HEALTH & BENEFITS PLAN
Blue Cross and Blue Shield of Oklahoma and The Petroleum Alliance of Oklahoma are working together to make it easier for small businesses to provide affordable group health coverage to employees. With The Petroleum Alliance of Oklahoma Health & Benefits Plan, businesses and their employees can choose the right health care plan, priced within their budget, with the physicians and other health care providers they trust.
The Petroleum Alliance of Oklahoma Health & Benefits Plan Features:
- Blue Preferred PPOSM and Blue Advantage PPOSM offered by Blue Cross and Blue Shield of Oklahoma
- No medical underwriting
- Available in all 77 counties
- Network availability in all 50 states
- Prescription drug coverage: Six-tier drug card or deductible/coinsurance plans available
- Dental coverage
- Vision coverage
- Basic Life coverage
ELIGIBILITY
The Petroleum Alliance of Oklahoma Health & Benefits Plan is available to businesses that meet the following criteria:
- Must be a member of the Petroleum Alliance of Oklahoma
- Must have between two and 50 employees
- Company must be headquartered in Oklahoma
- Must meet the SIC code requirements set forth by The Petroleum Alliance of Oklahoma Association Health Plan
Note: Each employer member enrolling for coverage in the Petroleum Alliance of Oklahoma Association Health Plan must elect all lines of coverage being offered: Medical, Dental, Vision and Basic Life.
The Petroleum Alliance of Oklahoma Health & Benefits Plan Rates
All monthly premiums are effective January 1, 2023, through December 31, 2023.
To obtain a quote, the following must be submitted:
Group Name
Address
Effective Date
Current Carrier
Census (with ZIP code)
Agent/producer number
SIC Code
For general questions about the Petroleum Alliance of Oklahoma Association Health Plan, call 405-601-2501 or email benefits@okpetro.com.
BLUE PREFERRED PPO
| MARKETING PLAN ID | MOBPF0042 | MOBPF0072 | MOBPF0142 | MOBPF1030 | MOBPF1040 |
|---|---|---|---|---|---|
| INDIVIDUAL DEDUCTIBLE | $1,000 | $1,500 | $4,000 | $3,000 | $5,000 |
| INDIVIDUAL OUT OF POCKET | $3,000 | $6,000 | $7,000 | $3,000 | $5,000 |
| FAMILY DEDUCTIBLE | $3,000 | $4,500 | $12,000 | $6,000 | $10,000 |
| FAMILY OUT OF POCKET | $9,000 | $13,000 | $14,000 | $6,000 | $10,000 |
| COINSURANCE | 80% | 50% | 70% | 100% | 100% |
| PCP OFFICE VISIT COPAY | $20 | $30 | $30 | DC | DC |
| SPECIALIST OFFICE VISIT COPAY | $20 | $50 | $50 | DC | DC |
| INPATIENT CARE COINSURANCE | DC* | $500+DC* | $750+DC | DC | DC |
| OUTPATIENT CARE COINSURANCE | DC* | $250+DC* | $250+DC | DC | DC |
| PREFERRED DRUG COVERAGE** | $0 / $10 / $35 / $75 / $150 / $250 | $0 / $10 / $50 / $100 / $150 / $250 | $0 / $10 / $50 / $100 / $150 / $250 | 100% | 100% |
| NON0PREFERRED DRUG COVERAGE | $0 / $10 / $50 / $100 / $150 / $250 | $0 / $10 / $50 / $100 / $150 / $250 | $0 / $10 / $50 / $100 / $150 / $250 | 100% | 100% |
* Deductible / Coinsurance
** Prescription Drug Coverage Tiers: Preferred Generic / Non-Preferred Generic / Preferred Brand / Non-Preferred Brand / Preferred Specialty / Non-Preferred Specialty
BLUE ADVANTAGE PPO
| MARKETING PLAN ID | MOBAP0072 | MOBAP0012 | MOBAP0032 | MOBAP0112 | MOBAP1040 | MOBAP1050 |
|---|---|---|---|---|---|---|
| INDIVIDUAL DEDUCTIBLE | $500 | $1,250 | $2,500 | $4,000 | $3,000 | $5,000 |
| INDIVIDUAL OUT OF POCKET | $1,250 | $3,000 | $6,000 | $7,000 | $3,000 | $5,000 |
| FAMILY DEDUCTIBLE | $1,500 | $3,750 | $7,500 | $12,000 | $6,000 | $10,000 |
| FAMILY OUT OF POCKET | $3,750 | $9,000 | $12,000 | $14,000 | $6,000 | $10,000 |
| COINSURANCE | 80% | 70% | 80% | 70% | 100% | 100% |
| PCP OFFICE VISIT COPAY | $25 | $35 | $30 | $30 | DC* | DC* |
| SPECIALIST OFFICE VISIT COPAY | $45 | $60 | $50 | $50 | DC* | DC* |
| INPATIENT CARE COINSURANCE | $150+DC* | $200+DC* | $750+DC* | $750+DC* | DC* | DC* |
| OUTPATIENT CARE COINSURANCE | $100+DC* | $150+DC* | $250+DC* | $250+DC* | DC* | DC* |
| PREFERRED DRUG COVERAGE** | $0 / $10 / $50 / $100 / $150 / $250 | $0 / $10 / $50 / $100 / $150 / $250 | $0 / $10 / $50 / $100 / $150 / $250 | $0 / $10 / $50 / $100 / $150 / $250 | 100% | 100% |
