HEALTHCHOICE PLANS 1

Available Plans HealthChoice High Option HealthChoice Basic HealthChoice S-Account HealthChoice USA 2 Using a HealthChoice Network Provider will lower your out-of-pocket costs.

When using a Network Provider: $30 copay for PCP office visits $50 copay for specialist office visits Annual deductible $500/individual or $1,500/family Plan pays 80%/member pays 20% of Allowed Charges $2,800 individual out-of-pocket maximum HIGH OPTION 3

When using a Network Provider: Office visit copays do not apply Plan pays first $500/member pays next $500 as deductible; $1,000 deductible for family Plan then pays 50% until $5,500/individual or $11,000/family out-of-pocket is met Plan pays 100% of Allowed Charges BASIC 4

Health Savings Account (HSA) Combined $1,500 deductible/individual and $3,000/family Entire deductible must be met before claims are paid (including prescriptions) $50 copay for office visits The calendar year out-of-pocket max is $4,000/individual or $8,000/family S-Account 5

For members who live and work outside of Oklahoma and Arkansas for more than three months Benefits are the same as High Option Plan Members have access to the USA Plan’s nationwide provider network USA 6

Network Pharmacy Benefits 7 No lifetime maximum *NEW* HealthChoice offers certain prescription tobacco cessation medications for a $5 copay *NEW* A separate $2,500 annual out-of- pocket maximum applies (does not apply to S-Account Plan) Benefits are the same for the High Option, Basic, USA, and S-Account plans once the annual deductible is met

Network Pharmacy Benefits 8 For Preferred medications: You pay $30 or actual cost of medications costing up to $100 You pay 25% up to $60 for medications costing more than $100 May cover the greater of a 34-day supply or 100 units (tablets/capsules) Benefits are the same for the High Option, Basic, and USA plans and for the S-Account plan once the annual deductible is met