MEDICARE SUPPLEMENT
PLANS HANDBOOK
EVIDENCE OF COVERAGE
P L A N Y E AR 2 0 2 3
DRAFT
HealthChoice SilverScript
High and Low Option Plans
HealthChoice High and Low
Option Plans Without Part D
4881
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Medicare Supplement Plans HandbookPlan Year 2023
TABLE OF CONTENTS
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2
HealthChoice Plan Contact Information. . . . . . . . . . . . . . . . . . . . . . . . . . . .3
HealthChoice Plan Identication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
Information About Your Premiums . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
General Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
HealthChoice High and Low Option
Medicare Supplement Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
HealthChoice SilverScript High Option
Medicare Supplement Plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
HealthChoice SilverScript Low Option
Medicare Supplement Plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14
HealthChoice High Option Medicare Supplement Plan without Part D . . . . . . . . . . 15
HealthChoice Low Option Medicare Supplement Plan without Part D . . . . . . . . . . 16
Your Prescription Drug Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Claims Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Eligibility, Enrollment and Disenrollment . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Privacy Notice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34
Grievances and Appeals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Fraud, Waste and Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42
Notications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43
Plan Denitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44
INTRODUCTION
HealthChoice Medicare Supplement Handbook effective
Jan. 1 through Dec. 31, 2023
This handbook/Evidence of Coverage replaces and supersedes any Medicare supplement
handbook/Evidence of Coverage the Ofce of Management and Enterprise Services
Employees Group Insurance Division previously issued. This handbook/Evidence of Coverage
will, in turn, be superseded by any subsequent Medicare supplement handbook/Evidence of
Coverage EGID issues. The most current version can be found on the HealthChoice website at
HealthChoiceOK.com.
This handbook, your enrollment form, conrmation statement and HealthChoice SilverScript
Medicare documents represent our responsibilities to you. This handbook provides details
about your benets, formulary, pharmacy network, premiums, deductibles, copays and
coinsurance for 2023. It explains what is covered and what you pay as a member of the
plan. Be aware that these amounts may change at the beginning of the next plan year, which
begins on Jan. 1. This is an important document, so keep it in a safe place. Please note, the
HealthChoice Medicare supplement plans are often referred to throughout this handbook as
the plan or plans.
HealthChoice SilverScript members
If you have Medicare Part D coverage through HealthChoice SilverScript, you should refer to
this handbook and other documents provided by HealthChoice SilverScript for additional rules
and information about your plan.
Read this handbook carefully
A dispute concerning information contained within any HealthChoice written or electronic
materials or oral communications, regardless of the source, shall be resolved by applying
OMES EGID Administrative Rules or benet administration procedures and guidelines as
adopted by the plan.
All benets and limitations of these plans are governed in all cases by the relevant plan
documents, insurance contracts, handbooks, OMES EGID Administrative Rules and the
regulations governing the Medicare Prescription Drug, Improvement, and Modernization Act
of 2003. The Federal Regulation at 42 C.F.R. § 423, et seq. and the rules of the Oklahoma
Administrative Code, Title 260, are controlling in all aspects of plan benets.
No oral statement of any person shall modify or otherwise affect the benets, limitations or
exclusions of any plan.
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Medicare Supplement Plans Handbook Plan Year 2023
HEALTHCHOICE PLAN CONTACT INFORMATION
HealthChoice Customer Care
Medical benet coverage, claims, certication inquiries
800-323-4314 or TTY 711
HealthChoiceOK.com
Claims and correspondence
P.O. Box 30511
Salt Lake City, UT 84130-0511
Appeals and provider inquiries
P.O. Box 30546
Salt Lake City, UT 84130-0546
Pharmacy benet manager
Pharmacy benets
CVS Caremark, 24/7
Live operator available 7 a.m. to midnight Central time
caremark.com
SilverScript plans: 866-275-5253 or TTY 711
Without Part D plans: 877-720-9375 or TTY 711
Pharmacy prior authorization
SilverScript plans: 855-344-0930 or TTY 711
Without Part D plans: 800-294-5979 or TTY 711
CVS Specialty Pharmacy: 800-237-2767
Eligibility and enrollment
EGID Member Services
Monday through Friday, 8 a.m. to 4:30 p.m. Central time
405-717-8780 or 800-752-9475
TTY 711
HEALTHCHOICE PLAN IDENTIFICATION
Plans
HealthChoice SilverScript High
HealthChoice SilverScript Low
HealthChoice High Without Part D
HealthChoice Low Without Part D
Plan administrator
Ofce of Management and Enterprise Services
Employees Group Insurance Division
405-717-8780 or 800-752-9475
2401 N. Lincoln Blvd., Ste. 300
Oklahoma City, OK 73105
HealthChoiceOK.com
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Medicare Supplement Plans HandbookPlan Year 2023
INFORMATION ABOUT YOUR PREMIUMS
Medicare premiums
If you currently pay a premium for Medicare Part A or Part B, you must continue to pay your
premiums to keep your Medicare coverage. Most people do not pay a premium for Part A. If
you do not qualify for premium-free Part A, you can buy Part A if you are at least 65 and meet
certain other eligibility requirements. You can also buy Part A if you are under 65 and were
once entitled to Medicare benets because of a disability.
Late enrollment penalty
Medicare applies a late enrollment penalty to your Part B and Part D premiums when:
● You do not enroll in Part B or Part D coverage, or in creditable coverage, when you
rst become Medicare eligible at 65 or when you become eligible prior to 65 due to a
disability.
● You have a lapse in creditable prescription drug coverage of 63 continuous days or
longer.
EGID pays the Part D late enrollment penalty for its HealthChoice SilverScript plan members,
but the penalty could be applied if you leave EGID and enroll in another insurance plan.
Extra Help paying for Part D (Medicare Low Income
Subsidy)
People with limited income may qualify for the Extra Help Medicare program, also known
as the Low Income Subsidy. This helps pay for prescription drug costs, including premiums,
deductibles and copays. To learn more or apply, call Social Security toll-free at 800-772-1213.
TTY users call toll-free 800-325-0778. More information is also available at SSA.gov. You can
also call Medicare toll-free at 800-MEDICARE (800-633-4227). TTY users call toll-free 877-
486-2048.
After you apply for Extra Help, you will get a letter letting you know whether you qualify and
what you need to do next. You may receive full or partial help depending on your income,
family size and resources. Be aware that if you qualify for Extra Help, some of the information
in this handbook will not apply to you.
Income-related monthly adjustment amount
If you are a member of a HealthChoice SilverScript plan, your premium for Part D coverage is
included in your regular monthly premium. Part B premiums are paid through Social Security.
However, if your income is above a certain level, the law requires your Part B and Part D
premiums be adjusted; i.e., income-related monthly adjustment amount (IRMAA). If you must
pay this extra amount, Social Security will notify you.
Note: If you fail to pay any Part D IRMAA, HealthChoice must move you to a plan without Part D.
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Medicare Supplement Plans Handbook Plan Year 2023
Paying your plan premiums
You must pay your full monthly plan premium unless you qualify for the Extra Help Medicare
program. Monthly premiums are reduced if you qualify for Extra Help. Payment of your monthly
premium is handled in one of three ways:
● Withheld from your retirement check.
● Withdrawn automatically from your bank account through an automatic draft.
● Paid directly to EGID. You will receive a monthly premium statement.
Consolidated Omnibus Budget Reconciliation Act (COBRA) participants must pay premiums
directly to EGID. Your premiums can be:
● Withdrawn automatically from your bank account through an automatic draft.
● Paid directly to EGID. You will receive a monthly premium statement.
Changes in your monthly premium
Generally, your premium does not change during the year; however, in certain cases, a
premium change can occur if:
● You do not currently get Extra Help from Medicare but qualify for it during the plan year;
your monthly premium will be lower.
● You currently get Extra Help from Medicare, but the amount of help you qualify for
changes; your premium will be adjusted accordingly.
● You add or drop dependents to or from your coverage sometime during the plan year;
your premium will be adjusted accordingly.
Nonpayment of premiums
If your monthly plan premiums are late, HealthChoice noties you in writing that you must pay
your premium by a certain date, which includes a grace period, or we will end your coverage.
HealthChoice has a grace period of two months. Refer to When HealthChoice Must End Your
Coverage in the Eligibility, Enrollment and Disenrollment section.
GENERAL INFORMATION
This HealthChoice Medicare Supplement Plans Handbook provides a guide to features of the
plans. It is not a complete description of the plans. Please read this handbook carefully for
information about eligibility rules and benets.
These plans are designed to provide supplemental benets to Medicare Part A and Part B.
These plans also cover Part D prescription drug benets. Except as noted otherwise in this
handbook, services not covered by Medicare are not covered by the plans. The medical
benets are based on Medicare’s approved amounts. For more information, review your 2023
Medicare & You handbook, visit Medicare.gov or call Medicare toll-free at 800-MEDICARE
(800-633-4227) or TTY 877-486-2048.
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Medicare Supplement Plans HandbookPlan Year 2023
The HealthChoice medical benets are paid as if you are enrolled in both Medicare Part A and
Part B. If you are not enrolled in Medicare, HealthChoice estimates Medicare’s benets and
provides coverage as if Medicare were your primary insurance carrier.
The HealthChoice plans supplement Medicare Part A
(hospitalization) by paying for:
● The inpatient hospitalization deductible and coinsurance.
● An additional 365 lifetime reserve days for hospitalization.
● The coinsurance for skilled nursing facility days 21 through 100.
● The rst three pints of blood while hospitalized.
The HealthChoice plans supplement Medicare Part B
(medical) by paying for:
● Outpatient medical expenses.
● Durable medical equipment.
● Limited outpatient prescription drugs.
Note: You must meet the Part B deductible before Medicare or HealthChoice pays benets.
HealthChoice SilverScript Medicare supplement plans
HealthChoice SilverScript Medicare supplement plans provide supplemental benets to
Medicare Part A and Part B. Benets are adjusted Jan. 1 of each year to coincide with
Medicare.
These plans provide primary Part D prescription drug coverage through our partnership with
CVS Caremark and their SilverScript Employer Prescription Drug Plan.
HealthChoice Medicare supplement plans without Part D
HealthChoice Medicare supplement plans without Part D include creditable prescription drug
coverage but not Part D coverage. These plans were specically designed for members who:
● Already have Medicare Part D coverage through another plan or employer.
● Receive a subsidy for prescription drug benets from their or their spouse’s employer.
● Receive VA benets for prescription drugs but desire to maintain additional prescription
coverage for drugs not covered by the VA.
