THE UNIVERSITY OF OKLAHOMA...your fingertips. Please take a few minutes to look through this summary guide. BCBSOK members don’t just have access to traditional insurance coverage;

THE UNIVERSITY OF OKLAHOMA RETIREE BENEFITS2020

THE UNIVERSITY OF OKLAHOMAPOST-65 RETIREE PLAN

For years, Blue Cross and Blue Shield of Oklahoma (BCBSOK) has delivered high value products and

unrivaled customer service to more Oklahomans than any other health insurance plan. And our nationwide

network of physicians and hospitals, coupled with local resources and friendly service, keeps you connected

to your health care coverage no matter where you are.

Through the University of Oklahoma, we are pleased to offer benefits that give you and your family the best

care possible and services that allow you to put your health care decisions and health education closer to

your fingertips. Please take a few minutes to look through this summary guide.

BCBSOK members don’t just have access to traditional insurance coverage; you also have a complete suite

of health and wellness resources and tools at your fingertips, to encourage healthier living and smarter

health decisions. Blue Cross and Blue Shield of Oklahoma is a health care industry leader in creating and

promoting wellness programs that you and your family can conveniently integrate into your daily life.

Merging technology and medical management with online resources, education, one-on-one coaching,

rewards and multiple touch points, BCBSOK’s Blue Care Connection® program aims to ultimately improve

you and your family’s health and wellness.

Our goal at Blue Cross and Blue Shield of Oklahoma is to provide you with first class service, and to do the

job right the first time, every time. We appreciate the opportunity to serve you.

Sincerely,

Stephania GroberVice President, Health Care Management, Network, and Government RelationsBlue Cross and Blue Shield of Oklahoma

Welcome to Blue Cross and Blue Shield of Oklahoma, and to your benefit enrollment period. This is your opportunity to select health benefits for you and your family for the coming year.

WELCOME

This enrollment guide highlights OU’s Benefits plans. A complete description of each plan can be found in your Certificate of Benefits Booklet or Member Handbook. Every effort has been made to provide an accurate summary of the plans. However, this is a summary guide. If there is a conflict between this material and the Certificate of Benefits or Member Handbook, the Certificate of Benefits Booklet or Member Handbook will govern. If you have any questions after reviewing your enrollment materials, please contact BCBSOK customer service.

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Eligibility

Please visit the “Benefits” section of the OU Human Resources website for information at hr.ou.edu. You must currently be enrolled in Medicare Part A and B to enroll in this plan

Plan Coverage

The following pages provide an overview of the plan benefits available to you. These are only summaries — not the actual plan descriptions. If you have questions that aren’t answered in the summary information in this guide, please contact customer service at 888-881-4648 or review the detailed Certificate of Benefits or Member Handbook. Dental care benefits are offered separately, and are not highlighted in this benefit guide.

A brief description of the various aspects of each program follows on the next pages.

ID Cards

You should present your ID card when visiting a physician’s office or hospital, and verify that they have the correct insurance information on file for you. Your card will resemble the card below, and will be customized with your name and plan information. Additional cards can be ordered through BCBSOK customer service or by logging in to the Blue Access for MembersSM (BAMSM) website at bcbsok.com.

Tools for Heal thy L iv ing

Well onTarget® — A Dynamic Wellness Program

At Blue Cross and Blue Shield of Oklahoma, we believe in supporting your health and well-being. Well onTarget offers personalized tools and resources to help all members — no matter where you may be on the path to health and wellness. Program highlights include:

Liveon Member Wellness Portal

The Liveon portal is the heart of the Well onTarget program. It inspires and supports you through healthy living programs, online courses, tools and trackers. Leading-edge technology offers you a gateway to a suite of interactive programs:

n onmywayTM Health Assessmentn onmytime Self-directed Courses on topics such as healthy

eating, stress, weight management and fitnessn Health and Wellness contentn Tools and Trackers such as a food diaryn Blue PointsSM program

onmyway Health Assessment (HA)

The HA features adaptable questions to learn more about you. After you take the HA, you will get a personal wellness report. The confidential record offers tips for living your healthiest life. Your answers will be used to tailor the Liveon portal with the programs that may help you reach your goals.

Blue Points

With the Blue Points program, you can earn points by taking part in healthy activities. This program makes it easy for you to track your points from one screen. Real-time granting of points lets you instantly use your points. Points can be redeemed for a host of products from the online shopping mall. To earn a larger reward, you can add to your point total at checkout.