| NON0PREFERRED DRUG COVERAGE** | $0 / $10 / $50 / $100 / $150 / $250 | $0 / $10 / $50 / $100 / $150 / $250 | $0 / $10 / $50 / $100 / $150 / $250 | $0 / $10 / $50 / $100 / $150 / $250 | 100% | 100% |
* Deductible / Coinsurance
** Prescription Drug Coverage Tiers: Preferred Generic / Non-Preferred Generic / Preferred Brand / Non-Preferred Brand / Preferred Specialty / Non-Preferred Specialty
Some items will not be applied to the out-of-pocket expense limit including office visit copayments, deductibles including per-occurrence deductible on inpatient, outpatient, ER or mental health/substance abuse covered charges, reductions in benefits due to non-compliance with utilization management program requirements and mental health and chemical dependency treatment services (groups 50 employees and fewer). The information noted above is current as of the date of publication for non-grandfathered reform plans; however, Blue Cross and Blue Shield of Oklahoma reserves the right to amend this information at any time without notice. This is only a brief description of some of the plan benefits. For more complete details, including benefits, limitations and exclusions, please refer to your certificate of coverage. This information is not intended nor does it modify the terms of any agreement in any way. The coverage provided under any group contract may only be changed in accordance with the terms of the agreement and in accordance with the law.
BLUECARE DENTAL PPOSM
Featuring a Benefits Administration Platform That’s Seamless and Intuitive
| MARKETING PLAN ID | DONHR33 | DONLR36 |
|---|---|---|
| DEDUCTIBLE | $50 | $50 |
| ANNUAL MAXIMUM | $1,500 | $1,000 |
| ORTHO LIFETIME MAX | $1,500 | N/A |
| DIAGNOSTIC AND PREVENTIVE | 100% | 100% |
| MISC PREVENTIVE SERVICES | 100% | 100% |
| BASIC RESTORATIVE | 80% | 80% |
| NON-SURGICAL EXTRACTIONS, NON-SURGICAL PERIODONTICS, AND ADJUNCTIVE SERVICES | 80% | 80% |
| ENDODONTICS | 80% | 50% |
| ORAL SURGERY | 80% | 50% |
| SURGICAL PERIODONTAL | 80% | 50% |
| MAJOR RESTORATIVE AND PROSTHODONTICS | 50% | 50% |
| IMPLANTS | 50% | N/A |
| ORTHODONTICS | 50% | N/A |
The Petroleum Alliance of Oklahoma Health & Benefits Plan groups now have the advantage of an employee benefits administration portal called SIMON®. It delivers a seamless experience for employers and brokers to more easily maintain membership and billing for their group.
SIMON is a sophisticated, yet user-friendly way to simplify the process of enrollment, benefits, management and billing. With the use of SIMON, you can access and manage employee benefits and group bill payment from one online portal – anywhere and anytime. The result? A much more streamlined and efficient process, which allows you to accomplish more in less time and to do so confidently knowing that the data is current, accurate and secure with SIMON.
The Petroleum Alliance of Oklahoma now offers the IndustrialEyes Safety Eyewear Program with the vision benefit on the Alliance Health Plan. IndustrialEyes’ offers a full line of ANSIZ87 safety frames and lenses made to order with your prescription. These are available at participating LensCrafters, Target Optical, and Pearle Vision stores.
FREQUENCY
| EYE | ONCE EVERY 12 MONTHS |
| LENSES | ONCE EVERY 12 MONTHS |
| FRAMES | ONCE EVERY 24 MONTHS |
| CONTACT LENS EVALUATION/FITTING | ONCE EVERY 12 MONTHS |
| EXAM COPAY | $10 |
| LENS COPAY | $10 |
ALLOWANCE
| FRAME & CONTACT | $130 |
| FIT & FOLLOW-UP | NO |
| STANDARD PROGRESSIVE LENSES | NO |
| SCRATCH COATING | YES |
| KIDS POLYCARB | YES |
* Industrial Eyes Safety Eyewear Program included.
| RATE GUARANTEE PERIOD | 24 MONTHS |
| PER EMPLOYEE PER MONTH RATE | $5 |
| BASIC LIFE BENEFIT | $20,000 |
HEALTH & BENEFITS PLAN
Blue Cross and Blue Shield of Oklahoma and The Petroleum Alliance of Oklahoma are working together to make it easier for small businesses to provide affordable group health coverage to employees. With The Petroleum Alliance of Oklahoma Health & Benefits Plan, businesses and their employees can choose the right health care plan, priced within their budget, with the physicians and other health care providers they trust.
