.
    • Required initially for intensive outpatient therapy services.
    • Required initially for transcranial magnetic stimulation treatment.
    • Required initially for esketamine.
    • Required initially for Applied Behavioral Analysis services.
  • Myocardial PET scan.
  • Observation stays 48 hours or longer.
  • Occupational therapy (outpatient).
    • Required after initial 20 visits per calendar year.
  • Oral splints and appliances (some exceptions apply).
  • Oral surgery (inpatient/outpatient).
  • Outpatient surgical procedures:
    • Blepharoplasty.
    • Mammoplasty (including reduction, removal of implants and symmetry).
    • Correction of lid retraction.
    • Panniculectomy.
    • Rhinoplasty.
    • Septoplasty.
    • Varicose vein surgeries and procedures.
      • Including sclerotherapy.
    • Sleep apnea related surgeries, limited to:
      • Radiofrequency ablation (coblation, somnoplasty).
      • Uvulopalatopharyngoplasty, including laser-assisted procedure.
  • Organ transplants.
  • Oxygen.
  • Physical medicine/physical therapy (outpatient).
    • Required only after initial 20 visits per calendar year.
    • Visits are limited to 60 total per calendar year (some exceptions apply).
  • Prophylactic and gynecomastia mastectomies.
  • Prostheses and orthopedic appliances (some exceptions apply).
  • Proton beam radiation therapy.
  • Skilled nursing facility.
  • Speech therapy.
    • Required only for age 17 years and younger.
    • Visits limited to 60 total per calendar year (some exceptions apply)
  • Spinal cord stimulator placement and revision.
  • Spinal surgical procedures
    • Cervical
    • Lumbar.
    • Thoracic.
  • Substance use disorder treatment.
    • Inpatient, residential and partial hospitalization.
    • Outpatient services after initial 20 visits per calendar year.
    • Intensive outpatient treatment.
  • Unlisted and not otherwise specified – required for specified codes.

The term emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) so that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part. This is in accordance with section 1867(e)(1)(A) of the Social Security Act (42 U.S.C. § 1395dd(e)(1)(A).

  • All related facility and professional emergency department claims, and all ambulance transport claims are processed in accordance with your network benefits, regardless of network status. This includes your plan provisions for copays, deductible and coinsurance.
    • You are still responsible for any charges for non-covered services.
    • If you receive services from a non-network provider, you are responsible for charges above the allowable amount if you are billed by the provider (balance billing).
    • There is a $200 emergency room copay for each emergency department visit under the High Option plans and the HDHP. The Basic Option plans do not require a $200 emergency room copay.
      • This copay is waived if the patient is admitted or death occurs prior to admission.
      • Certification is required for the inpatient admission. Refer to Certification.
      • If emergency treatment cannot be provided, and the patient is referred to another emergency room for treatment, the emergency room copay is waived on the emergency room that could not provide treatment.

HealthChoice offers additional assistance and coverage for out-of-state emergency services. To request assistance or additional benefits, call Customer Care. Refer to HealthChoice Plan Contact Information.

These are covered services provided for overall health maintenance — such as routine health/ wellness exams and tests, vaccinations, well-baby care and well-child care. Health screenings and wellness exams can discover problems you may not know you have. The earlier problems are found, the greater the opportunity for treatment.

HealthChoice covers qualifying preventive care services at 100% of allowable amounts when rendered by a participating network provider. Qualifying coverage may be determined by age, gender or other factors. There may be exceptions, limitations or clinical criteria to qualify for these services at no cost. If you receive services during a preventive care visit other than for qualifying preventive care, you may have to pay for those services.In addition to Affordable Care Act specific requirements, HealthChoice follows the recommendations of the United States Preventive Services Task Force and The American Academy of Pediatrics Bright Futures recommendations for the basis of coverage and criteria.

For more details on qualifying preventive care services and coverage criteria, you can visit healthchoiceconnect.com or contact Customer Care and a member advocate will be happy to assist you. Refer to HealthChoice Plan Contact Information.


Preventive services

This is not an all-inclusive list. Qualifying coverage criteria may apply.

