Health Alliance 301 S. Vine St. Urbana, IL 61801-3347 1-800-851-3379 www.healthalliance.org Health Alliance Plus Group Plan Description of Coverage Worksheet Maximums/Deductibles/Limitations Description of Coverage Preauthorization Penalty** Preferred Provider (applies if you fail to Preauthorize required services) Medical Not Applicable 50% up to $500 (whichever is less) Plan Year Deductibles Preferred Provider (Deductible applies unless otherwise specified. If Deductible applies, the Deductible must be met before benefits are paid by the Plan.) Medical Single: $1,000 Single: $2,000 Family: $3,000 Family: $6,000 Plan Year Out-of-Pocket Maximums Preferred Provider (The maximum annual out-of-pocket expense includes Deductible expenses) Medical Single: $3,500 Family: $8,000 Single: $12,000 Family: $26,000 Specialty Prescription Drugs Single: $1,500 Family: $4,500 Single: Unlimited Family: Unlimited Plan Year Maximum Benefits Spinal Manipulation $500 Combined Preferred and Prescription Drugs Unlimited Preferred Provider Specialty Prescription Drugs $300,000 Preferred Provider Pre-Existing Condition Limitation** 50% (if applicable) Lifetime Maximum Benefits Overall $5,000,000 Combined Preferred and Inpatient Mental Health Care and Substance Abuse $10,000 Combined Preferred and Treatment Temporomandibular Joint (TMJ) Disorder $2,500 Combined Preferred and See section for visit, day and unit limits In the Hospital Emergency Hospital Care (includes semi-private room and other Medically Necessary services) Emergency () $175 Copayment per visit Preferred Provider benefit applies Page 1 of 6 Plan - 12,077 -SGPLUS610 No IF $10/20/40-0110-12/2/2009
Emergency In the Doctor's Office Medical Emergency Ambulance Transportation. Ground ambulance for Emergency Medical Condition; air ambulance when cannot be safely transported by ground. Includes services received in or outside of the Service Area for an Emergency Medical Condition. $100 Copayment Preferred Provider benefit applies Office Visit Primary Care $20 Copayment per visit for office 40% Coinsurance visit charge only (other services obtained while in the office may require an additional Copayment or Coinsurance amount). Office Visit Specialty Care $40 Copayment per visit for office visit charge only (other services obtained while in the office may require an additional Copayment or Coinsurance amount). 40% Coinsurance Other services obtained while in the Doctor s Office, including Allergy Treatment and Testing or Wellness Care, may require an additional Copayment or Coinsurance amount Allergy Treatment and Testing Wellness Care ( not provided in the Physician s office may be subject to the Surgery/Procedures Copayment, Coinsurance and/or Refer to your Policy) $0 Copayment per service 40% Coinsurance Diagnostic Testing and X-Rays Surgery/Procedures ( performed in an setting, including colonoscopy, when there is an associated facility fee) Page 2 of 6 Plan - 12,077 -SGPLUS610 No IF $10/20/40-0110-12/2/2009
Medical Maternity Care Hospital Care Routine Prenatal Care Newborn Care Infertility ** Diagnostic and treatment services Serious Mental Health Care 60 visits per Plan Year Inpatient 45 days per Plan Year Non-Serious Mental Health Care 20 visits per Plan Year Inpatient 10 days per Plan Year $0 for the first two days following a vaginal delivery. Beginning with the third day of $0 for the first four days following a Caesarean delivery. Beginning with the fifth day of $0 for the first two days following a vaginal delivery. Beginning with the third day of $0 for the first four days following a Caesarean delivery. Beginning with the fifth day of Page 3 of 6 Plan - 12,077 -SGPLUS610 No IF $10/20/40-0110-12/2/2009
Medical Substance Abuse Treatment 20 visits per Plan Year Inpatient 10 days per Plan Year Rehabilitation (speech, physical and occupational) (includes home setting) Combined total of 60 visits per condition per Plan Year Inpatient (including Skilled Care) Combined total of 120 days per Plan Year combined Preferred and Other Durable Medical Equipment, 20% Coinsurance 50% Coinsurance Orthopedic Appliances and Orthotics** (a maximum benefit limit may apply) Prostheses** 20% Coinsurance 50% Coinsurance Hospice Care Office Visit and Hospital Care Office Visit and Hospital Care Copayments or Coinsurance apply Copayments or Coinsurance apply Home Health Prescription Drugs Vision Care** Spinal Manipulation ** Human Organ Transplant Temporomandibular Joint (TMJ) Disorder Prescription Contraceptive Devices/Injectables** $40 Copayment per visit 50% Coinsurance 50% Coinsurance Office Visit and Hospital Care Copayments or Coinsurance apply. Transplants are covered when performed at a Health Alliance approved facility. Office Visit and Hospital Care Office Visit and Hospital Care Copayments or Coinsurance apply Copayments or Coinsurance apply 20% Coinsurance 50% Coinsurance Page 4 of 6 Plan - 12,077 -SGPLUS610 No IF $10/20/40-0110-12/2/2009
