Oklahoma City and Tulsa
OK HMO - Oklahoma City
Blue Cross Medicare Advantage Basic (HMO) H3979-001
OK PPO - Oklahoma City
HCSC Medicare Advantage Classic (PPO) H4801-007
OK PPO - Tulsa
2022 HCSC Medicare Advantage Classic (PPO) H4801-008
In-Network
Out of Network
In-Network
Out of Network
Plan Premium
$0
$0
$0
Doctors Office Visits
Primary Care Provider
$0 copay
$5 copay
$35 copay
$5 copay
$35 copay
Specialist
$30 copay
$45 copay
$55 copay
$40 copay
$55 copay
Maximum Out-of-Pocket
$4,000
$5,900
$10,000
$5,900
No Limit
Inpatient Hospital Copay
$372/day (days 1-5)
$325/day (days 1-6)
50% coinsurance
$325/day (days 1-7)
40% coinsurance
Retail Preferred Pharmacy
$0-$10/$10 -$20/$47/$100/28%
Full coverage or tier 1 in gap
Full coverage or tier 1 in gap
$0-$10/$10-$20/$47/$100/30%
Full Coverage on Tier 1
Full Coverage on Tier 1
$0-$10/$10 -$20/$47/$100/28%
Full Coverage on Tier 1
Full Coverage on Tier 1
Prescription Drug Deductible
$250 (Tiers 3, 4 and 5)
$150 (Tiers 4-5)
$250 (Tiers 4-5)
Extra Health & Wellness Benefits
Optional Supplemental Benefits Premium
N/A
N/A
N/A
Dental
Preventive
2 exams, 2 cleanings, 1 x-ray
2 exams, 2 cleanings, 1 x-ray per year
2 exams, 2 cleanings, 1 x-ray per year
Comprehensive
$1,000 Annual Max
Combined Max $1,000 yearly
Combined Max $1,000 yearly
Vision
Eye Exam
1 routine eye exam yearly
$0 copay (routine) 1 per year
$40 allowance
$0 copay (routine) 1 per year
$40 allowance
Eye Wear
$100 yearly allowance
$100 yearly allowance
$100 yearly allowance
Hearing Aids
$699 - $999 per year
$0 copay (routine) $1,000 every 3 years
$0 copay (routine) $1,000 every 3 years
Over-The-Counter (OTC) Purchase Allowance
$25/Quarterly
$25/Quarterly
$40/Quarterly
Silver Sneakers Fitness Program
✓
✓
✓
24/7 Nurse Line
✓
✓
✓
Rewards
✓
✓
✓
Transportation
Not Covered
Not Covered
Not Covered
Telehealth
$0 copay Urgent Care Only MD Live
$0 copay Urgent Care Only MD Live
$0 copay Urgent Care Only MD Live