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www.bcbsok.com

L13

RxBIN: 011552RxPCN: 1215

THE UNIVERSITY OF OKLAHOMA

Group Number: 207194

PPO

Preauthorization will be required for all inpatient and certain outpatient services. Refer to your policy for a full list or call a Health Advocate for assistance.Provider Note: This is a Primary Package that requires you to call to pre-notify for MRI/CT/PET/NUCCAR scans.

Health AdvocateRX Cust Svc*RX Tech Support*

1-855-649-96141-877-546-27791-877-353-0992

*Group contracts directly

If you lose or misplace your ID card, you can print a temporary ID card and order a replacement card by logging in to Blue Access for Members (BAM) at bcbsok.com.

Liveon, onmyway, and onmytime are owned by Onlife(R) Health. Onlife is an independent company that provides wellness services to Blue Cross and Blue Shield of Oklahoma. Onlife is solely responsible for the products and services they provide.

Blue Points Program Rules are subject to change without prior notice. See the Program Rules on the Well onTarget Member Wellness Portal at wellontarget.com for further information.

Group NumberEffective DateBenefit Network

The University of Oklahoma

Office Visit Copay:

Specialist Copay:

PlanName


www.bcbsok.com

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Customer ServicePreauthorizationProvider Locator24/7 NurselineRX Tech SupportRX Cust Svc*

1-800-XXX-XXXX1-800-XXX-XXXX1-800-XXX-XXXX1-800-XXX-XXXX1-877-XXX-XXXX1-877-XXX-XXXX

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Blue Care Connection

Through the Blue Care Connection program, you’ll find tools and services that inform, support and motivate you on your journey to wellness.

Weight ManagementSupport for a slimmer, healthier you

The program offers guidance and support through behavioral and motivational coaching, personalized goal setting with an action plan, online tools and discounts to wellness-related products and services. To get started, call BCBSOK customer service.

Fitness ProgramJoin a network of gyms

Take advantage of a gym membership to a nationwide network of fitness centers. To get started, access the Well onTarget portal, or call BCBSOK customer service.

Tobacco CessationSupport for tobacco users who want to quit

The program provides personal coaching, online tools and discounts for wellness-related products and services. To participate call BCBSOK customer service. There is also a tobacco cessation benefit described on the plan comparison chart.

24/7 Nurseline

Health concerns don’t always follow a 9-to-5 schedule. Fortunately, you can call the toll-free 24/7 Nurseline 24 hours a day, 7 days a week to get the information you need…when you need it.

The 24/7 Nurseline is staffed by registered nurses who can answer your general health questions, direct you to your doctor or encourage you to seek emergency services if necessary. A nurse can help identify options and provide information to help you choose the appropriate care for your concerns. Plus, when you call, you also have the option to access an audio library of more than 1,000 health topics.

Call the 24/7 Nurseline toll free at 800-581-0407.

Blue Care AdvisorsSM

If you have certain chronic health conditions or are at risk for medical complications, a Blue Care Advisor may contact you to offer health counseling, coaching and support. Working with you through regularly scheduled telephone calls, these registered nurses and other health care professionals can help you learn to manage your condition more successfully, identify behaviors that may be barriers to better health, set goals for improving your health and help you adopt healthier habits.

Case Managers

In the event that you or a covered family member experiences multiple or complex medical problems, our case management nurses — registered nurses with specialized training and clinical experience — can work with you.

At a time that’s usually stressful, case managers can be your advocate by:

n Helping to explain your medical problem(s) and treatment plan(s)

n Facilitating communication among your many health care providers

n Coordinating a treatment plan(s)

n Explaining your health care benefits and how to get the most out of them

n Helping you access the right resources and services

n Assisting with transitions from one health care setting to another

Other Resources to Help You

Blue Cross and Blue Shield of Oklahoma also provides other health and wellness information.

Preventive Health Care Guidelines are published each year and made available via bcbsok.com. This is a good source of information on preventive care guidelines, which are based on recommendations set by national health agencies and medical associations. You can learn about recommended screenings, and immunizations and doctor visits for all ages.

Start your journey to wellness today!