● Did not enroll in Part D coverage through EGID timely or at all and must wait for a Part
D enrollment period or the next annual Option Period to enroll.
Note: Premiums for these plans are higher because HealthChoice does not receive a
prescription drug subsidy from Medicare for members enrolled in these plans.
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Medicare Supplement Plans Handbook Plan Year 2023
Provider-patient relationship
Your provider is responsible for the medical advice and treatment they provide or any liability
resulting from that advice or treatment. Although a provider may recommend or prescribe a
service or supply, this does not of itself establish coverage by the plans.
Medicare’s limiting charge
Under Medicare guidelines, the highest amount you can be charged for a covered medical
service is called the limiting charge. This applies when you receive services from doctors
and other health care service suppliers who do not accept Medicare assignment. The limiting
charge is 15% above the Medicare-approved amount and does not apply to medical supplies
or equipment.
Certication
Since HealthChoice is secondary to your Medicare coverage, certication through Customer
Care by your provider is required only for the additional 365 lifetime reserve days for
hospitalization covered by HealthChoice. If you have questions, call Customer Care. Refer to
HealthChoice Plan Contact Information.
HealthChoice explanation of benets
Each time a medical claim is processed, the claims administrator processes an explanation of
benets (EOB), which explains how your benets are applied. You will receive your EOB in the
mail. They are also available through the HealthChoice member portal at HealthChoiceOK.
com. If you have not already registered, create a username and password to access your
information.
Plan ID cards
Unless enrolled in a plan without Part D, HealthChoice members have two ID cards, one for
medical and/or dental benets and one for pharmacy benets. HealthChoice issues you ID
cards when you enroll in a HealthChoice plan.
New ID cards are not issued unless at least one of the following occurs:
● Dependents are added to your plan.
● You change HealthChoice health plans.
● You request a replacement ID card.
Medical/dental card
When you receive services, please present your HealthChoice medical/dental card.* When you
receive medical services, you also need to present your red, white and blue Medicare card.
To request a replacement medical/dental card, visit HealthChoiceOK.com or call Customer
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Medicare Supplement Plans HandbookPlan Year 2023
Care. Refer to HealthChoice Plan Contact Information.
*While the medical card and dental card are the same, dental services are not covered unless
you are also enrolled in the HealthChoice Dental Plan.
Prescription drug card
Please present your HealthChoice SilverScript prescription drug card when you purchase
prescriptions. The pharmacy provides automatic claims processing to HealthChoice for its
share of drug costs. You do not need to present your Medicare card at the pharmacy.
If you do not have your prescription drug card when you ll a prescription, have your pharmacy
contact the pharmacy benet manager for your information. If your pharmacy cannot get the
needed information, you may have to pay for your prescription and then le a paper pharmacy
claim for reimbursement. Refer to the Claim Procedures section.
To request a replacement prescription drug card, visit caremark.com or call the pharmacy
benet manager. Refer to HealthChoice Plan Contact Information.
Your contact information
It is important to keep your contact information current. You risk delaying claims processing,
missing communications and even being disenrolled from the plan when your information is
incorrect. Additionally, Medicare requires that you report any changes in your name, address
or phone number to your insurance plan. Be sure to keep your email address updated with
HealthChoice as well. You can fax changes to EGID Member Accounts at 405-717-8939 or
send in writing to HealthChoice, P.O. Box 11137, Oklahoma City, OK 73136-9998.
Let HealthChoice know if you move
If you move outside the United States and its territories, you cannot remain a member of a
SilverScript plan.
If you move within the United States and its territories, you still need to let HealthChoice know
so we can update your information.
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Medicare Supplement Plans Handbook Plan Year 2023
HEALTHCHOICE HIGH AND LOW OPTION
MEDICARE SUPPLEMENT PLANS
Medicare Part A (hospitalization) services
All benets are based on Medicare-approved amounts.
Services or items Description
Medicare Part A
pays
HealthChoice
pays
You
pay
Hospitalization
Includes semiprivate room,
meals, drugs as part of your
inpatient treatment, and
other hospital services and
supplies.
First 60 days All except Part A
deductible
100% of Part A
deductible
0%
Days 61 through 90 All except the
coinsurance per
day
Coinsurance per
day
0%
Days 91 and after while
using Medicare’s 60
lifetime reserve days.
All except the
coinsurance per
day
Coinsurance per
day
0%
Once Medicare’s lifetime
reserve days are used,
HealthChoice provides
additional lifetime reserve
days
Limited to 365 days.
0% 100% of
Medicare
eligible
expenses.
Certication by
HealthChoice is
required.
0%
Beyond the 365 lifetime
reserve days.
0% 0% 100%
Skilled nursing facility
care
Must meet Medicare
requirements, including
inpatient hospitalization
for at least three days
and entering a Medicare-
approved facility within 30
days of leaving the hospital;
limited to 100 days per
calendar year.
First 20 days. All approved
amounts
0% 0%
Days 21 through 100 All except the
coinsurance per
day
Coinsurance per
day
0%
Days 101 and after 0% 0% 100%
Providers who do not accept Medicare assignment cannot charge a Medicare beneciary more than 115% of
the Medicare-approved amount.
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Medicare Supplement Plans HandbookPlan Year 2023
Medicare Part A (hospitalization) services
All benets are based on Medicare-approved amounts.
Services or items Description
Medicare Part A
pays
HealthChoice
pays
You
pay
Hospice care
Your doctor and hospice
provider must certify you
are terminally ill and you
elect hospice.
Includes physical care,
counseling, equipment,
supplies, respite care,
inpatient care and drugs
for pain and symptom
control.
All but very limited
coinsurance for
outpatient drugs
and inpatient
respite care.
0% Up to $5 per
palliative
drug or
biological;
5% of
Medicare
amounts
for inpatient
respite care.
Blood
Limited to the rst three
pints unless you or
someone else donates
blood to replace what you
use.
0% 100% 0%
Medicare Part B (medical) services
All benets are based on Medicare-approved amounts.
Services or items Description
Medicare Part B
pays
HealthChoice
pays
You
pay
Medical expenses
Medically necessary
outpatient services and
supplies.
Includes doctor’s visits,
outpatient hospital treatments,
surgical services, physical and
speech therapy and diagnostic
tests.
80%
coinsurance
after Part B
deductible
20%
coinsurance
after Part B
deductible
Part B
deductible
Clinical diagnostic
laboratory services
Blood tests, urinalysis and
tissue pathology.
100% 0% 0%
Home health care
Medicare-approved
services.
Intermittent skilled care and
medical supplies.
100% 0% 0%
Durable medical
equipment
Items such as nebulizers,
wheelchairs and walkers.
80%
coinsurance
after Part B
deductible
20%
coinsurance
after Part B
deductible
Part B
deductible
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Medicare Supplement Plans Handbook Plan Year 2023
Medicare Part B (medical) services
All benets are based on Medicare-approved amounts.
Services or items Description
Medicare Part B
pays
HealthChoice
pays
You
pay
Diabetes monitoring
supplies
Includes coverage for glucose
monitors, test strips and
lancets for those with diabetes.
Must be requested by your
doctor.
80%
coinsurance
after Part B
deductible
20%
coinsurance
after Part B
deductible
Part B
deductible
Ostomy supplies
Includes ostomy bags, wafers
and other ostomy supplies for
those with a need based on
their condition.
80%
coinsurance
after Part B
deductible
20%
coinsurance
after Part B
deductible
Part B
deductible
Blood
Includes amounts in addition
to the coverage under Part A
unless you or someone else
donates blood to replace what
you use.
80%
coinsurance
after Part B
deductible
20%
coinsurance
after Part B
deductible
Part B
deductible
Outpatient
prescription
Includes infused, oral end-
stage renal disease and some
cancer and transplant drugs.
80%
coinsurance
after Part B
deductible
20%
coinsurance
after Part B
deductible
Part B
deductible
Coverage for additional medical services
Services or items
Medicare
pays
HealthChoice
pays
You
pay
Foreign travel
Medically necessary emergency
care services beginning during the
rst 60 days of each trip outside
the U.S.
0% 80% coinsurance
after the rst $250
and until the $50,000
lifetime maximum
You pay the rst
$250 each calendar
year, then 20% and
all amounts over
the $50,000 lifetime
maximum
Bariatric Surgery
0% 100% after Part B
deductible
Part B deductible
National Diabetes Prevention
Program
0% 100% You pay $0
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Medicare Supplement Plans HandbookPlan Year 2023
Medicare preventive services
Medicare Part B covers many preventive services, such as your annual u vaccination,
wellness visit and screening mammogram, at 100% when you use a doctor or other health
care provider who accepts Medicare assignment; however, certain preventive services may still
require the normal Part B deductible and/or coinsurance. Coinsurance can apply depending on
where you receive certain services.
For Medicare to cover preventive services, you must follow their guidelines for each service.
Guidelines can include criteria for age, frequency and disease risk.
For a list of preventive services and details on coverage, go to CMS.gov or Medicare.gov.
You can also refer to the 2023 Medicare & You handbook.
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Medicare Supplement Plans Handbook Plan Year 2023
HEALTHCHOICE SILVERSCRIPT HIGH OPTION
MEDICARE SUPPLEMENT PLAN
Pharmacy copay structure for network benets
Pharmacy deductible
You pay the rst $100 in drug costs before copays apply.
Prescription drugs 30-day supply 31- to 90-day supply
Generic (Tier 1) drugs
Up to $10 copay Up to $25 copay
Preferred (Tier 2) drugs
Up to $45 copay Up to $90 copay
Non-preferred (Tier 3) drugs
Up to $75 copay Up to $150 copay
Specialty (Tier 4) drugs
Up to $100 copay 30-day copay applies to each 30-
day supply
Preferred tobacco cessation
$0 copay $0 copay
Insulin
Up to $35 copay. Copay is applied
before the deductible.
30-day copay applies to each 30-
day supply and is applied before
the deductible.
Vaccinations
$0 copay $0 copay
Pharmacy out-of-pocket maximum
The annual out-of-pocket maximum is $7,400. Only your deductible and copays for covered
prescription drugs purchased at network pharmacies count toward the out-of-pocket maximum.
Once you reach the pharmacy out-of-pocket maximum, you pay $0 for covered prescription drugs
purchased at network pharmacies for the remainder of the calendar year.
● No coverage gap.
● Pharmacy benets generally cover up to a 30- or 90-day supply. Specic therapeutic categories,
drugs and/or dosage forms may have more restrictive quantity and/or duration of therapy limitations.