The Petroleum Alliance of Oklahoma Health & Benefits Plan Features:
- Blue Preferred PPOSM and Blue Advantage PPOSM offered by Blue Cross and Blue Shield of Oklahoma
- No medical underwriting
- Available in all 77 counties
- Network availability in all 50 states
- Prescription drug coverage: Six-tier drug card or deductible/coinsurance plans available
- Dental coverage
- Vision coverage
- Basic Life coverage
ELIGIBILITY
The Petroleum Alliance of Oklahoma Health & Benefits Plan is available to businesses that meet the following criteria:
- Must be a member of the Petroleum Alliance of Oklahoma
- Must have between two and 50 employees
- Company must be headquartered in Oklahoma
- Must meet the SIC code requirements set forth by The Petroleum Alliance of Oklahoma Association Health Plan
Note: Each employer member enrolling for coverage in the Petroleum Alliance of Oklahoma Association Health Plan must elect all lines of coverage being offered: Medical, Dental, Vision and Basic Life.
The Petroleum Alliance of Oklahoma Health & Benefits Plan Rates
All monthly premiums are effective January 1, 2023, through December 31, 2023.
To obtain a quote, the following must be submitted:
Group Name
Address
Effective Date
Current Carrier
Census (with ZIP code)
Agent/producer number
SIC Code
For general questions about the Petroleum Alliance of Oklahoma Association Health Plan, call 405-601-2501 or email benefits@okpetro.com.
BLUE PREFERRED PPO
| MARKETING PLAN ID | MOBPF0042 | MOBPF0072 | MOBPF0142 | MOBPF1030 | MOBPF1040 |
|---|---|---|---|---|---|
| INDIVIDUAL DEDUCTIBLE | $1,000 | $1,500 | $4,000 | $3,000 | $5,000 |
| INDIVIDUAL OUT OF POCKET | $3,000 | $6,000 | $7,000 | $3,000 | $5,000 |
| FAMILY DEDUCTIBLE | $3,000 | $4,500 | $12,000 | $6,000 | $10,000 |
| FAMILY OUT OF POCKET | $9,000 | $13,000 | $14,000 | $6,000 | $10,000 |
| COINSURANCE | 80% | 50% | 70% | 100% | 100% |
| PCP OFFICE VISIT COPAY | $20 | $30 | $30 | DC | DC |
| SPECIALIST OFFICE VISIT COPAY | $20 | $50 | $50 | DC | DC |
| INPATIENT CARE COINSURANCE | DC* | $500+DC* | $750+DC | DC | DC |
| OUTPATIENT CARE COINSURANCE | DC* | $250+DC* | $250+DC | DC | DC |
| PREFERRED DRUG COVERAGE** | $0 / $10 / $35 / $75 / $150 / $250 | $0 / $10 / $50 / $100 / $150 / $250 | $0 / $10 / $50 / $100 / $150 / $250 | 100% | 100% |
| NON0PREFERRED DRUG COVERAGE | $0 / $10 / $50 / $100 / $150 / $250 | $0 / $10 / $50 / $100 / $150 / $250 | $0 / $10 / $50 / $100 / $150 / $250 | 100% | 100% |
BLUE ADVANTAGE PPO
| MARKETING PLAN ID | MOBAP0072 | MOBAP0012 | MOBAP0032 | MOBAP0112 | MOBAP1040 | MOBAP1050 |
|---|---|---|---|---|---|---|
| INDIVIDUAL DEDUCTIBLE | $500 | $1,250 | $2,500 | $4,000 | $3,000 | $5,000 |
| INDIVIDUAL OUT OF POCKET | $1,250 | $3,000 | $6,000 | $7,000 | $3,000 | $5,000 |
| FAMILY DEDUCTIBLE | $1,500 | $3,750 | $7,500 | $12,000 | $6,000 | $10,000 |
| FAMILY OUT OF POCKET | $3,750 | $9,000 | $12,000 | $14,000 | $6,000 | $10,000 |
| COINSURANCE | 80% | 70% | 80% | 70% | 100% | 100% |
| PCP OFFICE VISIT COPAY | $25 | $35 | $30 | $30 | DC* | DC* |
| SPECIALIST OFFICE VISIT COPAY | $45 | $60 | $50 | $50 | DC* | DC* |
| INPATIENT CARE COINSURANCE | $150+DC* | $200+DC* | $750+DC* | $750+DC* | DC* | DC* |
| OUTPATIENT CARE COINSURANCE | $100+DC* | $150+DC* | $250+DC* | $250+DC* | DC* | DC* |
| PREFERRED DRUG COVERAGE** | $0 / $10 / $50 / $100 / $150 / $250 | $0 / $10 / $50 / $100 / $150 / $250 | $0 / $10 / $50 / $100 / $150 / $250 | $0 / $10 / $50 / $100 / $150 / $250 | 100% | 100% |