  • Abdominal aortic aneurysm screening.
  • Alcohol misuse: screening and counseling.
  • Blood pressure screenings.
  • BRCA screening/assessment.
  • Breast cancer screening.
  • Breastfeeding supply and services.
  • Cervical cancer screening.
  • Colorectal cancer screening.
  • Depression screening.
  • Diabetes Prevention Program (CDC recognized).
  • Diabetes screening.
  • Gonorrhea screening.
  • Newborn screening and medication.
  • Hepatitis B screening.
  • Hepatitis C screening.
  • HIV screening.
  • Intimate partner violence screening.
  • Lung cancer screening.
  • Obesity screening.
  • Osteoporosis screening.
  • Prenatal screenings, services and tests.
  • Sexually transmitted infection screening.
  • Tobacco use counseling.
  • Tuberculosis screening.
  • Vaccinations.
  • Vision screening (children).

Vaccinations for adults and children

Vaccinations, including the vaccine and its administration, are covered under both medical and pharmacy benefits. Qualifying preventive vaccinations are covered at 100% by the plan when using a network pharmacy or medical provider, such as a physician or health department.

HealthChoice covers all CDC-recommended vaccinations through a network pharmacy or provider, such as for shingles, under the preventive services benefits. There may be limitations or qualification criteria for coverage. When using a non-network provider, you are subject to non-network benefits and can be balance billed for amounts above the allowable amounts.

Please note that free-standing ambulatory care clinics located inside pharmacies, grocery stores or supercenters may not be participating network providers, and your services may not be covered at these locations. Always verify network provider status by visiting the HealthChoice website or calling Customer Care. Refer to HealthChoice Plan Contact Information.

The following vaccinations are covered under medical or pharmacy benefits:

  • Anthrax.
  • Flu.
  • Haemophilus influenzae.
  • Hepatitis A.
  • Hepatitis B.
  • Human papillomavirus.
  • Influenza A.
  • Influenza HD.
  • Japanese encephalitis.
  • Measles.
  • Meningococcal.
  • Mumps.
  • Pneumococcal.
  • Poliomyelitis.
  • Rabies (human diploid).
  • Rabies (purified chick embryo cell vaccine).
  • Rotavirus.
  • Rubella.
  • Shingrix (shingles).
  • Smallpox (vaccinia) vaccine.
  • Tetanus booster.
  • Tetanus, diphtheria, pertussis.
  • Typhoid.
  • Varicella.
  • Yellow fever.
  • Zoster (shingles).

This list is not all-inclusive.Due to the rapidly changing conditions of COVID-19, refer to healthchoiceconnect.com for updated COVID-19 preventive service coverage.

SwiftMD offers medical consults from board certified physicians via telephone or teleconference 24/7 for eligible members. Services include many common and minor illnesses or injuries such as allergies, rashes, fever, flu, pink eye, sinusitis and sore throat. SwiftMD is easy to use and helps prevent unnecessary emergency department/urgent care visits or long waits for doctor appointments. All SwiftMD physicians have a minimum of 10 years of practice experience.

SwiftMD is available to HealthChoice members who are 3 or older. For HealthChoice High and Basic Option Plan members, there is $0 cost per visit with no limitations. For HDHP members, refer to your HealthChoice member materials. SwiftMD is available toll-free 833-980-1442 or by visiting SwiftMD.com. Be sure to activate your SwiftMD membership online before calling for an appointment.

HealthChoice also offers telehealth coverage for select services. Standard plan provisions apply including copays, deductible and coinsurance.

Note: Refer to healthchoiceconnect.com for any temporary COVID-19 expanded benefits in 2021.

The pharmacy benefits of the HealthChoice High, High Alternative, Basic and Basic Alternative Plans and High Deductible Health Plan include the following features:

  • Electronic point-of-sale claims processing.
  • An extensive pharmacy network.
  • Coverage of up to a 90-day supply of medication at mail and retail for the applicable copay.
  • Coverage of certain tobacco cessation medications for $0 copay.

Note: Specific therapeutic categories, medications and/or dosage forms may have more restrictive quantity and/or duration of therapy limitations. Pharmacy benefits are subject to and limited by your physician’s orders. Refer to Medications Limited in Quantity in this section.HealthChoice pharmacy benefits include the following provisions:

  • Generic medications are preferred medications. If no generic exists, then a preferred brand-name medication is usually the next least expensive choice.
  • If you choose a non-preferred medication instead of a preferred medication, you are responsible for the higher non-preferred copay.
  • If you choose a brand-name medication when a generic is available, you are responsible for the difference in cost, plus the copay.
  • The cost difference between generic and brand-name medications, medications purchased at non-network pharmacies and excluded medications do not count toward your pharmacy out-of-pocket maximum.
  • Certain medications require prior authorization for coverage. Refer to Pharmacy Prior Authorization in this section.
  • Ostomy bags and wafers are covered under both medical and pharmacy benefits.
  • Diabetic supplies, including insulin syringes with needles, testing strips, lancet devices and glucometers are covered under pharmacy benefits; quantity limitations apply.