● Some drugs require prior authorization.
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Medicare Supplement Plans HandbookPlan Year 2023
HEALTHCHOICE SILVERSCRIPT LOW OPTION
MEDICARE SUPPLEMENT PLAN
Pharmacy copay structure for network benets
Pharmacy
deductible
Initial coverage
limit
Coverage gap
Catastrophic
coverage
Insulin
You pay the
rst $505 in
drug costs.
After the
deductible, you
and HealthChoice
share prescription
drug costs. You pay
25% ($1,165) and
HealthChoice pays
75% ($3,495) until
total drug spending
reaches $4,660.
You pay 100% of
your prescription
drug costs at
discounted rates –
25% of the cost of
generic drugs and
25% of the cost of
brand-name drugs.
What you pay
for brand-name
drugs plus the
70% manufacturer
discount applies to
your out-of-pocket
to get out of the
Coverage Gap.
For generic drugs,
only what you pay
applies.
After you reach
$7,400 out-of-
pocket, you pay
$0 for covered
prescription drugs at
network pharmacies
for the remainder of
the calendar year.
You pay up to $35
copay per 30-day
supply. Copay is
applied before the
deductible.
● Pharmacy benets generally cover up to a 30- or 90-day supply. Specic therapeutic categories,
drugs and/or dosage forms may have more restrictive quantity and/or duration of therapy limitations.
● Some drugs require prior authorization.
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Medicare Supplement Plans Handbook Plan Year 2023
HEALTHCHOICE HIGH OPTION MEDICARE SUPPLEMENT
PLAN WITHOUT PART D
Pharmacy copay structure for network benets
Prescription drugs 30-day supply 31- to 90-day supply
Generic (Tier 1) drugs
Up to $10 copay Up to $25 copay
Preferred (Tier 2) drugs
Up to $45 copay Up to $90 copay
Non-Preferred (Tier 3) drugs
Up to $75 copay Up to $150 copay
Specialty (Tier 4) drugs
Generic – $10 copay
Preferred – $100 copay
Non-Preferred – $200 copay
30-day copay applies to each 30-
day supply
Preferred tobacco cessation
$0 copay $0 copay
Insulin
Up to $30 copay. Copay is applied
before the deductible.
Up to $90 copay. Copay is applied
before the deductible.
Vaccinations
$0 copay $0 copay
Pharmacy out-of-pocket maximum
The annual out-of-pocket maximum is $7,400. Only your copays for covered prescription drugs
purchased at network pharmacies count toward the out-of-pocket maximum. Once you reach the
pharmacy out-of-pocket maximum, you pay $0 for covered prescription drugs purchased at network
pharmacies for the remainder of the calendar year.
● No coverage gap.
● Pharmacy benets generally cover up to a 30- or 90-day supply. Specic therapeutic categories,
drugs and/or dosage forms may have more restrictive quantity and/or duration of therapy limitations.
● Some drugs require prior authorization.
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Medicare Supplement Plans HandbookPlan Year 2023
HEALTHCHOICE LOW OPTION MEDICARE SUPPLEMENT PLAN
WITHOUT PART D
Pharmacy copay structure for network benets
Pharmacy
deductible
Initial coverage
limit
Coverage gap
Catastrophic
coverage
Insulin
You pay the
rst $505 in
drug costs.
After the
deductible, you
and HealthChoice
share prescription
drug costs. You pay
25% ($1,165) and
HealthChoice pays
75% ($3,495) until
total drug spending
reaches $4,660.
You pay 100% of
your prescription
drug costs at
discounted rates –
25% of the cost of
generic drugs and
25% of the cost of
brand-name drugs.
What you pay
for brand-name
drugs plus the
70% manufacturer
discount applies to
your out-of-pocket
to get out of the
Coverage Gap.
For generic drugs,
only what you pay
applies.
After you spend
$7,400 out-of-
pocket, you pay
$0 for covered
prescription drugs
for the remainder of
the calendar year.
You pay up to $30
copay per 30-day
supply and up to $90
copay per 31- to 90-
day supply. Copay
is applied before the
deductible.
● Pharmacy benets generally cover up to a 30- or 90-day supply. Specic therapeutic categories,
drugs and/or dosage forms may have more restrictive quantity and/or duration of therapy limitations.
● Some drugs require prior authorization.
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Medicare Supplement Plans Handbook Plan Year 2023
YOUR PRESCRIPTION DRUG COVERAGE
Pharmacy out-of-pocket maximum
All the plans have a pharmacy out-of-pocket maximum of $7,400. This total includes amounts
you spend, including deductibles, copays and coinsurance, at network pharmacies. If you are
a Low Option plan member, this total includes amounts you spend during the coverage gap.
Once you reach the out-of-pocket maximum, HealthChoice pays 100% for covered drugs
purchased at network pharmacies for the remainder of the calendar year.
Costs that do not apply to the pharmacy out-of-pocket
maximum
● Amounts paid by HealthChoice for drugs in the coverage gap (HealthChoice SilverScript
Low Option).
● Costs for drugs purchased outside the United States and its territories.
● Costs for non-covered drugs.
● Costs for drugs purchased at non-network pharmacies when exception requirements
are not met.
● Costs for drugs covered under Medicare Part A or Part B.
● Payments made by another group health plan or government health plan such as
TRICARE, the VA or Indian Health Service.
● Payments for drugs made by a third party with a legal obligation to pay.
HealthChoice Pharmacy Network
The HealthChoice Pharmacy Network includes more than 68,000 pharmacies nationwide.
Pharmacies contract with our plans to provide covered prescription drugs to members. They
also provide electronic claims processing, so there are no paper claims to le.
The HealthChoice Pharmacy Network includes specialized pharmacies, such as pharmacies
that:
● Supply drugs for home infusion therapies.
● Supply drugs to residents of long-term care facilities; usually, each facility has its own
pharmacy, and residents can get their prescription drugs through the facility’s pharmacy
if it is in the HealthChoice Pharmacy Network.
● Serve the Indian Health Service/Tribal/Urban Indian Health Program.
Sometimes a pharmacy leaves the HealthChoice network. When this occurs, you must get
your prescriptions lled at another network pharmacy.
You can locate a HealthChoice network pharmacy at HealthChoiceOK.com.
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Medicare Supplement Plans HandbookPlan Year 2023
● HealthChoice SilverScript members: Select HealthChoice SilverScript Pharmacy
Network. You can also call the pharmacy benet manager. Refer to HealthChoice Plan
Contact Information.
● HealthChoice Medicare supplement without Part D members: Select HealthChoice
Pharmacy Network. You can also call the pharmacy benet manager. Refer to
HealthChoice Plan Contact Information.
Non-network pharmacies
HealthChoice covers your prescriptions when they are lled at a non-network pharmacy
subject to the following provisions.
SilverScript plans
When you ll your prescriptions at a non-network pharmacy, a reduced benet applies. In
certain emergency situations, your prescriptions can be covered as if they were lled at a
network pharmacy. An exception can be made if you cannot access a network pharmacy due
to the following emergencies:
● You travel outside the HealthChoice service area and lose or run out of drugs or
become ill and need a Part D drug.
● You cannot ll a specialty drug timely because it is not in stock.
● There is no network pharmacy within reasonable driving distance with 24/7 service.
● You receive a Part D drug while in an emergency, observation or other outpatient
setting.
● Evacuation or displacement from your residence due to a federal declared national
disaster or other public health emergency.
You can replace drugs that were lost or damaged due to a declared national disaster or public
health emergency. Your pharmacy must contact the pharmacy helpline toll-free at 866-693-
4620. The helpline staff will work with your pharmacy to provide early rells or override the
maximum supply per ll. You must still pay the applicable copay per ll.
If you must use a non-network pharmacy, you must pay the full cost for your drugs and
then le a paper claim for HealthChoice to repay you for its share of the cost. Before you
ll a prescription under these circumstances, check for a network pharmacy in your area by
contacting the pharmacy benet manager. Refer to HealthChoice Plan Contact Information.
Without Part D plans
When you ll your prescriptions at a non-network pharmacy, a reduced benet applies. When
you use a non-network pharmacy, you pay the full amount and submit your claim to the
pharmacy benet manager for reimbursement.
Before you ll your prescriptions at a non-network pharmacy, when possible, check to nd out
if there is a network pharmacy in your area by contacting the pharmacy benet manager. Refer
to HealthChoice Plan Contact Information.
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Medicare Supplement Plans Handbook Plan Year 2023
Drug formularies
HealthChoice SilverScript Medicare Formulary (SilverScript plans)
To nd out how your drugs are covered, call the pharmacy benet manager. Refer to
HealthChoice Plan Contact Information. You can also visit their website at caremark.com or
go to HealthChoiceOK.com.
HealthChoice formulary lists (without Part D plans)
The HealthChoice Comprehensive Formulary is a list of drugs covered by the without Part D
plans. To nd out how your drugs are covered, call the pharmacy benet manager. Refer to
HealthChoice Plan Contact Information. You can also go to HealthChoiceOK.com.
Drug tiers
HealthChoice has a four-tier drug formulary and, in general, each tier represents a different
cost group:
● Tier 1 – Generic drugs.
● Tier 2 – Preferred brand-name drugs.
● Tier 3 – Non-preferred drugs.
● Tier 4 – Specialty drugs.
The drugs in Tiers 1 and 2 offer the preferred (lowest) copay while Tier 3 drugs are non-
preferred and have a higher copay. Tier 4 drugs include preferred very high-cost and unique
formulary drugs. Drugs not listed in the formulary are not covered.
Drugs covered under Medicare Part A and Part B
Medicare Part A and Part B provide coverage for some drugs.
● Medicare Part A covers drugs you receive during a Medicare-covered stay in a hospital
or skilled nursing facility or for symptom control or pain relief as part of hospice care.
● Medicare Part B covers certain chemotherapy drugs and certain drug injections you
receive in an ofce visit setting or are given at a dialysis facility.
Drugs covered under Medicare Part D and Part B
Most drugs are covered under Part D, but there are some drugs that can be covered under
both Part B or Part D depending on what the drug is used for and how it is administered. Your
physician must provide this information to get prior authorization to determine how the drug
should be billed.
Some drugs have restrictions
Some drugs have additional requirements or coverage limits. If there is a restriction on a drug
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Medicare Supplement Plans HandbookPlan Year 2023
you are taking, your provider must take extra steps for HealthChoice SilverScript to cover your
drug. Refer to the HealthChoice SilverScript Medicare formulary.
