HEALTH CARE HIGHLIGHTS 02-03

HEALTH CARE HIGHLIGHTS 02-03

The same three-tiered design next year -- Option 1 (BC) Options 2 and 3 (S-A)
Full funding of Option 2 by the University at $235

What changed in order to fund the plan?

Expansion and improvement of the University’s own network of direct–contracted facilities
Increased cost-effective medical management
Pharmacy benefits re-designed to encourage more generic drug usage whenever possible
Pharmacy management consolidated to one company
Compensation for employees who waive health insurance changed from $95 a month to $50 a month
Various co-pays and co-insurance, deductibles, increased for participants on all three plans

What specific benefits have changed?

Option 1, Blue Cross

Increase in deductible from $150 to $200
Increased Physician visit co-pay, $10 to $15
Increase in co-insurance from 15% to 20%
Increase in pharmacy co-pays from $10-$20-$30 to $10-$25-$45

Option 2, Schaller –Anderson

Increased Hospital co-pay, different levels for OU direct contracts and PPO network
Increased physician visit co-pay, $10 to $15
Outpatient co-pays increased to same as inpatient due to changes in medical pricing
Increased Pharmacy co-pays $7-$14-$28 to $5-$22-$45

Option 3, Schaller Anderson

Only significant change is pharmacy over current year Option 3
Will have same formulary and medical management as Option 2

What are next year’s monthly premiums?

Option 2 employee only rate fully funded by the University at $235
Option 1 (Blue Cross) is $278, requires a $43 monthly contribution by the employee
Option 3 employee only is $217, $18 lower than Option 2

Why is Blue Cross more expensive?

The Blue Cross plan does not use University direct contracts
The Blue Cross plan does not have active medical management
The Blue Cross network is slightly larger (5% to 10%) than the Schaller PPO network
The Blue Cross plan has had a much more costly pharmacy plan, and while planned consolidation of the drug formulary and administration will help, insufficient data is available to make reasonable estimates of savings next year
There are disproportionate numbers of retirees on Option 1, a fact which lends itself to the theory the Option 1 population is less healthy than Option 2, but again, insufficient data is available to confirm the theory. It is possible that the first four reasons listed account for virtually all of the difference in the premium rates.

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University of Oklahoma - Current Benefit Summary

			CURRENT		PROPOSED
			Option 1 (Blue Cross)		Option 1
	Benefit Highlights		In-Network	Out-Network	In-Network	Out-Network
PCP Requirement			None		None
1	Lifetime Maximum		$2 million combined		$2 million combined
2	Contract Year Deductible
		Individual	$150	$400	$200	$500
		Family	$375	$900	$600	$1,500
3	Maximum Out-of-Pocket
		Individual	$1,000	$5,000	$1,500	$5,000
		Family	$3,000	$15,000	$4,500	$15,000
4	Physician Office Visits - PCP		$10 copay	70%	$15 copay	60%
	Physician Office Visits - Specialist		85%		80%
5	Diagnostics, X-ray and lab billed		85%	70%	80%	60%
	from free-standing lab/x-ray facility or OP facility
6	Allergy injections and		85%	70%	80%	60%
	Serum for injections
7	Hospitalization - Facility		85%	70%	80%	60%

8	Outpatient Services - Facility		85%	70%	80%	60%

9	Prescription Drug		Max OOP $1500		Max OOP $1500
		Retail	$10 generic	50% of allowable amt	$10 generic	50% of allowable
			$20 pref. brand		$25 pref. Brand
			$30 non-pref.		$45 non-pref.

		Mail Order	$20 generic	not covered	$25 generic	not covered
		(90 day supply)	$40 pref. brand		$62 pref. Brand
			$60 non-pref.		$112 non-pref.
10	Preventive Care
		Annual Routine Physicial / Adult Preventative	$10 copay for PCP 85% for Specialist after deductible	70%	$15 copay for PCP 80% for Specialist after deductible	60%

		Prostate Screening	$10 copay for PCP 85% for Specialist max $65	70% max $65	$15 copay for PCP 80% for Specialist after deductible	60%
					max $65 combined in or OON
		Cervical Screening	$10 copay for PCP 85% for Specialist after deductible	70%	$15 copay for PCP 80% for Specialist after deductible	60%

					$15 copay for PCP 80% for Specialist after deductible
		Mammogram	100% max $115	70% max $115		60%
					max $115 combined in or OON
		Well Child Care	$10 copay for PCP 85% for Specialist after deductible	70%	$15 copay for PCP 80% for Specialist after deductible	60%

