Table of Content

Header
Your 2025 JMA Energy Benefits
1. Open Enrollment Window: [insert date range]
2. How to Enroll
3. Eligibility & Qualifying Life Events
Medical & RX
1. Summary of Benefits and Coverage (SBC)
2. Prescriptions
3. Virtual Visits
4. Blue Cross Blue Shield of Oklahoma Resources
5. Anthem Resources
6. UnitedHealthcare Resources
7. Cigna Resources
HSA
1. HSA Forms and Resources
FSA
1. FSA Forms and Resources
Dental
1. Dental Summary
2. Dental Enrollment and Change Forms
Vision
1. Vision Summary
2. Vision Enrollment and Change Forms
Basic Life and Voluntary Life
Disability
Cancer Insurance
Page
1. Open Enrollment Window: November 21st - December 21st
2. How To Enroll
3. Benefits Overview
4. Medical
5. Dental
6. Vision
7. Life & AD&D
8. Disability
9. American Benefits Group (ABG)
10. Cancer Policy
11. Enrollment and Beneficiary Forms
12. Helpful Benefit Videos
13. Contact Us
Footer

Your 2025 JMA Energy Benefits

Welcome to JMA Energy’s 2025 Open Enrollment. This site houses all our benefit summaries and forms required to enroll or make changes to your current benefit elections.

For 2025, Blue Cross Blue Shield of Oklahoma (BCBSOK) will continue to provide our medical coverage. There will be an increase of $100 in the deductible for individuals and $300 for families on both the High Deductible Health Plan (HDHP) and PPO Plans. Additionally, there will be slight increases to some copays under the PPO plan. You may visit Find a Doctor or Hospital | Blue Cross and Blue Shield of Oklahoma (bcbsok.com) to locate providers or call Member Services at 800-942-5837 for help locating in-network providers.

Kindly ensure that you register to access your Blue Access for Members (BAM) account if you haven't already. Having a BAM account with BCBS lets you view a digital version of your Member ID Cards, locate providers based on your current location, check your benefits and claims information, including Explanation of Benefits (EOBs), and enjoy other perks and benefits offered by your BCBS health plan. Please refer to Page 6 of the benefit guide for 2025 updates. These include changes to the BCBS Member Rewards Program, ComPsych EAP, Well on Target, and Blue Points for registered members, where you can earn points to redeem for gift cards in 2025. You can register for access today at www.bcbsok.com/member.

Dental Coverage and Vision moved to Sun Life for 2025. Please complete the Dental and Vision enrollment/change form provided or forms can be located in the Dental and Vision sections below or contact Human Resources. To locate providers or check to see if your provider is in network, visit Sun Life's website www.sunlife.com/findadentist or call Sun Life member services at 800-442-7742 for help locating in-network providers. After January 1st, 2025, you are encouraged to visit the Sun Life website to register for 24/7 access to your benefits, tap or click the link to register---> Plan members and families | Sun Life U.S.. One of the key advantages of the Sun Life benefits portal is the convenience of having your Dental and Vision Cards readily available on your mobile device. By saving these digital cards, you ensure that they are always accessible when you need them, whether for routine check-ups, emergencies, or regular appointments.

In addition, all of our money accounts remain with American Benefit Group (ABG) for 2025. The IRS requires you to make new elections every year, so you’ll need to make sure to download the HSA, FSA or Limited Purpose FSA form to make your 2025 contributions to those accounts. If you currently have an HSA, your current funds will rollover to 2025. Please obtain and complete the appropriate election change form(s) from the HSA and FSA Sections below or contact Human Resources.

Please be sure to review the benefit guide for pricing and plan information.

Required Notices for Open Enrollment

Plan Year 2025

Required Notices for Open Enrollment

Plan Year 2025

JMA Energy offers Medical Plans through Blue Cross Blue Shield of Oklahoma.

PPO Plan options offers the freedom to see any provider when you need care. When you use providers from within the PPO network, you receive benefits at the discounted network cost. Most expenses, such as office visits, emergency room and prescription drugs are covered by a copay. Other expenses are subject to a deductible and coinsurance.