Prior authorization
Prior authorization is required before HealthChoice will cover certain drugs, even though they
are listed in the formularies. Generally, prior authorization is required because the drug:
● Has a high cost.
● Has preferred alternatives available.
● Has specic prescribing guidelines.
● Is generally used for cosmetic purposes.
● Might be covered under Medicare Part B.
Quantity limits
Due to approved therapy guidelines, certain drugs have quantity limits. Quantity limits can
apply to the number of rells you are allowed or how much of the drug you can receive per ll.
Quantity limits also apply if the drug is in a form other than a tablet or capsule.
Limited availability
Certain drugs are subject to limited availability and can be purchased only at certain
pharmacies. For more information, call the pharmacy benet manager toll-free at 866-275-
5253. TTY users call 711.
Step therapy
Step therapy requires you to rst try a less costly drug to treat your medical condition before
HealthChoice covers another drug for that same condition. For example, drugs A and B both
treat the same medical condition, but drug A is less costly. You must rst try drug A, and if it
does not work, HealthChoice SilverScript will cover drug B.
Requesting a pharmacy prior authorization
A request for prior authorization must be submitted by your physician. Your request must be
approved before you ll your prescription. To apply:
1. Have your physician’s ofce call the pharmacy benet manager toll-free at:
a. SilverScript plans 855-344-0930.
b. Without Part D plans 800-294-5979.
2. The pharmacy benet manager will assist your physician’s ofce with completing a prior
authorization form.
3. If your prior authorization is approved, your physician’s ofce is notied of the approval
within 24 to 48 hours. You are also notied in writing.
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Medicare Supplement Plans Handbook Plan Year 2023
4. If your prior authorization is denied, your physician’s ofce is notied of the denial within
24 to 48 hours. You are also notied in writing.
Note: In most cases, a prior authorization is valid for one year from the date it is issued and
must be renewed when it expires.
Tier exception (High Option plans only)
If you choose a non-preferred drug when a preferred drug is available, you must pay the non-
preferred copay unless you get a tier exception for a lower copay. Specic medical guidelines
must be met, and your physician must supply information to justify your request. Your physician
can call the pharmacy benet manager toll-free at 855-344-0930.
Non-formulary or excluded drug prior authorization
If you are prescribed a drug that is non-formulary or excluded, you can:
● Ask your physician for a prescription for a generic (Tier 1) or preferred (Tier 2) drug that
is listed on the formularies.
● Continue your non-covered/non-formulary/excluded drug and pay the full cost.
● Request a prior authorization to receive your drug at the non-preferred copay.
For more information, call the pharmacy benet manager. Refer to HealthChoice Plan Contact
Information.
Drug quantities
Pharmacy benets generally cover up to a 30- or 90-day supply. Quantities cannot exceed the
FDA-approved usual dosing recommendations. Some drugs have more restrictive quantity and
length of therapy limits. Quantities are also subject to your doctor’s written orders.
Specialty drugs
Specialty drugs are usually high cost drugs that require special handling and extensive
monitoring. These drugs may be limited to a 30-day supply.
Tobacco cessation products
HealthChoice covers the following tobacco cessation drugs at 100% when purchased at a
network pharmacy:
● Buproban 150mg SA Tabs.
● Bupropion HCL SR 150mg Tabs.
● Chantix 0.5mg and 1mg Tabs.
● Nicotrol 10mg Cartridge.
● Nicotrol NS 20mg/m Nasal Spray.
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Medicare Supplement Plans HandbookPlan Year 2023
HealthChoice covers up to a 168-day 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 phone coaching at no charge to
HealthChoice health plan members. To take advantage of these benets, call toll-free
800-QUIT-NOW (800-784-8669) and identify yourself as a HealthChoice member. The hours of
operation are now 24/7.
Members living outside of Oklahoma call toll-free 866-QUIT-4-LIFE (866-784-84540).
Vaccinations covered under your pharmacy benets
Generally, HealthChoice covers all commercially available vaccinations needed to prevent
illness.
The coverage of vaccinations includes two parts – the cost of the vaccine itself and the cost
of the vaccination (administration of the shot). What you pay for a vaccination depends on
the type of vaccine, where you purchase the vaccine and who gives you the shot. The rules
for coverage of vaccinations are complicated. If you have a question about how a vaccine is
covered, call the pharmacy benet manager. Refer to HealthChoice Plan Contact Information.
Without Part D plans
You are responsible for administration fees for vaccines covered under pharmacy benets.
When you are hospitalized
Part A covers your prescription drugs as part of your inpatient treatment for a Medicare-
covered stay. Once you leave the hospital, HealthChoice covers your prescription drugs as
long as they meet the rules for coverage. HealthChoice also covers your drugs if they are
approved through a coverage determination, exception or appeal.
When you are admitted to a skilled nursing facility
Part A covers your prescription drugs during all or part of a Medicare-covered stay. If Part
A stops paying for your prescriptions, HealthChoice covers them if they meet the rules for
coverage. The facility’s pharmacy must be a network pharmacy, and the drug cannot be
covered under Part B. HealthChoice also covers your drugs if they are approved through a
coverage determination, exception or appeal.
When you receive hospice care
The hospice drugs you receive for symptom control or pain relief are covered under Medicare
Part A.
Drugs for the treatment of conditions unrelated to the terminal illness are covered under Part
D. Drugs are never covered under both Part A and Part D at the same time.
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Medicare Supplement Plans Handbook Plan Year 2023
Prior Authorization is required on drugs prescribed for hospice patients. If you are receiving
hospice care and are prescribed an anti-nausea, laxative, pain or anti-anxiety drug that is not
covered by Medicare because it is unrelated to your terminal illness, your prescriber or hospice
provider must notify HealthChoice SilverScript before the plan can cover your drug.
To prevent delays in receiving drugs that are covered by HealthChoice SilverScript, you can
ask your hospice provider or prescriber to make sure they have notied the plan that your drug
is unrelated to your terminal illness before you ask a pharmacy to ll your prescription.
In the event you revoke your hospice election or are discharged from hospice, HealthChoice
should cover all your drugs. To prevent any delays at your pharmacy when your Medicare
hospice benet ends, bring documentation to the pharmacy to verify your revocation of, or
discharge from, hospice care.
Drug safety programs
The pharmacy benet manager conducts drug reviews to make sure members receive safe
and appropriate prescription therapies. These reviews can be important if you have more than
one provider prescribing different types of drugs. Each time you ll a prescription, a review is
conducted to look for possible problems such as:
● Drug errors.
● Dosage errors.
● Drugs that are unnecessary because you already take another drug for the same
condition.
● Drugs that may be unsafe or inappropriate because of your age or gender.
● Drugs combinations that could harm you if you take them at the same time.
● Drugs you are allergic to.
If any possible problems are detected, the pharmacy benet manager noties your pharmacist
at the time your prescription is lled.
Creditable prescription drug coverage
The HealthChoice Medicare supplement plans provide creditable coverage. Prescription drug
coverage is creditable if it meets or exceeds Medicare’s prescription drug coverage guidelines.
The HealthChoice plans provide coverage equal to (Low Option plans) or better than (High
Option plans) the standard benets set by Medicare. HealthChoice is not required to send
you a Creditable Coverage letter, but if you need one, call EGID Member Services. Refer to
HealthChoice Plan Contact Information.
Types of drugs NOT covered
If you take a drug that is excluded from coverage, you must pay for the drug yourself.
Generally, HealthChoice cannot cover drugs that are:
● Purchased outside the United States.
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Medicare Supplement Plans HandbookPlan Year 2023
● Prescribed for off-label use (any use of a drug other than those indicated on the drug’s
label).
The following drug categories are also excluded from coverage:
● Cough and cold drugs.
● Fertility drugs.
● Over-the-counter drugs.
● Lost, stolen or damaged drugs.
● Drugs used for the treatment of anorexia, weight loss or weight gain.
● Drugs not approved by the FDA, except those used for the treatment of COVID-19 that
have FDA Emergency Use Authorization.
● Impotency drugs such as Cialis, Levitra, Viagra and Caverject.*
● Drugs used for cosmetic purposes or hair regrowth.
● Brand-name drugs from manufacturers that do not participate in the Coverage Gap
Discount Program.
● All over-the-counter and prescription vitamins, except prenatal vitamins.
*These drugs are specically excluded from coverage unless you have had radical retropubic
prostatectomy surgery or certain other medical conditions. Prior authorization is required.
CLAIMS PROCEDURES
Claims ling deadline
Claims must be submitted within 180 days from the date of service.
If you have questions about any of the following medical claim procedures, call Customer
Care. Refer to HealthChoice Plan Contact Information.
Filing a medical claim
Most providers le your claims with Medicare and then automatically le your claims with
HealthChoice. To process your claim electronically, your and your dependents’ Medicare
numbers must be on le with the plan.
If you have to le your claim with HealthChoice yourself, once you receive your Medicare
Summary Notice for Part A and Part B services, you can le your claim by sending a copy of
the notice to Customer Care. Refer to HealthChoice Plan Contact Information.
Medical coordination of benets
If you or your covered dependents are covered by another group health plan, HealthChoice
coordinates benets with your other plan so total benets are not more than the amount billed
or your liability. If your other group coverage is primary over your HealthChoice coverage,
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Medicare Supplement Plans Handbook Plan Year 2023
you must le claims with your primary plan rst. If your other health coverage terminates, call
Customer Care. Refer to HealthChoice Plan Contact Information.
Medicare beneciaries with end-stage renal disease
If you are diagnosed with end-stage renal disease, Medicare is the secondary payer to
HealthChoice for the rst 30 months of coverage. This rule applies regardless of whether
you are a primary member or covered as a dependent under a group health plan. During this
period, HealthChoice always pays rst.
If you have questions about ESRD coverage, visit Medicare.gov or call Medicare toll-free at
800-MEDICARE (800-633-4227) or TTY 877-486-2048.
Filing a direct pharmacy claim
Usually, your claim is processed electronically at the pharmacy. If your pharmacist has
questions, have them call the pharmacy helpline:
● SilverScript plans toll-free 866-693-4620.
● Without Part D plans toll-free 800-364-6331.
In some cases, you may need to pay the full cost of your drug and then ask HealthChoice to
repay you for its share. You may need to le a paper claim for reimbursement when:
● You use a non-network pharmacy due to an emergency.
● You pay the full cost for a drug because you did not have your plan ID card.
● Your drug has a restriction, and you decide to purchase the drug immediately.