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Coverage Traditional Indemnity†† (No Network)

Calendar Year Deductible Individual/Family $300

Out-of-Pocket Maximum Individual/Family $3,000/$6,000

Lifetime Health Care maximum (per person) Unlimited

PHYSICIAN SERVICES

Office visit & related routine services / consultation / second opinion 20% after deductible

Physical, Occupational, Speech, and Chiropractic Therapies (60 visit maximum combined for all therapies) 20% after deductible

Allergy Injections 20% after deductible

Allergy Testing 20% after deductible

Allergy Serum 20% after deductible

Inpatient Physician Services 20% after deductible

Outpatient Physician Services / non-routine office services 20% after deductible

Lab & X-ray (Physician Office) 20% after deductible

PREVENTIVE CARE SERVICES

Routine Exam Covered at 100% of allowed amount

Adult Immunizations Covered at 100% of allowed amount

Well Child Exams Covered at 100% of allowed amount

Routine Eye Exam* (does not include hardware) Covered at 100% of allowed amount

Routine Hearing Exam* (does not include hardware/hearing aids) Covered at 100% of allowed amount

Routine Ob/Gyn Exam Covered at 100% of allowed amount

Routine Mammograms Covered at 100% of allowed amount

Routine Prostate Specific Antigen (PSA) Covered at 100% of allowed amount

Routine Colonoscopy Covered at 100% of allowed amount

Well Child Immunizations Covered at 100% of allowed amount

Benefit Summary

*Routine vision and hearing exams limited to once every 24 months. †Up to the allowed amount. If an out-of-network provider charges more than the allowed amount, you may be responsible for the difference.††Medicare Part A and Part B coverage is required.

The amounts shown below are what you are responsible for paying for each type of service or treatment.



HOSPITAL SERVICES

Inpatient Hospital 20% after deductible

Outpatient Surgery 20% after deductible

Emergency Room 20% after deductible

Urgent Care Facility 20% after deductible

EXTENDED CARE INPATIENT/HOME

Skilled Nursing Facility 20% after deductible

Skilled Nursing Facility Maximum 90 days per calendar year

Home Health 20% after deductible

Home Health Maximum 120 visits per calendar year

Private Duty Nursing 20% after deductible

Private Duty Nursing Maximum 70 visits per calendar year

Hospice - Inpatient (no benefit limit) 20% after deductible

Hospice - Outpatient (no benefit limit) 20% after deductible

MATERNITY & FAMILY PLANNING

Prenatal & Postnatal visits 20% after deductible

Inpatient Hospital 20% after deductible

Infertility Testing & Treatment ( 20% after deductible

Voluntary Sterilization ( 20% after deductible

Pregnancy Termination (therapeutic & non-therapeutic) 20% after deductible

Contraceptive Devices 20% after deductible

MENTAL HEALTH

Inpatient Hospital/Facility 20% after deductible

Outpatient Charges 20% after deductible

†Up to the allowed amount. If an out-of-network provider charges more than the allowed amount, you may be responsible for the difference.††Medicare Part A and Part B coverage is required.

Benefit Summary

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†Up to the allowed amount. If an out-of-network provider charges more than the allowed amount, you may be responsible for the difference. ††Medicare Part A and Part B coverage is required.††††Please see Annual Notice of Change (ANOC) for non-preferred pharmacy coverage.††††These services are coordinated though Magellan. Please contact 877-794-0678


SUBSTANCE ABUSE

Inpatient Hospital/Facility 20% after deductible

Outpatient Charges 20% after deductible

OTHER SERVICES & SUPPLIES

MRI, CT, PET, EEG, and other similar imaging tests 20% after deductible

Diagnostic Lab & X-ray 20% after deductible

Tobacco Cessation Benefit (non-RX) — 100% member reimbursement for over-the-counter medications, acupuncture, hypnosis, stop smoking aids, etc., to a maximum of 20 visits/services per calendar year (per person)

Applies

Bariatric/Weight Loss Surgery Not covered

Durable Medical Equipment 20% after deductible

Ambulance (Ground/Air) 20% after deductible

Routine Audiological Exam 20% after deductible


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6Blue Cross MedicareRx (PDP)SM

If you are enrolled in both the Traditional Indemnity Medical plan and the Pharmacy MedicareRx (PDP) Part D plan you will receive both a medical card and a pharmacy card (pharmacy card pictured left).

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.You must continue to pay your Medicare Part B premium.Blue Cross MedicareRx is a prescription drug plan provided by HCSC Insurance Services Company (HISC), an Independent Licensee of the Blue Cross and Blue Shield Association. A Medicare-approved Part D sponsor. Enrollment in HISC’s plan depends on contract renewal.