| NON0PREFERRED DRUG COVERAGE** | $0 / $10 / $50 / $100 / $150 / $250 | $0 / $10 / $50 / $100 / $150 / $250 | $0 / $10 / $50 / $100 / $150 / $250 | $0 / $10 / $50 / $100 / $150 / $250 | 100% | 100% |
* Deductible / Coinsurance
** Prescription Drug Coverage Tiers: Preferred Generic / Non-Preferred Generic / Preferred Brand / Non-Preferred Brand / Preferred Specialty / Non-Preferred Specialty
Some items will not be applied to the out-of-pocket expense limit including office visit copayments, deductibles including per-occurrence deductible on inpatient, outpatient, ER or mental health/substance abuse covered charges, reductions in benefits due to non-compliance with utilization management program requirements and mental health and chemical dependency treatment services (groups 50 employees and fewer). The information noted above is current as of the date of publication for non-grandfathered reform plans; however, Blue Cross and Blue Shield of Oklahoma reserves the right to amend this information at any time without notice. This is only a brief description of some of the plan benefits. For more complete details, including benefits, limitations and exclusions, please refer to your certificate of coverage. This information is not intended nor does it modify the terms of any agreement in any way. The coverage provided under any group contract may only be changed in accordance with the terms of the agreement and in accordance with the law.
BLUECARE DENTAL PPOSM
| MARKETING PLAN ID | DONHR03 | DONLR06 |
|---|---|---|
| DEDUCTIBLE | $50 | $50 |
| ANNUAL MAXIMUM | $1,500 | $1,000 |
| ORTHO LIFETIME MAX | $1,500 | N/A |
| DIAGNOSTIC AND PREVENTIVE | 100% | 100% |
| MISC PREVENTIVE SERVICES | 100% | 100% |
| BASIC RESTORATIVE | 80% | 80% |
| NON-SURGICAL EXTRACTIONS, NON-SURGICAL PERIODONTICS, AND ADJUNCTIVE SERVICES | 80% | 80% |
| ENDODONTICS | 80% | 50% |
| ORAL SURGERY | 80% | 50% |
| SURGICAL PERIODONTAL | 80% | 50% |
| MAJOR RESTORATIVE AND PROSTHODONTICS | 50% | 50% |
| IMPLANTS | 50% | N/A |
| ORTHODONTICS | 50% | N/A |
Featuring a Benefits Administration Platform That’s Seamless and Intuitive
The Petroleum Alliance of Oklahoma Health & Benefits Plan groups now have the advantage of an employee benefits administration portal called SIMON®. It delivers a seamless experience for employers and brokers to more easily maintain membership and billing for their group.
SIMON is a sophisticated, yet user-friendly way to simplify the process of enrollment, benefits, management and billing. With the use of SIMON, you can access and manage employee benefits and group bill payment from one online portal – anywhere and anytime. The result? A much more streamlined and efficient process, which allows you to accomplish more in less time and to do so confidently knowing that the data is current, accurate and secure with SIMON.
FREQUENCY
| EYE | ONCE EVERY 12 MONTHS |
|---|---|
| LENSES | ONCE EVERY 12 MONTHS |
| FRAMES | ONCE EVERY 24 MONTHS |
| CONTACT LENS EVALUATION/FITTING | ONCE EVERY 12 MONTHS |
| EXAM COPAY | $10 |
| LENS COPAY | $10 |
ALLOWANCE
| FRAME & CONTACT | $130 |
|---|---|
| FIT & FOLLOW-UP | NO |
| STANDARD PROGRESSIVE LENSES | NO |
| SCRATCH COATING | YES |
| KIDS POLYCARB | YES |
| RATE GUARANTEE PERIOD | 24 MONTHS |
|---|---|
| PER EMPLOYEE PER MONTH RATE | $5 |
| BASIC LIFE BENEFIT | $20,000 |
500 NE 4TH Street, Suite 200
Oklahoma City, OK 73104
405.942.2334