To ask for reimbursement, send your pharmacy receipt and CVS Caremark Prescription
Reimbursement Claim Form to the pharmacy benet manager at the appropriate address listed
on the form.
If your claim involves coordination of benets with other group insurance, include a copy of the
pharmacy receipt that lists your name, the drug and the amount you paid for the prescription.
When your claim is received, the pharmacy benet manager will let you know if more
information is needed.
If your claim is for a covered drug and you followed all plan guidelines, HealthChoice will
reimburse you for its share of the cost.
If your claim is for a non-covered drug or you did not follow plan guidelines, HealthChoice will
send you a letter letting you know the reason your request was denied and what your rights
are to appeal the decision.
Claims for services outside the United States
If you receive medically necessary emergency treatment outside the United States, follow
these claim procedures:
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Medicare Supplement Plans HandbookPlan Year 2023
● Arrange to pay for the services or supplies.
● Have claims translated into English before you le your claim.
● Convert charges to U.S. dollars using the exchange rates for the dates of service.
● Claims must be submitted to Customer Care. Refer to HealthChoice Plan Contact
Information.
Note: HealthChoice does not pay for drugs purchased outside the United States.
Private contracts with physicians and practitioners
A private contract is a written agreement between a Medicare beneciary and a doctor or
practitioner who does not provide services through the Medicare program. These providers
have opted out of Medicare, and you must sign a private contract with them before they will
provide care. If you sign a private contract, be aware that:
● Medicare’s limiting charge does not apply. You pay what the practitioner charges.
● Claims for these services are not covered by Medicare or HealthChoice, and neither
Medicare nor HealthChoice pay anything for these services
Subrogation
Subrogation is the process through which HealthChoice has the right to recover any benet
payments made to you or your dependents by a third party or an insurer because of an injury
or illness caused by the third party. Third party means another person or organization.
Subrogation applies when you are sick or injured as a result of the negligent act or omission of
another person or party. If you or your covered dependents receive HealthChoice benets and
have a right to recover damages, the plan has the right to recover any benets paid on your
behalf. All payments from a third party, whether by lawsuit, settlement or otherwise, must be
used to repay HealthChoice.
Example: While in your vehicle, you are hit by another driver who is at fault. In the accident,
you have injuries that require medical attention. HealthChoice pays your medical claims and
when the auto insurance claim is settled, the other driver’s insurance (the third party) or your
uninsured/underinsured/med pay motorist policy repays HealthChoice the amounts it paid on
your medical claims related to the accident. If the third party or an insurer pays you or your
dependent directly, you are responsible for repaying HealthChoice.
If you are asked to provide information about the injury or accident to the HealthChoice
subrogation administrator at the law rm of McAfee & Taft, any related claims are pended until
you have supplied the necessary information. Failure to provide the required information in a
timely manner may result in your claim being denied.
The subrogation administrator can be reached by phone at 405-235-9621 or toll-free 844-724-
9386, fax at 405-235-0439 or mail at Two Leadership Square, 10th Floor, 211 N. Robinson
Ave., Oklahoma City, OK 73102.
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Medicare Supplement Plans Handbook Plan Year 2023
ELIGIBILITY, ENROLLMENT AND DISENROLLMENT
Medicare eligibility
Medicare is the federal health insurance program for people:
● 65 and older.
● Under 65 with qualied disabilities.
● With ESRD.
CMS manages the Medicare program. The Social Security Administration determines eligibility,
enrolls people in Medicare and collects Medicare premiums. For information about Medicare,
visit the CMS website at CMS.gov or the Social Security website at SSA.gov. You can also
call Social Security toll-free at 800-772-1213 or TTY 800-325-0778.
Medicare is divided into several parts. The parts of Medicare that apply to your plan include:
● Part A, which covers services provided by hospitals, skilled nursing facilities and home
health agencies.
● Part B, which covers most other medical services, such as physician ofce visits,
outpatient services and durable medical equipment and supplies.
● Part D, which covers prescription drugs.
Enrollment in Medicare
Enrollment in Medicare is handled in two ways – either you are automatically enrolled, or you
must apply.
If you receive Social Security or Railroad Retirement Board benets before you turn 65, you
are automatically enrolled, and your Medicare Health Insurance card is mailed to you about
three months before your 65th birthday.
Otherwise, you must apply for Medicare by contacting Social Security, or, if appropriate, the
Railroad Retirement Board, 60 to 90 days before you turn 65.
If you have been a disabled beneciary under Social Security or Railroad Retirement for 24
months, you will automatically get a Medicare Health Insurance card in the mail.
When you become Medicare eligible
Approximately two months before you turn 65, EGID sends you a letter advising you of your
options for Medicare supplement coverages and Medicare Advantage prescription drug plans.
An Application for Medicare Supplement With Prescription Drug Plan and an Application
for Medicare Advantage Prescription Drug Plan will be enclosed with your letter. You must
complete and return the appropriate application for the plan you wish to enroll in. You can
choose a different insurance carrier than the one you currently have when you become
Medicare eligible, but you must be eligible for the plan you select, and your election must
27
Medicare Supplement Plans HandbookPlan Year 2023
be made within your initial enrollment period. Once your plan election is made and your
enrollment is effective, you cannot make another plan change until the annual Option Period or
during a special enrollment period.
If you or your covered dependents become Medicare eligible before 65, you must notify EGID
and provide your Medicare number as it appears on your Medicare Health Insurance card.
EGID will mail you an Application for Medicare Supplement With Prescription Drug Plan and
an Application for Medicare Advantage Prescription Drug Plan. You must complete and return
the appropriate application for the plan you wish to enroll in by the deadline indicated on the
form. You can choose a different insurance carrier than the one you currently have when you
become Medicare eligible, but you must be eligible for the plan you select, and your election
must be made within your initial enrollment period. Once your plan election is made and your
enrollment is effective, you cannot make another plan change until the annual Option Period
or during a special enrollment period. Your enrollment will be effective on the rst day of the
month following receipt of your completed application or on the effective date of your Medicare
coverage, whichever is later.
Eligibility requirements
You are eligible to enroll in a HealthChoice SilverScript Medicare supplement plan if you are:
● Entitled to Medicare Part A or enrolled in Medicare Part B.
● Listed as eligible in Medicare’s system for Part D.
● A permanent resident of the United States or its territories.
If you live abroad or are in prison, you cannot enroll in a HealthChoice SilverScript plan;
however, you can enroll in one of the HealthChoice Medicare supplement plans without Part D.
Enrollment periods and plan changes
There are three time periods when you can enroll in or disenroll from the HealthChoice
Medicare supplement plans:
Annual coordinated election period – This is Medicare’s annual election period, Oct. 15
through Dec. 7, which EGID follows for Option Period plan changes. Effective date is Jan. 1.
Initial enrollment period – This is when you rst become eligible for Medicare. The effective
date is the rst day of the month you become eligible or the rst day of the month following
receipt of your completed application, whichever is later.
● If initial Medicare eligibility occurs outside of the annual coordinated election period, you
can switch health insurance carriers provided that:
○ You are eligible for the plan you select, and your election must be made within your
initial enrollment period.
○ Once a plan election is made and your enrollment is effective, you cannot make
another plan change until the annual Option Period or during a special enrollment
period.
○ The entire family must remain covered by the same carrier, and the receiving plan
must be able to accommodate all family members.
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Medicare Supplement Plans Handbook Plan Year 2023
Special enrollment period – This is when you can make midyear changes under certain
circumstances (effective date follows receipt of your completed application), such as:
● You move outside the United States.
● CMS or HealthChoice terminates the plan’s participation in the Part D program.
● You lose creditable coverage for reasons other than failure to pay premiums.
● You meet other exception rules as set out by CMS.
For more information about SEPs, call toll-free 800-MEDICARE (800-633-4227). TTY users
call toll-free 877-486-2048.
Conrmation statement
Anytime a change is made to your coverage, EGID mails you a conrmation statement
that lists the coverage you are enrolled in, the effective date of coverage and the premium
amounts. Review your statement as soon as you receive it so any errors can be corrected as
soon as possible.
If you do not make any changes to your coverage, you will not receive a conrmation
statement.
Dependent coverage
Dependents can be added to coverage only if at least one of the following conditions is met:
● Your dependent loses other group or qualied individual health coverage. Application
for enrollment and proof of termination of the other health coverage must be submitted
within 30 days of the loss. You must cover all eligible dependents. Some exceptions
apply. Refer to the Excluding Dependents from Coverage in this section.
● You marry and want to add your new spouse and dependent children to your coverage.
You must add them within 30 days of your marriage.
● You gain a new dependent through birth, adoption or legal guardianship. You must add
them within 30 days of the birth, adoption or gaining legal guardianship.
COBRA continuation of coverage is available for dependents who lose eligibility. Refer to
COBRA in this section.
Eligible dependents
Eligible dependents include:
● Your legal spouse (including common-law).
● Your daughter, son, stepdaughter, stepson, eligible foster child, adopted child, child
for whom you have been granted legal guardianship or child legally placed with you
for adoption, guardianship or other legal custody, up to age 26, whether married or
unmarried. Note: Plan coverage that terminates upon the dependent’s 26th birthday will
terminate at the end of the month in which the birthday occurs.
● Your dependent, regardless of age, who is incapable of self-support due to a disability
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Medicare Supplement Plans HandbookPlan Year 2023
diagnosed prior to age 26. A Disabled Dependent Assessment form must be submitted
at least 30 days prior to the dependent’s 26th birthday. The form must be approved by
EGID before coverage begins or is extended beyond age 26.
● Other unmarried children up to age 26 who live with you and for whom you are primarily
responsible. This requires completion of an acceptable Application for Coverage for
Other Dependent Children. A tax return showing dependency may be provided in lieu of
the application.
You can enroll dependents only in the same coverage and plans as you. Dependents who are
not enrolled within 30 days of your eligibility date cannot be enrolled unless there is a qualifying
event such as birth or marriage, or one of the above events occur.
If you drop eligible dependents from coverage, you cannot re-enroll them unless they lose
other group or qualied individual health coverage.
If your spouse is enrolled separately in a plan offered through EGID, your dependents can be
covered under only one parent’s health, dental or vision plan. However, both parents can cover
dependents under Dependent Life insurance.
In the event of the birth of a child when Medicare is primary, call HealthChoice Customer Care
for coverage information.