Annual DeductibleAmount member pays before Blue Cross MedicareRx begins to pay

$0

Initial Coverage Period Copays(30-day supply) Annual drug costs up to $3,750

Tier 1 — Preferred Generic Drugs $8

Tier 2 — Non-Preferred Generic Drugs $8

Tier 3 — Preferred Brand Drugs $35

Tier 4 — Non-Preferred Brand Drugs 50% ($100 minimum and $200 maximum)

Tier 5 — Specialty Drugs 50% ($100 minimum and $200 maximum)

Gap CoverageAnnual drug costs exceeding $3,750 (up to a total of $5,000 out-of-pocket costs)

Tier 1 — Preferred Generic Drugs $8

Tier 2 — Non-Preferred Generic Drugs $8

Tier 3 — Preferred Brand Drugs $35

Tier 4 — Non-Preferred Brand Drugs 50% ($100 minimum and $200 maximum)

Tier 5 — Specialty Drugs 50% ($100 minimum and $200 maximum)

After the Gap CopaysAfter your total out-of-pocket costs exceed $5,000

Member pays whichever is greater:

• 5% of the total cost, or

• $3.35 copay for generic (including brand drugs treated as generic) and a $8.35 copayment for all other drugs

Please Note: The Pharmacy MedicareRx (PDP) Part D plan is separate from the medical plan and requires a separate enrollment application from the medical plan.


www.bcbsok.com

L13

RxBIN: 011552RxPCN: 1215

THE UNIVERSITY OF OKLAHOMA

Group Number: 207194

PPO

Preauthorization will be required for all inpatient and certain outpatient services. Refer to your policy for a full list or call a Health Advocate for assistance.Provider Note: This is a Primary Package that requires you to call to pre-notify for MRI/CT/PET/NUCCAR scans.

Health AdvocateRX Cust Svc*RX Tech Support*

1-855-649-96141-877-546-27791-877-353-0992

*Group contracts directly

Contacts This enrollment guide highlights OU’s Benefits Program. A complete description of each benefit can be found in your Certificate of Benefits Booklet or Member Handbook. Every effort has been made to provide an accurate summary of the plans in this guide. However, if there is a conflict between this material and the Certificate of Benefits or Member Handbook, the Certificate of Benefits Booklet or Member Handbook will govern. If you have any questions after reviewing your enrollment materials, please contact BCBSOK customer service at the phone numbers below.

Subject Contact

BCBSOK Customer Service 888-881-4648

BlueCard® 800-810-BLUE (2583)

24/7 Nurseline 800-581-0407

Pharmacy 877-838-3833

Resource Purpose How to Access

BCBSOK website • Log in to Blue Access for Members to access the Well onTarget portal or view claims

• View/print benefit brochures • Locate a doctor or hospital

Go to bcbsok.com

Blue Access for Members

Website provides:• Ability to print a temporary member ID card

and order a new card• Claim Status• Find a doctor or hospital• Access to Well onTarget• Explanation of Benefits (EOB)

Go to bcbsok.com• Enter Blue Access for Members

user ID and password • If you do not have a user ID and

password, click on “Register Now”

Blue Points Earn points, redeemable for rewards, for health-related activities

Go to BAM at bcbsok.com• Click on Well onTarget

Locate a Health Care Provider

Find a doctor, specialist, or hospital in your area

Go to bcbsok.com• Click on your plan type in the Find a

Doctor section

OU Benefits website Find benefit related information Go to hr.ou.edu

Pharmacy • Compare drugs• Find generic alternatives• Obtain cost estimates• View drug formulary

Go to myprime.com

Online Benefit Resources

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Prime Therapeutics LLC, a separate company, is a pharmacy benefit management company. Blue Cross and Blue Shield of Oklahoma (BCBSOK) contracts with Prime Therapeutics to provide pharmacy benefit management and other related services. In addition, contracting pharmacies are contracted through Prime Therapeutics. The relationship between BCBSOK and contracting pharmacies is that of independent contractors. BCBSOK, as well as several other independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics.

Through It All.®

Blue Cross and Blue Shield of Oklahoma, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association 606963.1119

Through It All® bcbsok.com

Documents

THE UNIVERSITY OF OKLAHOMA...your fingertips. Please take a few minutes to look through this summary guide. BCBSOK members don’t just have access to traditional insurance coverage;