		Child Immunizations	100% coverage	100% coverage	$15 copay for PCP 80% for Specialist after deductible	60%
11	Emergency Care Facility		$50 copay	$50 copay	$75 copay	$75 copay
			(waived	(waived if admit)	(waived	(waived if admit)
			if admitted)		if admitted)
			85%	70%
12	Maternity Care Office Visit		85%	70%	80%	60%


13	Mental Health
		Inpatient - 30 days/contract yr	85%	70%	80%	60%
		Outpatient - 24 visits	85%	70%
					80%	60%

14	Chemical Dependency
					80%	60%

		Inpatient - 30 days/contract yr	85%	70%
		Outpatient - 24 visits	80%	50%	80%	60%


15	Ambulance		85%	70%	80%	60%
16	TMJ		$1,500 lifetime max		$1,500 lifetime max
			85%	70%	80%	60%
17	Home Health		85% 30 visits applies in/out	70% 30 visits applies in/out	80% 30 visits applies in/out	60% 30 visits applies in/out
18	Hospice		85%	70%	80%	60%
19	Chiropractic		85%	70%	80%	60%
			Limit $1000 annually		Limit $1000 annually $5000 lifetime max
20	Durable Medical Equipment		85%	70%	80%	60%
21	Rehabilitation Services (Outpatient)		85%	70%	80%	60%
					60 visits per occurrence
22	Urgent Care
	Free Standing Facility		85%	70%	80%	60%
	Emergency Room		$50 copay (waived if admitted)	70%	$50 copay (waived if admitted)	60%
23	Skilled Nursing Facility		85%	70%	80%	60%
			Not to exceed $20 per day		Not to exceed $20 per day 100 day max per year

			CURRENT		PROPOSED
			Option 2(Schaller)		Option 2
	Benefit Highlights		In-Network	Out-Network	In-Network	Out-Network
PCP Requirement			None		None
1	Lifetime Maximum		$2 million combined		$2 million combined
2	Contract Year Deductible
		Individual	None	$500	None	$500
		Family	None	$1,250	None	$1,250
3	Maximum Out-of-Pocket
		Individual	$1,000	$4,000	$1,000	$4,000
		Family	$3,000	$10,000	$3,000	$10,000
4	Physician Office Visits - PCP		$10 copay	70%	$15 copay	65%
	Physician Office Visits - Specialist		$20 copay		$30 copay
5	Diagnostics, X-ray and lab billed from		100% coverage	70%	100%	65%
	free-standing lab/x-ray facility or OP faciliy
6	Allergy injections and		$10 PCP/$20 Specialist	70%	$15 PCP initial visit only	65%
	Serum for injections		(initial visit only)		$30 Specialist initial visit only
7	Hospitalization - Facility		$200 copay	70%	$250 copay OU Contract	65%
					$400 Copay Non-OU
8	Outpatient Services - Facility		100% coverage	70%	$250 copay OU Contract	65%
					$400 Copay Non-OU
9	Prescription Drug		Max OOP $1500		Max OOP $1500
		Retail	$7 generic	50% of allowable	$5 generic	50% of allowable
			$14 pref. brand		$22 pref. Brand
			$28 non-pref.		$45 non-pref.

		Mail Order	$14 generic	not covered	$15 generic	not covered
		(90 day supply)	$28 pref. brand		$55 pref. Brand
			$56 non-pref.		$112non-pref.
10	Preventive Care
		Annual Routine Physicial /	$10 copay	70%	$15 copay	65%
		Adult Preventative
		Prostate Screening	100% coverage	70%	$15 copay	65%

		Cervical Screening	100% coverage	70%	$15 copay	65%

		Mammogram	100% coverage	70%	$15 copay	65%

		Well Child Care	$10 copay	70%	$15 copay	65%
		Child Immunizations	100% coverage	70%	$15 copay	65%
11	Emergency Care Facility		$75 copay	70%	$75 copay	65%
			(waived if admit)		(waived if admit)

12	Maternity Care Office Visit		$10 copay	70%	$15 (initial visit)	65%
			(initial visit)

13	Mental Health
		Inpatient - 30 days/contract yr	$25 copay	70%	$250 Copay OU Contract	65%
		Outpatient - 24 visits	$25 copay	70%	$400 Copay Non-OU
					$30 copay	65%

14	Chemical Dependency		$10,000 lifetime max		$250 Copay OU Contract	65%
					$400 Copay Non-OU

		Inpatient - 30 days/contract yr	$25 copay	70%	$30 copay	65%
		Outpatient - 24 visits	$25 copay	70%