Excluding dependents from coverage
Eligible dependents can be excluded from coverage if they have other group or qualied
individual health coverage or are eligible for Indian or military health benets. You can
exclude eligible dependent children who do not live with you, are married or are not nancially
dependent on you for support. You can also exclude your spouse. If you exclude your spouse
while covering other eligible dependents, you and your spouse must both sign the Spouse
Exclusion Certication on your Application for Retiree/Vested/Non-Vested/Defer Insurance
Coverage, or your Option Period Enrollment/Change Form if you drop your spouse during
Option Period.
To request coverage changes
All requests for changes in coverage must be made in writing. Verbal requests for changes are
not accepted, unless directed by Medicare. A request for change must be made within 30 days
of a qualifying event. Please send all requests for changes to HealthChoice, P.O. Box 11137,
Oklahoma City, OK 73136-9998; or fax your request to 405-717-8939.
When your employer changes insurance carriers
Education retirees
If you were a career tech employee or a common school employee who terminated
employment on or after May 1, 1993, you can continue coverage through the plan as long as
the school system from which you retired or vested continues to participate in the plan. If your
30
Medicare Supplement Plans Handbook Plan Year 2023
school system terminates coverage with the plan, you must follow your former employer to its
new insurance carrier.
If you were an employee of an education entity other than a common school, e.g., higher
education, charter school, etc., you can continue coverage through the plan as long as the
education entity from which you retired or vested continues to participate in the plan. If your
former employer terminates coverage with the plan, you must follow your former employer to
its new insurance carrier.
Local government retirees
If you were a local government employee who terminated employment on or after Jan. 1, 2002,
you can continue coverage through the plan as long as the employer from which you retired or
vested continues to participate in the plan. If your former employer terminates coverage with
the plan, you must follow your former employer to its new insurance carrier.
New employer retirees
All retirees of employers who joined the plan after the grandfathered dates must follow their
former employer to its new insurance carrier.
Following your employer to a new plan
When you terminate employment, your benets are tied to your most recent employer. If that
employer discontinues participation with EGID, some or all of their retirees and dependents
(depending on the type of employer) must follow the employer to its new insurance carrier. This
is true regardless of the amount of time you work for any participating employer. If you retire
and then return to work for another employer and enroll in benets through that employer, your
benets are tied to your new employer in most cases.
If you return to work
If you return to work and enroll in a group health plan offered through your employer, that plan
is your primary insurance carrier. However, you may be eligible to continue Medicare as your
primary carrier with HealthChoice as your supplement plan.
If you can opt out of your employer’s group health plan and keep your HealthChoice Medicare
supplement plan, Medicare is your primary insurance carrier and HealthChoice is your
secondary carrier. Be aware that your employer cannot provide a Medicare supplement plan or
pay for any premiums related to a Medicare supplement plan.
If you are a retired or vested member returning to work, and you did not continue health
coverage at the time you retired or vested, you must meet all the eligibility requirements of a
new employee.
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Medicare Supplement Plans HandbookPlan Year 2023
Ending your coverage with HealthChoice
Ending your coverage with HealthChoice can be voluntary or involuntary. You can choose to
leave the plan, or HealthChoice may be required to end your coverage.
You have the option to leave the plan during Option Period. Medicare denes certain
situations, known as Special Enrollment Periods, when you can leave the plan at other times of
the year.
If you terminate coverage in retirement or as a vested member, you cannot re-enroll in the
plans offered through EGID. As a retiree, you will forfeit any retirement system contribution
paid toward your health insurance premium. Your terminated health, dental or life coverage
cannot be reinstated later unless you return to work as an employee of a participating
employer for at least three years. Vision coverage is the only benet that can be elected during
Option Period as long as you keep one other benet through EGID.
If your dependent is dropped from your plan, they cannot be re-enrolled unless they lose other
group or qualied individual health coverage.
If you are enrolled in a HealthChoice SilverScript plan and you drop that coverage, you must
enroll in another Part D plan within 63 days to avoid a late enrollment penalty.
When HealthChoice must end your coverage
HealthChoice must end your coverage in the plan when:
● You fail to pay premiums.
● You move out of the United States or its territories for more than 12 months.
● You go to prison.
● You lie about or withhold information about other prescription coverage you have.*
● You continuously behave in a way that is disruptive.*
● You allow someone else to use your ID card to purchase prescription drugs.
*We cannot end your coverage for these reasons unless we rst get permission from
Medicare. If HealthChoice ends your coverage, we send you a letter explaining our reasons
and include instructions about how you can le a complaint with the plan.
In the event of your death
Your surviving dependents can continue any coverage that is in effect at the time of your death
as long as all premiums are paid. Surviving dependents have 60 days from the date of your
death to elect survivor benets.
If your dependents are enrolled in a HealthChoice SilverScript plan, their coverage is continued
automatically; however, they have the option to cancel coverage.
Coverage is effective on the rst day of the month following your death. Surviving dependents
will receive new ID cards and a bill for premiums through current month.
Notice of your death should be directed to your retirement system and HealthChoice.
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Medicare Supplement Plans Handbook Plan Year 2023
COBRA
COBRA is federal legislation that gives members and their covered dependents who lose
health benets the right to choose to continue group health benets for limited periods of time
under certain circumstances.
If you are not Medicare eligible before you begin COBRA coverage, your health coverage
will end once you gain Medicare. If you are already Medicare eligible when you elect COBRA
coverage, you must continue your employee status coverage and cannot enroll in the Medicare
supplement plan until the next Option Period.
It is the policy of EGID that for any benet continued under COBRA, one person must always
pay the primary member premium. In cases where a spouse, child or children are insured
under a particular benet, but the member did not keep that coverage, one person will always
be billed at the primary member rate.
When you are enrolled in vested, non-vested or retirement
coverage and your dependents become eligible for COBRA
Your covered spouse and dependent children are eligible to continue coverage for up to 36
months if coverage is lost for reasons such as:
● Divorce or legal separation.*
● Your dependent loses eligibility.
● Your death (refer to In the Event of Your Death in this section).
As a former employee, you must notify EGID in writing within 30 days of a divorce,* legal
separation* or your child’s loss of dependent status under this plan. Your eligible dependents
must elect continuation of coverage within 60 days after the later of these events occurs:
● The date the qualifying event would cause your dependents to lose coverage.
● The date EGID noties your dependents of continuation of coverage rights.
If you have questions about COBRA, call EGID Member Services. Refer to HealthChoice Plan
Contact Information.
*Oklahoma law prohibits dropping your spouse or other dependents in anticipation of a divorce
or legal separation. If you are in the process of a divorce or legal separation, contact your
legal counsel for advice before making changes to your coverage.
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Medicare Supplement Plans HandbookPlan Year 2023
State of Oklahoma
Ofce of Management and Enterprise Services
PRIVACY NOTICE
Revised January 2023
This notice describes how medical information about you may be used and disclosed
and how you can get access to this information. Please review this notice carefully.
For questions or complaints regarding privacy concerns with OMES, please contact:
OMES HIPAA Privacy Ofcer
2401 N. Lincoln Blvd., Ste. 300, Oklahoma City, OK 73105
405-717-8780 or toll-free 800-543-6044
TTY 711
oklahoma.gov/omes
Why is the notice of privacy practices important?
This notice provides important information about the practices of OMES pertaining to the way
it gathers, uses, discloses and manages your Protected Health Information and also describes
how you can access this information. PHI is health information that can be linked to a particular
person by certain identiers including, but not limited to, names, Social Security numbers,
addresses and birth dates.
Oklahoma privacy laws and the federal Health Insurance Portability and Accountability Act
of 1996 protect the privacy of an individual’s health information. For HIPAA purposes, OMES
has designated itself as a hybrid entity. This means that HIPAA only applies to areas of OMES
operations involving health care and not to all lines of service offered by OMES. This notice
applies to the privacy practices of the following OMES divisions and positions that may share
or access your PHI as needed for treatment, payment and health care operations:
● Employees Group Insurance Division (EGID).
● General Counsel Legal.
● Information Services as it applies to maintenance and storage of PHI.
● OMES Deputy Director.
● The Director of Policy and Legislative Affairs and the Legislative Liaison.
OMES is committed to protecting the privacy and security of your PHI as used within the
components listed above.
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Medicare Supplement Plans Handbook Plan Year 2023
Your information. Your rights. Our responsibilities.
>
Your rights
When it comes to your health information, you have certain rights. This section explains
your rights and some of our responsibilities to help you.
Get an electronic or paper copy of your health and claims records.
● You can ask to see or get an electronic copy of your medical record and other health
information we have about you. Ask us how to do this using the contact information at
the beginning of this notice.
● We will provide a copy or a summary of your health information, usually within 30 days
of your request. We may charge a reasonable, cost-based fee.
Ask us to correct health and claims records.
● You can ask us to correct your health and claims records if you think they are incorrect
or incomplete. Ask us how to do this using the contact information at the beginning of
this notice.
● We may decline your request but will explain the reasons in writing within 60 days.
Request condential communications.
● You can ask us to contact you in a specic manner; e.g., home or ofce phone, or to
send mail to an alternate address.
● We will consider all reasonable requests.
○ If declining would put you in danger, tell us and we will automatically approve your
request.
Ask us to limit what we use or share.
● You can ask us not to use or share certain health information for treatment, payment or
our operations.
○ We are not required to approve your request and may decline if it would affect your
care.
Get a list of those with whom we’ve shared information.
● You can ask for an accounting of the times we’ve shared your health information for six
years prior to the date you ask, who we shared it with and why.
● We will include all the disclosures except for those about treatment, payment and health
care operations, and certain other disclosures (such as any you asked us to make).
● We will provide one free accounting per year but will charge a reasonable fee if you
request an additional accounting within 12 months.
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Medicare Supplement Plans HandbookPlan Year 2023
Get a copy of this privacy notice.
● You can ask for a paper copy of this notice at any time, even if you have agreed to
receive the notice electronically. We will promptly provide you with a paper copy.
Choose someone to act for you.
● If you have named a medical power of attorney, or if someone is your legal guardian,
that person can exercise your rights and make decisions about your health information.
● We will verify the person has this authority and can act for you before any action is
taken.
File a complaint if you feel your rights are violated.
● You can le a complaint if you feel we have violated your rights by contacting us using
the information at the beginning of this notice.
● You may also le a complaint with the U.S. Department of Health and Human Services
Ofce for Civil Rights by sending a letter to 200 Independence Ave., S.W., Washington,
D.C. 20201, calling 1-877-696-6775, or visiting hhs.gov/ocr/privacy/hipaa/
complaints/.
● We will not retaliate against you for ling a complaint.