HealthChoice pharmacy network

In Oklahoma, there are more than 930 pharmacies that participate in the HealthChoice pharmacy network. Nationwide, there are nearly 68,000 participating pharmacies. To locate a HealthChoice network pharmacy, go to healthchoiceconnect.com or contact the pharmacy benefit manager. Refer to HealthChoice Plan Contact Information.

Network pharmacy benefits

Pharmacy deductible Before benefits are available for HealthChoice High, High Alternative, Basic and Basic Alternative plan members, the separate pharmacy deductible of $100 per individual/$300 maximum per family must be met, and for HDHP members, the combined medical and pharmacy deductible of $1,750 individual/$3,500 per family must be met.

Note: Medications on the HealthChoice Preventive Medication List are not subject to the deductible. Copays apply to the pharmacy out-of-pocket maximum, but they do not apply to the deductible.

 

Medication Type Up to a 30-Day Supply of a Medication 31- to 90-Day Supply of a Medication
Generic Up to $10 copay Up to $25 copay
Preferred Up to $45 copay Up to $90 copay
Non-Preferred Up to $75 copay Up to $150 copay
Specialty Generic – $10 copay
Preferred –$100 copay
Non-preferred – $200 copay
Specialty medications are covered only for up to a 30-day supply

*All plan provisions apply. Only copays for preferred medications purchased at network pharmacies apply to the pharmacy out-of-pocket maximums for each plan. Some medications are subject to prior authorization and/or quantity limitations. When a generic is available, and you choose a brand-name medication for any reason, you will pay the cost difference between the brand-name medication and the generic plus the brand-name copay.


Non-network pharmacy benefits

Preferred Medication Non-Preferred Medication
50% of the cost of the medication, plus the dispensing fee. 75% of the cost of the medication, plus the dispensing fee.

*All plan provisions apply. Only copays for preferred medications purchased at network pharmacies apply to the pharmacy out-of-pocket maximums for each plan.

When you use a non-network pharmacy, you pay the full amount and submit your claim to the pharmacy benefit manager for reimbursement. Refer to the Claims Procedures section for more information.


Calendar year out-of-pocket maximum

High Option and Basic Option plans network pharmacy HDHP network pharmacy (combined medical and pharmacy)
$2,500 individual/$4,000 family $6,000 individual/$12,000 family

 

After meeting the out-of-pocket maximum, the plan pays 100% of the cost of preferred medications purchased at network pharmacies for the remainder of the calendar year.Note: When a generic is available and you choose a brand-name medication for any reason, you will pay the difference between the brand-name medication and the generic plus the brand-name copay. The brand-generic cost difference does not count toward your pharmacy out-of-pocket maximum and is always your responsibility even after your out-of-pocket maximum is met.

The following charges do not count toward your pharmacy out-of-pocket maximum and do not qualify for 100% payment after your out-of-pocket maximum is met:

  • Non-network pharmacy purchases.
  • Cost differences between generic and brand-name medications.
  • Non-covered medications.
  • Amounts paid by copay assistance programs, manufacturer copay cards or other third parties do not apply toward deductibles or out-of-pocket maximums.


HealthChoice Formulary

The HealthChoice Formulary is a list of medications covered by the plan. To find out how your medications are covered, contact the pharmacy benefit manager. Refer to HealthChoice Plan Contact Information. You can also go to healthchoiceconnect.com. Here you can also find lists of commonly prescribed medications, excluded medications with preferred alternatives, and specialty medications.Your share of the cost of a medication is subject to:

  • The cost of the medication.
  • Network copays.
  • Pharmacy deductible.
  • Non-network coinsurance.
  • The cost difference between a brand-name and generic medication if a brand-name is purchased when a generic is available.
  • Medication quantity limits per copay.

HealthChoice medication lists
 
Following are the medication lists of covered medications. The lists are by therapeutic category and are not all-inclusive. (Generics should be considered the first line of prescribing.) Generic medications are listed in lowercase, branded generics are in upper- and lowercase, and brand- name products are in all uppercase.
 