A HDHP is similar to the PPO Plan in that you have the option to choose any provider when you need care. However, in exchange for a lower per-paycheck cost, you must satisfy a higher deductible that applies to almost all health care expenses, including those for prescription drugs. All expenses are your responsibility until the deductible is reached, with the exception of preventive care, which is covered at 100% when you visit a physician in the network. Once the deductible is met, you are responsible for coinsurance for medical expenses and a copay for prescription drug expenses.

Utilizing In-Network providers will allow for the highest level of coverage. In-Network providers agree to accept Blue Cross Blue Shield of Oklahoma's contract rate as the final charge and the member is not balanced billed.

What is a PPO?

What is an HDHP with HSA?

HDHP vs PPO

Medical Summary

Summary of Benefits and Coverage (SBC)

Looking for more details about how items are covered? Please refer to the formal Summary of Benefits and Coverage (SBC) below.

BCBS HDHP G8J3ADT SBC

Blue Advantage Network - PPO

BCBS HDHP G8J3ADT SBC

Blue Advantage Network - PPO

BCBS PPO G746ADT SBC

Blue Advantage Network - PPO

BCBS PPO G746ADT SBC

Blue Advantage Network - PPO

Prescriptions

TRADITIONAL DRUGS

Preferred Generic (GENERIC) | Lowest copay (Tier 1): Most drugs in this category are generic drugs. Members pay the lowest copay for generics, making these drugs the most cost-effective option for treatment.

Non-Preferred Generic | Low copay (Tier 2): This category includes non-preferred and low-cost generic drugs

Preferred Brand | Higher copay (Tier 3): This category includes preferred, brand name drugs that don't yet have a generic equivalent. These drugs are more expensive than generics, and a higher copay.

Non-Preferred Brand | Highest copay (Tier 4): In this category are nonpreferred brand name drugs for which there is either a generic alternative or a more cost-effective preferred brand including most specialty medications. These drugs have the highest copay. Make sure to check for mail-order discounts that may be available.

Preferred Specialty & Non-Preferred Specialty | Specialty Drugs (Tier 5 & 6): are the most expensive class of medications. Mail order is not available for Specialty Medications.

WHERE CAN I FIND A DRUG LIST?

Typically, a full listing of covered drugs is found on your provider’s website. A drug list, also called a formulary, is a list of generic and brand-name drugs covered by a health plan. Although a drug may be on the drug list, it might not be covered under every plan. Review the plan materials for details on specific benefits.

You can use drug lists to see if a medication is covered by your health insurance plan. You can also find out if the medication is available as a generic, needs prior authorization, has quantity limits and more.

Helpful Rx Cost Savings Tools & Tips:

MAIL ORDER - Many drugs are available in a 90-day supply, rather than the 30-day retail supply. Typically, you will pay less if you choose to get a mail-order 90-day supply.

GOOD Rx - There are many tools online that you can use in order to save on prescription costs. One is GoodRx.com, an online Rx database that allows you to find what pharmacy is the cheapest for your specific prescription. Additionally, you may be able to find a coupon that will greatly reduce your cost. It is important to remember that many of the coupons can only be used outside of your plan (which will not count towards your maximums).

ASK YOUR DOCTOR – Make sure to ask if there are cost-saving alternatives to the prescription they are providing. Many times, there are generic or different manufacturers that will save you money at the pharmacy.

RX Summary

Managing Prescription Costs

Prescription Overview

A virtual visit lets you see and talk to a doctor from your mobile device or computer. When you use one of the provider groups in our virtual visit network, you have benefit coverage for certain non-emergency medical conditions. Virtual visit costs vary based on the medical plan you choose.

PPO Plan copay is $35; HDHP copay is approximately $44.

WHEN CAN I USE A VIRTUAL VISIT?

When you have a non-emergency condition and:

your doctor is not available;
you become ill while traveling;
When you are considering visiting a hospital emergency room for a non-emergency health condition.

*Your covered children may also use Virtual Visits when a parent or legal guardian is present for the visit.

Examples of Non-Emergency Conditions:

Bladder infection
Seasonal flu
Sinus
Sore throat
Stomach
Rash
Bronchitis
Diarrhea
Fever
Pink eye

Virtual visits with licensed behavioral health therapists are available by appointment. Get virtual care for:

Depression
Eating Disorders
ADHD
Substance use disorders
Trauma and PTSD
Autism spectrum disorder

HOW DOES IT WORK?