>
Your choices
For certain health information, you can tell us your choices about what we share. If you
have a clear preference for how we share your information in the situations described below,
talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
● Share information with your family, close friends, or others involved in payment for your
care.
● Share information in a disaster relief situation.
● Contact you for fundraising efforts.
If you are not able to tell us your preference (e.g., if you are unconscious), we may share your
information if we believe it is in your best interest. We may also share your information when
needed to lessen a serious and imminent health or safety threat.
In these cases, we never share your information unless you give us written permission:
● Marketing purposes.
● Sale of your information.
● Most sharing of psychotherapy notes.
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Medicare Supplement Plans Handbook Plan Year 2023
>
Our uses and disclosures
How do we typically use or share your health information?
Your PHI is used and disclosed by OMES employees and other entities under contract with
OMES according to HIPAA Privacy Rules and the “minimum necessary” standard, which
releases only the minimum necessary health information to achieve the intended purpose or to
carry out a desired function within OMES.
We typically use or share your health information in the following ways:
Help manage the health care treatment you receive.
● We can use your health information and share it with professionals who are treating
you.
Example: A doctor sends us information about your diagnosis and treatment plan so we can
arrange additional services.
Run our organization.
● We can use and disclose your information to run our organization and contact you when
necessary.
● We are not allowed to use genetic information to decide whether we will give you
coverage and the price of that coverage. This does not apply to long term care plans.
Examples: We use health information about you to develop better services for you, provide
customer service, resolve member grievances, member advocacy, conduct activities to
improve member health and reduce costs, assist in the coordination and continuity of health
care, and to set premium rates.
Pay for your health services.
● We can use and disclose your health information as we pay for your eligible health
services.
Example: We share information about you with your dental plan to coordinate payment for your
dental work.
Administer your plan.
● We may disclose summarized health information to your health plan sponsor for plan
administration.
Example: Your employer contracts with us to provide a health plan, and we provide the
employer with certain statistics to explain the premiums we charge.
How else can we use or share your health information?
We are allowed or required to share your information in other ways – usually in ways that
contribute to the public good, such as public health and research. We must comply with the law
to share your information for these purposes. For more information, refer to
hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
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Medicare Supplement Plans HandbookPlan Year 2023
Help with public health and safety issues.
We can share your health information for certain situations such as:
● Preventing disease.
● Helping with product recalls.
● Reporting adverse reactions to medications.
● Reporting suspected abuse, neglect or domestic violence.
● Preventing or reducing a serious threat to anyone’s health or safety.
Do research.
We can use or share your information for health research, as permitted by law.
Comply with the law.
We will share information about you if state or federal laws require it, including with the
Department of Health and Human Services if it wants to ensure we are complying with federal
privacy laws.
Respond to organ and tissue donation requests.
We can share health information about you with organ procurement organizations.
Work with a medical examiner or funeral director.
We can share health information with a coroner, medical examiner or funeral director when an
individual dies.
Address workers’ compensation, law enforcement and other government requests.
We can use or share health information about you:
● For workers’ compensation claims.
● For law enforcement purposes or with a law enforcement ofcial.
● With health oversight agencies for activities authorized by law.
● For special government functions such as military, national security, and presidential
protective services.
Respond to lawsuits and legal actions.
We can share health information about you in response to a court or administrative order or in
response to a subpoena.
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Medicare Supplement Plans Handbook Plan Year 2023
>
Our responsibilities
When it comes to your health information, we have specic obligations such as:
● We are required by law to maintain the privacy and security of your Protected Health
Information.
● We will let you know promptly if a breach occurs that may have compromised the
privacy or security of your PHI.
● We must follow the duties and privacy practices described in this notice and give you a
copy of it.
● We will not use or share your PHI other than as described here unless you notify us
in writing that we can. You may change your mind at any time but must let us know in
writing if you do.
For more information, refer to hhs.gov/ocr/privacy/hipaa/understanding/consumers/
noticepp.html.
Changes to the terms of this notice.
We can change the terms of this notice, and the changes will apply to all information we have
about you. The new notice will be available upon request, on our website, and we will deliver a
copy to you. You may also subscribe online to receive notice of changes to this page via email
or text message.
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Medicare Supplement Plans HandbookPlan Year 2023
GRIEVANCES AND APPEALS
What to do if you have a complaint, a denied claim or you disagree with a decision that has
been made about your medical or pharmacy benets. You cannot be disenrolled from the plan
or penalized in any way for making a complaint, grievance or appeal.
When your medical claim is denied under HealthChoice
If your medical claim was denied by Medicare and you would like to appeal it, you should
contact Medicare and follow its appeal procedures. If the claim was approved by Medicare, but
the balance was denied in whole or in part for any reason by HealthChoice, either you or your
authorized representative can request that the claim be reviewed by calling Customer Care or
by submitting a written request to the HealthChoice Appeals Unit at the address listed below
within 180 days of your receipt of a denial.
HealthChoice Appeals Unit
P.O. Box 30546
Salt Lake City, UT 84130-0546
Please follow the steps below to make sure that your appeal at any level is processed in a
timely manner:
● If applicable, send a copy of any letter regarding a decision of your appeal.
● Send a copy of the EOB with any relevant additional information, e.g., benet
documents, medical records, etc., that could help to determine if your claim is covered
under the plan.
● Provide a letter summarizing the request for reconsideration that includes your name,
the claim or transaction number, HealthChoice member ID number, the name of the
patient and their relationship to member.
● Include Attention: Appeals Unit on all supporting documents. Be certain the member
ID appears on each document.
● If you choose to designate an authorized representative, you must provide this
designation to us in writing.
● If your situation is medically urgent, you may request an expedited appeal, which is
generally conducted within 72 hours. If you believe your situation is urgent, follow the
instructions above for ling an internal appeal and call Customer Care to request a
simultaneous external review.
Your HealthChoice plan’s internal appeals process includes two internal review levels. If you
are not satised with the nal internal review determination due to denial of payment, coverage
or service requested, you may be able to ask for an independent, external review of our
decision by either an independent review organization or a grievance panel. The entity that
performs the external review depends on the nature of your appeal.
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Medicare Supplement Plans Handbook Plan Year 2023
When considering complaints by insured members, the three-member grievance panel shall
determine by a preponderance of the evidence whether EGID has followed its statutes, rules,
plan documents, policies and internal procedures. The grievance panel shall not expand upon
or override any EGID statutes, rules, plan documents, policies and internal procedures.
To request access to and copies of all documents, records and other information about your
claim, free of charge, or to nd out how to start an external review, contact Customer Care.
When your pharmacy claim is denied
We encourage you to contact us as soon as possible if you have questions, concerns or
problems related to your prescription drug coverage. If your pharmacy claim is denied and
you have questions concerning the denial, call the pharmacy benet manager. Refer to
HealthChoice Plan Contact Information.
SilverScript plans
If you want to appeal a denied pharmacy claim based on clinical criteria provided by your
physician, call the pharmacy benet manager.
Without Part D plans
If you want to appeal a denied pharmacy claim based on clinical criteria provided by your
physician, you can mail or fax your written appeal to:
HealthChoice Pharmacy Unit
P.O. Box 11137
Oklahoma City, OK 73136-9998
Fax: 405-717-8925
If your appeal is denied, you have the right to le a grievance with EGID. Please follow the
same procedures used when appealing a denied medical claim.
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Medicare Supplement Plans HandbookPlan Year 2023
FRAUD, WASTE AND ABUSE
The Ofce of Management and Enterprise Services Employees Group Insurance Division is
committed to conducting its business activities with integrity and in full compliance with the
federal, state and local laws governing its business. This commitment applies to relationships
with members, providers, auditors and all public and government bodies. Most importantly, it
applies to employees, subcontractors and representatives of EGID. This commitment includes
the policy that all such individuals have an obligation to report problems or concerns involving
ethical or compliance violations related to its business.
If you suspect that EGID has been defrauded or is being defrauded or that resources
have been wasted or abused, report the matter to the HealthChoice Program Integrity Unit
immediately by:
● Sending a report in writing to the HealthChoice Program Integrity Unit at 2401 N. Lincoln
Blvd., Ste. 300, Oklahoma City, OK 73105.
● Emailing a message to [email protected].
● Calling the EGID Fraud, Waste and Abuse toll-free hotline at 866-381-3815.
Individuals are encouraged to provide adequate information to assist with further investigation
of fraud. All investigations will be handled condentially. Every attempt will be made to
ensure the condentiality of any report, but please remember that condentiality may not be
guaranteed if law enforcement becomes involved. There will be no retaliation against anyone
who reports conduct that a reasonable person acting in good faith would have believed to be
fraudulent or abusive. Any employee who violates the non-retaliation policy will be subject to
disciplinary action up to and including termination.
Some examples of fraud, waste and abuse include:
● An individual or organization contacts you pretending to represent HealthChoice,
Medicare or Social Security and asks for your identication number, bank account
number, credit card number, money, etc.
● Someone asks you to sell your prescription drug card or account information.
● Someone asks you to get drugs for them using your prescription drug card.
● You are encouraged to disenroll from your plan or are offered cash or a gift worth more
than $15 to sign up for a Medicare prescription drug plan.
● Your pharmacy does not give you all of your drugs.
● You are billed for drugs or health services you did not receive.
● You receive a different drug than your doctor ordered.
● Billing for unlicensed staff.
● Providing medically unnecessary services to members.
● Provider bills for duplicate equipment or supplies or bills a used device as a new
purchase.
● You receive durable medical equipment that was not requested by you or prescribed by
your doctor.
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Medicare Supplement Plans Handbook Plan Year 2023
NOTIFICATIONS
Women’s Health Cancer Rights Act of 1998 notice*
Under the Oklahoma Breast Cancer Patient Protection Act, group health plans, insurers and
HMOs that provide medical and surgical benets in connection with a mastectomy must
provide benets for certain reconstructive surgeries effective for the rst plan year beginning
on or after Jan. 1, 1998. In the case of a participant or beneciary who is receiving benets
under a plan in connection with a mastectomy and who elects breast reconstruction, federal
law requires coverage in a manner determined in consultation with the attending physician and
the patient for:
● Reconstruction of the breast on which the mastectomy was performed.
● Surgery and reconstruction on the other breast to produce a symmetrical appearance.
● Prostheses and treatment of physical complications at all stages of the mastectomy,
including lymphedemas.
This coverage is subject to a plan’s annual deductibles and coinsurance provisions. These
provisions are generally described in the plan’s benet handbook.