15	Ambulance		100% coverage	100% coverage	100% coverage	100% coverage

			$1,500 lifetime max		$1,500 lifetime max

16	TMJ		100% coverage	70%	Applicable copay / coinsurance for each type of service will apply	65%

17	Home Health		100% coverage	70%	100%	65%

18	Hospice		100% coverage	70%	$30 copay	65%

19	Chiropractic		$20 copay	70%	$30 copay	65%
			Limit $1500 annually		Limit $1500 annually
20	Durable Medical Equipment		100% coverage	70%	100%	65%
21	Rehabilitation Services (Outpatient)		$10 copay	70%	$15 copay	65%
			60 visits per occurrence		60 visits per occurrence
22	Urgent Care
	Free Standing Facility		$25 copay	70%	$50 copay	65%
	Emergency Room		$25 copay	70%	$50 copay (waived if admitted)	65%
23	Skilled Nursing Facility		100% coverage	70%	100%	65%
					100 day max per year

			CURRENT		PROPOSED
			Option 3 (Schaller)		Option 3
	Benefit Highlights		In-Network	Out-Network	In-Network	Out-Network
PCP Requirement			None		None
1	Lifetime Maximum		$2 million combined		$2 million combined
2	Contract Year Deductible
		Individual	$300	$300	$300	$300
		Family	$900	$900 (non-agg)	$900	$900 (non-agg)
3	Maximum Out-of-Pocket
		Individual	$2,300	$2,800	$2,300	$2,800
		Family	per person	per person	per person	per person
4	Physician Office Visits - PCP		$20 copay	70%	$20 copay	0.65
	Physician Office Visits - Specialist		$20 copay		$20 copay
5	Diagnostics, X-ray and lab billed		80%	70%	80%	65%
	from free-standing lab/x-ray facility or OP facility
6	Allergy injections and		80%	70%	80%	65%
	Serum for injections
7	Hospitalization - Facility		80%	70% + $300	80%	$300 Copay + 65%
				copay		after deductible is met
8	Outpatient Services - Facility		80%	70%	80%	65%

9	Prescription Drug				$2,500 OOP max for Pref.	$2,500 OOP max for Pref.
		Retail	$20 copay plus	$50 ded. $22.50 copay	Pref < $100 up to $25	Pref. Up to $75 copay or cost of drug + dispensing fee
			the cost difference	Plus cost difference	Copay or Cost of drug
			between gen/brand	then 25% coin	Pref > $100 25%
					co-ins up to $50 max
		Mail Order	not covered	not covered	Non-Pref. < $100	Non-Pref. Up to $125 copay or cost of drug + dispensing fee
		(90 day supply)			up to $50 copay or cost of drug
					Non-Pref. > $100 50% co-ins. Up to $100 max
10	Preventive Care
		Annual Routine Physicial / Adult Preventative	$20 copay	70%	$20 copay	65%

		Prostate Screening	$20 copay	70%	$20 copay	65%

		Cervical Screening	$20 copay	70%	$20 copay	65%

		Mammogram	$20 copay	70%	$20 copay (100% if 40 years or older)	65%

		Well Child Care	$20 copay	70%	$20 copay	65%

		Child Immunizations	$20 copay	70%	100%	65%
11	Emergency Care Facility		$100 copay	70%	80%	65%
			(waived if admit)


12	Maternity Care Office Visit		$20 copay	70%	80%	65%
			80% hosp coin

13	Mental Health
		Inpatient - 30 days/contract yr	80%	$300 copay , 70%	80%	65%
		Outpatient - 24 visits	80%	70%
					80%	65%


14	Chemical Dependency		$10,000 lifetime max		80%	$300 Copay + 65%
						after deductible is met.

		Inpatient - 30 days/contract yr	80%	$300 copay
		Outpatient - 24 visits	80%	70%	80%	65%
					$10,000 lifetime max

15	Ambulance		80%	70%	80%	65%

16	TMJ		$1,500 lifetime max		$1,500 lifetime max	Not Available
			80%	70%	80% $1,500 max non-surg	65% $1,500 max non-surg

17	Home Health		80%	70%	80% 100 visit max	65% 100 visit max

18	Hospice		80%	70%	80% 100 visit max	65% 100 visit max

19	Chiropractic		$20 copay	70%	80% 15 visit max	65% 15 visit max
			15 visits annually $1000 per person annually
20	Durable Medical Equipment		80%	70%	80%	65%

21	Rehabilitation Services (Outpatient)		80%	70%	80%	65%
			max 15 visits per contract year		max 15 visits per contract year
22	Urgent Care
	Free Standing Facility		$50 copay	70%	80%	65%
	Emergency Room		$50 copay	70%

23	Skilled Nursing Facility		80%	70%	80% + $100 copay (copay waived if admitted)	65% + $100 copay (waived if admitted)
					80% 100 day max	65% 100 day max