The first time you use a Virtual Visits provider, you will need to set up an account with that Virtual Visits provider group. You will need to complete the patient registration process to gather medical history, pharmacy preference, primary care physician contact information, and insurance information.

Each time you have a virtual visit, you will be asked some brief medical questions, including questions about your current medical concern. If appropriate, you will then be connected using secure live audio and video technology to a doctor licensed to deliver care in the state you are in at the time of your visit. You and the doctor will discuss your medical issue, and, if appropriate, the doctor may write a prescription* for you.

Virtual Visits doctors use e-prescribing to submit prescriptions to the pharmacy of your choice. Costs for the virtual visit and prescription drugs are based on, and payable under, your medical and pharmacy benefits.

Please note Medical and Pharmacy benefits are not covered as part of your Virtual Visit benefit, and you may still have a copay due at the time of service or when picking up a prescription from the pharmacy. *Prescription services may not be available in all states.

HOW DO I GET ACCESS?

Learn more about Virtual Visits and access direct links by downloading the MDLIVE App on your phone or utilizing the options below.

Go to Blue Access for Members at www.bcbsok.com or MDLIVE.com/bcbsok
Call MDLIVE at 888-970-4081
Text BCBSOK to 6356-483 (MDLIVE’s online assistant Sophie will help you activate your account.)

Blue Cross Blue Shield of Oklahoma Resources

www.BCBSOK.com

My Health Plan: Access your BCBSOK information 24/7.

A secure website specifically for Blue Cross Blue Shield of OK members, BCBSOK makes it easy and convenient to manage your plan and your health online.

Search for In-Network doctors, hospitals, and facilities. For example, a less expensive MRI location
View your EOB (Explanation of benefits)
View plan documents
Members that are located outside of Oklahoma please visit www.bcbsok.com website to find a provider or call the member services number on the back of your card, and member services will help you search for in-network providers by your current location.
and so much more!!

Blue Access for Members App or (BAM app)

With the Mobile App, you can get access to vital information when you are away from a computer. You can Track Claims and Spending Information, Estimate Costs, Find a Provider, and Access your Member ID Card. Download the BCBSOK app on the Apple Store or Google Play.

Chronic Management Program

If you suffer from one of the conditions below, this program may be right for you:

Asthma
Heart Failure
COPD
Diabetes
Hypertension

Call (800) 942-5837 to learn more or enroll in the Chronic Management Program.

HSA

A Health Savings Account (HSA) is a tax-free savings account that is owned by you, it is 100% vested from day one, and lets you build up savings for future needs. The funds may be used to pay for qualifying healthcare expenses not covered by insurance or any other plan for yourself, your spouse, or tax dependents. You decide how much you would like to contribute, when and how to spend the money on eligible expenses, and how to invest the balance. If you currently have an HSA your contributions and current fund will rollover to 2024.

To be eligible for an HSA, you must be enrolled in a High Deductible Health Plan (HDHP).

UNDERSTANDING YOUR HSA

Pre-tax contributions are deducted through payroll and deposited into your HSA account
You can use your HSA available funds to pay for qualified medical expenses tax-free
HSA funds can be used for non-eligible expenses but will be subject to regular income taxes and a 20% excise tax penalty
Unused funds remain in your account for future use and roll over each calendar year
HSAs remain with you even if you change health plans or companies. If you open an HSA and later become ineligible to make contributions, you can still use your remaining funds
You can change your HSA contribution at any time during the plan year for any reason.

MAINTAINING RECORDS

To protect yourself in the event that you are audited by the IRS, keep records of all HSA documentation and itemized receipts for at least as long as your income tax return is considered open (subject to an audit), or as long as you maintain the account, whichever is longer. HSA funds may be used for non-eligible expenses but will be subject to regular income taxes and a 20% excise tax penalty.

Health Savings Account (HSA) Overview

HSA Contribution Limits

HSA Forms and Resources

ABG HSA Election Form

American Benefits Group

ABG HSA Election Form

American Benefits Group

ABG HSA Contribution Change Form

American benefits Group

ABG HSA Contribution Change Form

American benefits Group

FSA

The Health Care and Dependent Care Flexible Spending Accounts (FSA) allow you to set aside pre-tax dollars to pay for eligible expenses. By contributing to one or both of the Flexible Spending Accounts you reduce your taxable income, so you pay less in taxes — which saves you money. The IRS requires you to make new elections every year, so you’ll need to make sure to download the FSA or Limited Purpose FSA form to make your 2025 contributions to those accounts.