The Health Insurance Portability and Accountability Act of 1996 provides that the plan sponsor
of a self-funded, nonfederal, governmental plan can exempt the plan from the requirement;
however, HealthChoice plans currently have comparable benets for our members.
Coverage of side effects associated with prostate-related
conditions*
HealthChoice provides coverage for side effects that are commonly associated with retropubic
prostatectomy surgery, including but not limited to impotence and incontinence and for other
prostate-related conditions.
*If you have questions about HealthChoice coverage of mastectomies and reconstructive
surgery or prostate-related conditions, call Customer Care. Refer to HealthChoice Plan
Contact Information.
Wigs and scalp prostheses
HealthChoice provides a benet for one wig or one scalp prosthesis per calendar year for
individuals who are experiencing hair loss due to radiation or chemotherapy treatment resulting
from a covered medical condition. Coverage is subject to annual deductibles and coinsurance.
The wig or scalp prosthesis must be obtained from a licensed cosmetologist or DME provider.
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Medicare Supplement Plans HandbookPlan Year 2023
PLAN DEFINITIONS
Appeal: A special kind of complaint you make if you disagree with the plan’s decision to deny
your request for benets. There is a specic process that HealthChoice must use when you
ask for an appeal.
Assignment: An arrangement with a physician or medical supplier who agrees to accept the
Medicare-approved amount as full payment for services and supplies covered under Medicare
Part B.
Brand-name drug: A prescription drug that is manufactured and sold by the pharmaceutical
company that developed the drug. A brand-name drug has the same active-ingredient formula
as generic versions of the drug.
Centers for Medicare & Medicaid Services: The federal agency that runs the Medicare
program.
Certication: A review process used to determine if services are medically necessary
according to HealthChoice guidelines. Certication is performed by Customer Care.
Copay: The set amount you pay as your share of the costs for covered services or drugs.
Coinsurance: The percentage of the costs of covered services or drugs that you pay as your
share of the expense.
Consolidated Omnibus Budget Reconciliation Act: Federal legislation that gives members
and their covered dependents who lose health benets the right to choose to continue group
health benets for limited periods of time under certain circumstances.
Cosmetic procedure: A procedure that primarily serves to improve appearance.
Coverage decision: A decision about whether a drug prescribed for you is covered by the
plan and the amount you are required to pay for the prescription.
Covered drugs: Prescription drugs covered by the plans.
Coverage gap (Low Option plans): The phase following the initial coverage limit when you
are responsible for the entire cost of your drugs (minus discounts for the SilverScript plan).
Creditable coverage: Coverage that is at least as good as the standard Medicare prescription
drug coverage.
Deductible: The initial out-of-pocket expense you pay before the plan pays.
Disenrollment: The process of ending your coverage with the plan.
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Medicare Supplement Plans Handbook Plan Year 2023
Eligible dependent
● Your legal spouse (including common-law spouse).
● Your daughter, son, stepdaughter, stepson, eligible foster child, adopted child, child
for whom the member has been granted legal guardianship or child legally placed with
you for adoption up to age 26, whether married or unmarried. Note: Plan coverage that
terminates upon the dependent’s 26th birthday will terminate at the end of the month in
which the birthday occurs.
● Your dependent, regardless of age, who is incapable of self-support due to a disability
that was diagnosed prior to age 26; subject to medical review and approval of the
Disabled Dependent Assessment form, which must be received at least 30 days prior to
the dependent’s 26th birthday.
● Other unmarried children up to age 26 who live with you and for whom you are primarily
responsible. This requires completion of an acceptable Application for Coverage for
Other Dependent Children. A tax return showing dependency can be provided in lieu of
the application.
Eligible former employee: An eligible employee who is participating in any of the plans
authorized by or through the Oklahoma Employees Insurance and Benets Act who retires,
has a vesting right with a state-funded retirement plan or has the required years of service
with an employer participating in the plan. Surviving dependents and COBRA participants are
considered as former employees.
Evidence of Coverage: This handbook, which explains your coverage, your rights and what
you must do as a member of our plan.
Exception: A type of coverage determination.
Generic drug: A prescription drug that has the same active ingredient as a brand-name drug.
Generic drugs usually cost less than brand-name drugs and are rated by the FDA to be as safe
and effective as brand-name drugs.
Grievance – medical: A medical benet grievance is an appeal you le with the plan when,
after a review, your request for health care coverage remains denied.
Grievance – pharmacy: A pharmacy benet grievance is a complaint such as a problem you
may have with getting accurate and timely information from HealthChoice or from customer
service at our pharmacy benet manager. A grievance issue does not involve coverage or
payment.
HealthChoice Comprehensive Formulary: A list of drugs covered by the plans without Part
D.
HealthChoice SilverScript Medicare Formulary: A list of drugs covered by the SilverScript
plans.
Initial coverage limit (Low Option plans): The total retail value of formulary drug purchases
you can make before entering the coverage gap.
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Medicare Supplement Plans HandbookPlan Year 2023
Late enrollment penalty: An amount added to your Part B monthly premium if you do not
enroll when you rst become Medicare eligible; or to your Part D premium if you go without
creditable coverage for 63 days or longer. You pay this higher amount as long as you have the
Medicare coverage. There are some exceptions. HealthChoice pays the Part D late enrollment
penalty for its SilverScript members.
Medically necessary: Medicare-covered health care services or supplies needed to prevent,
diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted
standards of medical practice. Services or supplies must be the most appropriate level of
which can safely be provided. For hospital stays, inpatient acute care is necessary due to the
severity of your condition, or when safe and adequate care cannot be received outpatient or in
a less intense medical setting. Services or supplies cannot be primarily for the convenience of
you, your caregiver or your provider. Medicare does not cover services that are not medically
necessary, and we follow their guidelines.
Medicare: The federal health insurance program for people 65 or older, some people under 65
with disabilities, and people with ESRD (permanent kidney failure requiring dialysis or a kidney
transplant).
● Medicare Part A: Covers services furnished by institutional providers such as hospitals,
skilled nursing facilities and home health agencies.
● Medicare Part B: Covers most other medical services such as physician’s services and
other outpatient services.
● Medicare Part D: Covers prescription drugs.
Medicare-approved amount: The fee Medicare sets as reasonable for a covered medical
service. Sometimes called the approved charge, you and Medicare pay this amount to a doctor
or supplier for a service or supply.
Medicare-eligible expenses: Medical costs recognized as reasonable and medically
necessary by Medicare.
Medicare’s limiting charge: The highest dollar amount you can be charged for a covered
service by doctors and other health care providers who do not accept Medicare assignment.
The limit is 15% above Medicare’s approved amount and does not apply to supplies or
equipment.
Member (of HealthChoice): A person enrolled in a HealthChoice plan.
Network pharmacy: Network pharmacies have contracted with our plan. In most cases, your
prescriptions are covered at the maximum benet only when they are lled at a HealthChoice
network pharmacy.
Non-covered service: Any service, procedure or supply excluded from coverage.
Non-network pharmacy: A pharmacy that does not have a HealthChoice contract. Most
services you get from non-network pharmacies are not covered by the plans except under
certain conditions.
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Medicare Supplement Plans Handbook Plan Year 2023
Option Period: A set time when you can change plans that follows Medicare’s annual election
period.
Out-of-pocket maximum: The maximum amount you pay before the plan pays 100% for
covered services or drugs.
Part D drugs: Drugs that Congress permits SilverScript to offer as part of a standard Medicare
prescription drug benet. HealthChoice may or may not cover all Part D drugs.
Participating employer: Any municipality, county, education employer or other state agency
whose employees or members are eligible to participate in any plan authorized by the
Oklahoma Employees Insurance and Benets Act.
Pharmacy prior authorization: A medical review process that is required before certain drugs
are covered by the plans.
Quantity limits: Benet restrictions on the amount of drugs you can receive.
Qualifying event: An event that changes a member’s family or health insurance situation
and qualies the member or dependent for a special enrollment period. Refer to the Eligibility
section for a list of qualifying events.
Step therapy: A requirement that you need to rst try a specic, more cost-effective drug
before moving to another drug which can be more costly or less cost effective.
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Medicare Supplement Plans HandbookPlan Year 2023
This publication was printed by the Ofce of Management and Enterprise Services as
authorized by Title 62, Section 34. 100 copies have been printed at a cost of $1,000.00. A
copy has been submitted to Documents.OK.gov in accordance with the Oklahoma State
Government Open Documents Initiative (62 O.S. 2012, § 34.11.3). This work is licensed under
a Creative Attribution-NonCommercial-NoDerivs 3.0 Unported License.
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Medicare Supplement Plans Handbook Plan Year 2023
HealthChoice complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex.
and written information in other formats (large print, audio, accessible electronic formats, other formats). HealthChoice provides free language services
800-323-4314 (TTY: 711).
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
.
711).
(Spanish)
(Vietnamese)
(Chinese) 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 800-323-4314 (TTY: 711).
(Korean) 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 800-323-4314 (TTY: 711) 번으로 전화해 주십시오.
(German)
4314 (TTY: 711).
.(711: ) 800800--323- . : (Arabic)
(Burmese) သတိျပဳရန္ - အကယ္၍ သင္သည္ ျမန္မာစကား ကို ေျပာပါက၊ ဘာသာစကား အကူအညီ၊ အခမဲ့၊ သင့္အတြက္ စီစဥ္ေဆာင္ရြက္ေပးပါမည္။ ဖုန္းနံပါတ္ 800-323-
4314 (TTY: 711) သုိ႔ ေခၚဆိုပါ။
(Hmong)
(Tagalog)
800-323-4314 (TTY: 711).
(French)
(Laotian) ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວົ້າພາສາ ລາວ, ການບໍລິການຊ່ວຍເຫຼືອດ້ານພາສາ, ໂດຍບໍ່ເສັຽຄ່າ,
ແມ່ນມີພ້ອມໃຫ້ທ່ານ. ໂທຣ 800-323-4314 (TTY: 711).
(Thai)
เรียน: ถ้าคุณพูดภาษาไทยคุณสามารถใช้บริการช่วยเหลือทางภาษาได้ฟรี โทร 800-323-4314 (TTY: 711).
.(TTY: 711) 800-323-4314
(Urdu)
(Cherokee) Hagsesda: iyuhno hyiwoniha [tsalagi gawonihisdi]. Call 800-323-4314 (TTY: 711)
(TTY: 711) 800-323-4314(Farsi)
HealthChoice is administered by EGID, a division of the
Oklahoma Ofce of Management and Enterprise Services.