These lists are on the HealthChoice website at healthchoiceconnect.com.
 
Preventive Medication List
 
The HealthChoice Preventive Medication List is a list of generic preventive medications that are not subject to a pharmacy deductible on the HealthChoice plans. Medications on this list will pay at the normal pharmacy copay.Standard Medication ListThe HealthChoice Standard Medication List is a list of commonly prescribed non-specialty medications that are preferred on the HealthChoice plans. This list also contains a summary of preferred alternatives to the non-specialty medications that are excluded from coverage.
 
Advanced Control Specialty Formulary
 
The Advanced Control Specialty Formulary is a list of commonly prescribed specialty medications that are preferred on the HealthChoice plans. This list also contains a summary of preferred alternatives to the specialty medications that are excluded from coverage.
 
Excluded Medication List
 
The Drug Removal List is a list of specialty and non-specialty medications that have been removed from coverage under the HealthChoice plans. For each excluded medication, preferred alternatives are listed next to the excluded medication.
 
Generics are preferred medications
 
If your medication is not a generic and does not appear on the HealthChoice Formulary, your options are to:
 
  • Ask your physician to prescribe a preferred medication you can receive at the preferred pharmacy copay.
  • Continue with your current non-preferred medication and pay the non-preferred copay.
  • Obtain a medical necessity exception if you have specific health problems that require a non-preferred medication. To be considered for this exception, specific criteria must be met and detailed documentation from your physician must justify your request for an exception. The steps to request a medical necessity exception are the same as the steps to request a prior authorization. Refer to Pharmacy Prior Authorization in this section.

Pharmacy prior authorization
 
Pharmacy prior authorization is a medical review that is required for coverage of certain medications such as those that:
 
  • Are high cost.
  • Are specialty medications.
  • Are limited in quantity.
  • Have lower cost preferred alternatives.
 
Follow the steps below to request a prior authorization:
 
  • Have your physician’s office call the pharmacy benefit manager. Refer to HealthChoice Plan Contact Information.
  • The pharmacy benefit manager will assist your physician’s office with completing a prior authorization form.
  • If your prior authorization is approved, your physician’s office is notified of the approval within 24 to 48 hours. You are also notified in writing.
  • If your prior authorization is denied, your physician’s office is notified of the denial within 24 to 48 hours. You are also notified in writing.
 
Types of prior authorizations
 
Traditional Prior Authorization Medications
 
Traditional prior authorization reviews typically require that specific medical criteria be met before the medication is covered.
 
Step Therapy Medications
 
A step therapy prior authorization requires you to first try a designated preferred drug to treat your medical condition before the plan covers another drug for that same condition. Some step therapy medications may also be limited in quantity.
 
Brand-Name Exceptions and Non-Preferred Medications
 
A prior authorization for a brand-name or non-preferred drug may be approved when you are unable to tolerate the generic or preferred drug.
 
All of these reviews follow the same process as described in the Pharmacy prior authorization section.
 

Medications limited in quantity
 
Certain medications are limited in the quantity you can receive per copay based on their recommended duration of therapy and routine use. If generics are available or become available for brand-name drugs that are limited in quantity, the generics are also limited in quantity. When new medications become available in drug categories that have quantity limits, they will automatically have quantity limits per copay. New drug categories also can become subject to quantity limits throughout the year.
 
Specialty medications
 
Specialty medications are usually high-cost medications that require special handling and extensive monitoring. You must pay a copay for each 30-day fill of a specialty medication. Copays are $10 for generic medications, $100 for preferred medications and $200 for non- preferred medications.
 
Tobacco cessation products
 
HealthChoice covers the following tobacco cessation medications at 100% when purchased at a network pharmacy:
 
  • Bupropion 150 mg SR/SA tabs.
  • Chantix.
  • Nicotrol inhaler system.
  • Nicotrol NS nasal spray.
 
HealthChoice covers up to 168 days’ supply of a prescription product each calendar year.
 
Additionally, HealthChoice provides members with over-the-counter nicotine replacement therapy products (patches, gum and lozenges) and telephone coaching at no charge to HealthChoice health plan members. To take advantage of these benefits, call toll-free 800-QUIT-NOW (800-784-8669) and identify yourself as a HealthChoice member. The hours of operation are 7 a.m. to 2 a.m., seven days a week.
 
Members living outside of Oklahoma call toll-free 866-QUIT-4-LIFE (866-784-8454).