Contributions

The election you make during enrollment is your election for the entire plan year. You may change it only if you have a qualifying life event and the change request must be consistent with the event. Plan ahead! At the end of the year or grace period, you lose any money left over in your FSA. Don’t put more money in your FSA than you think you'll spend within a year on things like copayments, coinsurance, drugs, and other allowed health care costs.

You may contribute as follows:

Health Care FSA

Up to $3,300 annually
All benefit eligible can participate unless you or your spouse are contributing to an HSA.
Reimbursements allowed for unreimbursed medical, prescription, dental, and vision expenses

Dependent Care FSA

Up to $5,000 annually
Limited to $2,500 if you are married and file separate tax returns

The Dependent Care FSA

Allows you to pay for eligible dependent care expenses with tax-free dollars so that you and your spouse can work or attend school Full-time.

Funds in a Dependent Care FSA are only available once they have been deposited into your account and you cannot use the funds ahead of time.

You may set aside up to $5,000 annually in pre-tax dollars, or $2,500 if you are married and file taxes separately from your spouse.
If you participate in a Dependent Care FSA, you cannot apply the same expenses for a dependent care tax credit when you file your income taxes.

How the Plan Works

You must incur your eligible expenses during the plan year — January 1st to December 31st. An expense is considered to be incurred when the service is performed, not when you are billed or pay for the service. You do, however, have until March 31st annually to file your claims. Any unclaimed funds after March 31st, will be forfeited.

What is an FSA?

What is a Dependent Care FSA?

FSA Forms and Resources

FSA, LPF, & DCAP Enrollment Form

American Benefits Group (ABG)

FSA, LPF, & DCAP Enrollment Form

American Benefits Group (ABG)

DCAP Enrollment Form

American Benefits Group (ABG)

DCAP Enrollment Form

American Benefits Group (ABG)

FSA & DCAP Reimbursement Claim Form

American Benefits Group (ABG)

FSA & DCAP Reimbursement Claim Form

American Benefits Group (ABG)

Dental

Dental Benefits through Sun Life provide comprehensive coverage to help you and your family maintain good dental health. Your coverage will be greater when you visit a participating in-network dentist, you will have lower out-of-pocket costs, no balance billing, and claims will be submitted by your dentist on your behalf. Please note, you have the freedom to select a dentist of your choice; When you visit an out-of-network dentist, your cost could be higher, possibly balance billed and the provider may not submit claims on your behalf.

NETWORK: Sun Life Dental Network

How do I find an In-Network Provider? Use the helpful link below!

In-Network providers can also be found by calling 1-800-442-7742 or by visiting your provider’s website below or the Ameritas Provider search button, both links direct you to the Sun Life portal where you can search by location, provider/facility name, or search by specialty. Provider finder www.sunlife.com/findadentist

Did You Know?

You have the freedom to select the dentist of your choice; however, when you visit a participating in-network dentist, you will have lower out-of-pocket costs, no balance billing, and claims will be submitted by your dentist on your behalf.

Pre-treatment Estimate

If your dental care is extensive and you want to plan ahead for the cost, you can ask your dentist to submit a pre-treatment estimate. While it is not a guarantee of payment, a pre-treatment estimate can help you predict your out-of-pocket costs.

PREVENTION FIRST!

Your dental health is an important part of your overall health. Make sure you take advantage of your preventive dental visits.

Preventive care services are covered at 100% if you visit an In-Network provider. They are also not subject to the annual deductible.

Looking for more details about how items are covered? Click on the link below to view the formal plan summary.

Dental Insurance Overview Video

Dental Summary

Sun Life Dental Summary

Vision

Sun Life offers vision coverage through the VSP Choice Network. Sun Life Vision helps pay for eye exams, prescription glasses and contact lenses. You receive a higher level of benefits when you see a provider in network, however, out-of-network coverage is provided but may only be handled as reimbursements in some situations. Please note: Members may choose between prescription glasses (lenses and frame) and contact lenses, not both.

Did You Know?