Prescription Drugs Prescription Drugs** For a 30 day supply, you pay: Value Based 10% Coinsurance 50% Coinsurance Tier 1 Drugs $10 Copayment 50% Coinsurance Tier 2 Drugs $20 Copayment 50% Coinsurance Tier 3 Drugs $40 Copayment 50% Coinsurance Specialty Prescription Drugs 20% Coinsurance 50% Coinsurance Infertility Prescription Drugs** Limited to manufacturer s standard packaging * You also pay any charges in excess of the Usual, Customary and Reasonable (UCR) amount. Amounts over the UCR do not apply to the Out-of-Pocket Maximum. ** Copayments and Coinsurance payments for these services do not apply to the Medical Plan Year Out-of-Pocket Maximum. Members with Medicare Parts A and B as their primary coverage will not be subject to Health Alliance Copayments, Coinsurance or any applicable Medicare deductibles or coinsurance, except for prescription drugs (if applicable) for services received from Preferred Providers. For services received from s, Members with Medicare Parts A and B as their primary coverage are responsible for Health Alliance Copayments, Coinsurance and Out-of-Pocket Maximums prior to the Plan covering any applicable Medicare deductibles or coinsurance. Service Area Listed below are the counties within which Health Alliance Medical Plans, Inc., is authorized to do business and is offering the Health Alliance Plus Plan. To be eligible for enrollment in the Plus Plan, you must live or work within the Service Area. Your Service Area is determined by where you live or work. Decatur Service Area: Macon East Central Illinois Service Area: Champaign, Clark, Coles, Crawford, Cumberland, DeWitt, Douglas, Edgar, Effingham, Fayette, Ford, Grundy, Iroquois, Jasper, LaSalle, Livingston, McLean, Moultrie, Piatt, Shelby, Tazewell, Vermilion, Woodford Bloomington Auxiliary Service Area: Livingston, McLean, Peoria, Tazewell, Woodford Central Region Service Area: Carroll, Cass, Champaign, Christian, Clark, Coles, Crawford, Cumberland, DeWitt, Douglas, Edgar, Effingham, Fayette, Ford, Greene, Grundy, Henry, Iroquois, Jasper, Jersey, Knox, LaSalle, Livingston, Logan, Macon, Macoupin,Mason, McLean, Menard, Mercer, Montgomery, Morgan, Moultrie, Peoria, Piatt, Rock Island, Sangamon, Scott, Shelby, Stark, Tazewell, Vermilion, Whiteside, Woodford, Clinton (Iowa), Scott (Iowa) Macomb Service Area: Fulton, Henderson, McDonough, Schuyler, Warren De Kalb Service Area: Boone, De Kalb, Winnebago Peoria Service Area: Bureau, Fulton, Knox, LaSalle, Livingston, Marshall, Mason, McLean, Peoria, Putnam, Stark, Tazewell, Warren, Woodford Quad Cities Service Area: Carroll, Henry, Knox, Mercer, Rock Island, Warren, Whiteside, Clinton (Iowa), Scott (Iowa) Quincy Service Area: Adams, Brown, Hancock, Pike, Schuyler, Lee (Iowa)] South Central Illinois Service Area: Clay, Edwards, Fayette, Hamilton, Jefferson, Lawrence, Madison, Marion, Richland, St. Clair, Wabash, Wayne, White Southern Illinois Service Area: Franklin, Gallatin, Hardin, Jackson, Johnson, Madison, Perry, Randolph, Saline, St. Clair, Union, Washington, Williamson Southern Tip of Illinois Service Area: Alexander, Massac, Pope, Pulaski Springfield Service Area: Cass, Christian, Greene, Jersey, Logan, Macoupin, Mason, Menard, Montgomery, Morgan, Sangamon, Scott Sterling/Rock Falls Service Area: Boone, Bureau, Carroll, DeKalb, Lee, Marshall, Ogle, Putnam, Stephenson, Whiteside, Winnebago, Clinton (Iowa) Page 5 of 6 Plan - 12,077 -SGPLUS610 No IF $10/20/40-0110-12/2/2009
Choose a Primary Care Physician from the Provider Directory in your Service Area. Female Members may also select a Woman s Principal Health Care Provider from the Provider Directory in their Service Area This is a brief summary of Health Alliance group Plus benefits and exclusions, which are subject to change. Please refer to your Health Alliance Policy for detailed information regarding your Plan. Page 6 of 6 Plan - 12,077 -SGPLUS610 No IF $10/20/40-0110-12/2/2009