Eyes can give doctors a clear picture of overall wellness. That’s why vision care—and vision benefits—can help employees stay healthy. A comprehensive eye exam can detect early signs of serious health problems, such as:

- Diabetes
- Heart disease
- High blood pressure
- High cholesterol
- Glaucoma and cataracts

To find out if your provider is in-network, please visit the website below.

Vision Insurance Overview

Vision Summary

Vision Benefit Summary

Basic Life and Voluntary Life

Life insurance is an important part of your financial security. Life insurance helps protect your family from financial risk and sudden loss of income in the event of your death. Accidental Death & Dismemberment (AD&D) insurance is equal to your Life benefit in the event of your death being a result of an accident and may also pay benefits for certain injuries sustained.

Basic - Employer Paid $50,000 Benefit

A sudden accident or death can leave you or your loved ones in a vulnerable position. Employees have the opportunity to enroll in Term Life and Accidental Death & Dismemberment insurance which will supplement lost income in the event of an accident or death. If you choose to enroll in employee coverage, this will be in addition to your employer-provided Basic Life coverage.

Voluntary - Employee Paid Life

Coverage is also available for your spouse and/or child dependents, but only after you've elected coverage for yourself. A sudden accident or death can leave you or your loved ones in a vulnerable position. Employees have the opportunity to enroll in Term Life and Accidental Death & Dismemberment insurance which will supplement lost income in the event of an accident or death. If you choose to enroll in employee coverage, this will be in addition to your employer provided Basic Life coverage. Review the full benefit summary below for additional details.

Employee: $10,000 increments up to a maximum of $500,000 ($100,000 GI)

Spouse: $5,000 increments up to $250,000 or 100% of what you elect for yourself ($25,000 GI)

Children: $10,000 Benefit, one premium covers all eligible dependent children ($10,000 GI - per covered child)

Who's Your Beneficiary?

Naming a beneficiary is a crucial part of electing life insurance. Also, don't forget to update your primary or secondary beneficiary if you experience a life event, such as a divorce or birth of a child.

*Guaranteed Issue (GI) and Evidence of Insurability (EOI)

When you are first eligible (at hire) for Voluntary Life and AD&D, you may purchase up to the Guaranteed Issue (GI) for yourself and your spouse without providing proof of good health (EOI). Annually, you are able to increase elections up to $100,000, not to exceed the GI amount without proof of EOI.

Any amount elected over the GI will require EOI. If you elect optional life coverage, and are required to complete an EOI, it is your responsibility to complete the EOI and send to the provider (address will be listed on your form). In addition, your spouse will need to provide EOI to be eligible for coverage amounts over GI, or if coverage is requested at a later date.

Disability

Overview of Short Term & Long Term Disability

Short Term Disability

Everyday illnesses or injuries can interfere with your ability to work. Even a few weeks away from work can make it difficult to manage household costs. Short Term Disability coverage provides financial protection for you by paying a portion of your income, so you can focus on getting better and worry less about keeping up with your bills. Your coverage pays 60% of your income up to a specific maximum in your benefit summary.

STD Benefit Features

Benefit begins 1st day Accident/8th day Illness (including pregnancy)
Benefit equal to 60% of pay, $500 max per week – benefit is taxable income; please consult with your tax advisor.
No Pre-existing condition limitations apply.

Long Term Disability

Insurance through Unum can pay you a weekly benefit if you have a covered disability that keeps you from working. Long Term Disability insurance can replace part of your income while you recover.

LTD Benefit Features

Benefit begins after 180-day elimination period if you remain disabled.
Benefit equal to 60% of pay – benefit is taxable income; please consult with your tax advisor.
Pre-existing condition limitations apply for first 12 months.

What is LTD Coverage?

What is STD Coverage?

Cancer Insurance

Allstate Cancer Insurance

Receiving a diagnosis of cancer or a specified disease can be difficult on anyone, both emotionally and financially. Having the right coverage to help when undergoing treatments is important. Cancer coverage can help provide added financial support when its needed most.

Cancer Insurance from Allstate Benefits pays cash benefits for Cancer care and other specified diseases to help with the costs associated with treatments and expenses as they happen. In the event a Cancer diagnosis happens, please reach out to Allstate for assistance with beginning the claims process (1-800-521-3535) or go online using the blue link (tap/click)---> Claims | Allstate Benefits. Be sure to register to access your coverage anytime either through the app, or directly on Allstate Benefits portal. You can also use your phones camera to scan the QR Code to access the Allstate portal.

What's covered?

Cancer initial diagnosis level benefit - Pays a one-time benefit if diagnosed for the first time with cancer (except skin cancer)
Cancer conditions, such as Breast Cancer and Skin Cancer
Radiation and Chemotherapy Benefits, Cancer related Hospital Confinement, Surgery, Lodging and Transportation Benefits.
20 Specified Diseases such as Muscular Dystrophy, Poliomyelitis, Multiple Sclerosis, Encephalitis, Rabies, Tetanus, Typhoid Fever, Bubonic Plague, Tuberculosis, Osteomyelitis, Diphtheria, Scarlet Fever, Epidemic Cerebrospinal Meningitis, Undulant Fever, Sickle Cell Anemia, Rocky Mountain Spotted Fever, Smallpox, Addison's Disease, Hansen's Disease, Tularemia.

Wellness Benefit

When you enroll in Cancer Insurance you can earn $50 just by getting an annual physical or covered preventive test.

What is Cancer Insurance?

Allstate Cancer Summary

Allstate Enrollment Form - JMA

Allstate Enrollment Form - IFS

Allstate Enrollment Form - CCSC

Allstate Wellness Claim Form

Enrollment and Beneficiary Forms

Medical - Enrollment/Change Form

BCBS

Medical - Enrollment/Change Form

BCBS

Dental & Vision - Enrollment/Change Form

Sun Life

Dental & Vision - Enrollment/Change Form

Sun Life

Standard Life & Disability Enrollment Form

Life and AD&D Beneficiary Form

Contact Us

Client Contacts

Arlena Hamby

arlenahamby@jmaenergy.com

(405) 418-2785

Account Team Contacts

Jon Stafford

Account Manager

jon.stafford@nfp.com

405-513-8932

JMA ENERGY COMPANY LLC

Table of Content

Your 2025 JMA Energy Benefits

Required Notices for Open Enrollment

Required Notices for Open Enrollment

What is a Qualifying Event?

What is a Qualifying Event?

What is a PPO?

What is a PPO?

What is an HDHP with HSA?

What is an HDHP with HSA?

HDHP vs PPO

HDHP vs PPO

Medical Summary

Summary of Benefits and Coverage (SBC)

BCBS HDHP G8J3ADT SBC

BCBS HDHP G8J3ADT SBC

BCBS PPO G746ADT SBC

BCBS PPO G746ADT SBC

Prescriptions

RX Summary

Managing Prescription Costs

Managing Prescription Costs

Prescription Overview

Prescription Overview

Blue Cross Blue Shield of Oklahoma Resources

HSA

Health Savings Account (HSA) Overview

Health Savings Account (HSA) Overview

HSA Contribution Limits

HSA Forms and Resources

ABG HSA Election Form

ABG HSA Election Form

ABG HSA Contribution Change Form

ABG HSA Contribution Change Form

FSA

What is an FSA?

What is an FSA?

What is a Dependent Care FSA?

What is a Dependent Care FSA?

FSA Forms and Resources

FSA, LPF, & DCAP Enrollment Form

FSA, LPF, & DCAP Enrollment Form

DCAP Enrollment Form

DCAP Enrollment Form

FSA & DCAP Reimbursement Claim Form

FSA & DCAP Reimbursement Claim Form

Dental

Dental Insurance Overview Video

Dental Insurance Overview Video

Dental Summary

Sun Life Dental Summary

Dental Enrollment and Change Forms

Sun Life Dental Enrollment Form

Sun Life Dental Enrollment Form

Vision

Vision Insurance Overview

Vision Insurance Overview

Vision Summary

Vision Benefit Summary

Vision Enrollment and Change Forms

Sun Life Vision Enrollment Form

Sun Life Vision Enrollment Form

Basic Life and Voluntary Life

Life/AD&D

Life/AD&D

Disability

What is LTD Coverage?

What is LTD Coverage?

What is STD Coverage?

What is STD Coverage?

Cancer Insurance

What is Cancer Insurance?

What is Cancer Insurance?

Allstate Cancer Summary

Allstate Cancer Summary

Allstate Enrollment Form - JMA

Allstate Enrollment Form - JMA

Allstate Enrollment Form - IFS

Allstate Enrollment Form - IFS