Upload
others
View
1
Download
0
Embed Size (px)
Citation preview
2020 Small Group Products Everything You Need for Great Healthcare Coverage
Illinois
Small Group DefinitionA small group in Illinois is defined as 1–50 total employees.
Plans to Fit Every NeedThe plans in this booklet are direct plans. For more information, please call Health Alliance at 1-800-851-3379, ext. 28151, or visit HealthAlliance.org.
TM
Hometown Care with World-Class QualityHealth Alliance is the largest health insurer based in downstate Illinois, with member-focused health plans in four states—Illinois, Iowa, Indiana and Ohio. Our sister company, Health Alliance Northwest began offering coverage in Washington in 2014. Our nearly 700 employees serve more than 230,000 members across all five states.
We promise to deliver access to reliable, high-quality health care. This means connecting patients with the right care at the right time and place for the right cost.
We are invested in the communities we serve and provide local customer service, sales and medical management support. We partner with local health systems for true patient-focused care.
Local and Accessible ServiceWe aren’t just another insurance option. With offices in Champaign, Illinois and a personal Health Alliance business consultant, we are accessible to you and your employees.
Charles Joujoute, Small Group Sales ManagerHealth Alliance3310 Fields South Drive Champaign, IL 61822Direct line: [email protected]
Companies based throughout Illinois have real options to improve the value of care and services their employees receive – total care coordination close to home.
Health Alliance Earns J.D. Power AwardHealth Alliance has earned “Highest Member Satisfaction among Commercial Health Plans in the Illinois/Indiana Region” 3 years in a row.
Health Alliance Medical Plans received the highest score in the following study factors: coverage and benefits, cost, customer service, and information and communication within Illinois-Indiana.
For J.D. Power 2019 award information, visit jdpower.com/awards.
• Strong provider networks so members see the doctors they know and trust
• Fast and helpful answers from our top-notch customer service reps
• Online member self-service at YourHealthAlliance.org
• Wellness programs so members can take charge of their health
• Help when traveling through Assist America
• Pharmacy discount programs
• Additional dental and vision coverage is available
Health Alliance plans for small groups provide the complete package for you and your employees:
At Health Alliance, we keep healthcare decisions where they belong—between patients and their doctors. We understand our role as the insurance provider and let our doctors provide the care.
We know employees get sick and hurt, and when they do, they need health care. They can’t always avoid the bad stuff life throws at them, but it’s nice to help them through it. That’s why we’re here—to give them insurance for real life.
Structure• Only care received within the HMO network is covered.
• Out-of-network coverage is available in emergencies or when preauthorization is given.
• Members choose a primary care physician (PCP) to coordinate all medical care.
• For specialty care, a PCP gives a referral to an in-network specialist.
• Women can select a Women’s Principal Health Care Provider (specializing in obstetrics, gynecology or family practice) in addition to a PCP.
Considerations• A PCP gives attention to members’ personalized, overall
health and serves as their healthcare partner.
HMO
This is a brief summary of Health Alliance benefits and exclusions, which are subject to change.Please refer to your Health Alliance Policy for detailed information regarding this plan.
*Facility coverage only; physicians fees may apply
mkt 2020 IL GRP DIR SOB 2020 HMO 500 Platinum 0120
2020 HMO 500 Platinum Platinum01/01/2020 Member Responsibility
Member Benefits In-Network Out-of-Network
Plan Year DeductibleIncludes Embedded Deductible. Members on this plan who meet theirindividual deductibles can use their coverage before the family deductibleis met.
Single: $500Family: $1,000
Single: Not ApplicableFamily: Not Applicable
Plan Year Out-of-Pocket MaximumCombined medical and pharmacy expenses including deductible,coinsurance amounts and copays.
Single: $3,500Family: $7,000
Single: Not ApplicableFamily: Not Applicable
Walk-in PatientServices
Annual Vision Exam $20 per exam Not CoveredPrimary Care Physician Office Visit $20 per visit Not Covered
Specialty Care Physician Office Visit $45 per visit Not CoveredAcupuncture $20 per visit Not Covered
Spinal Manipulations $45 per visit Not CoveredUrgent Care $45 per visit In Network Benefit AppliesVirtual Visits $0 visits 1-3, then $20 copay Not Covered
EmergencyServices
Emergency Department Visit $300 then 20% per visit In Network Benefit AppliesEmergency Ambulance
Transportation Deductible, 20% In Network Benefit Applies
HospitalServices
Outpatient Surgery/Procedures* Deductible, 20% Not CoveredInpatient Facility* Deductible, 20% Not Covered
Mental Health/Substance Abuse
Outpatient Office Visits $20 per visit Not CoveredInpatient Facility* Deductible, 20% Not Covered
Rehabilitative AndHabilitative Services
Physical Therapy Deductible, 20% Not CoveredOccupational Therapy Deductible, 20% Not Covered
Durable Medical Equipment Deductible, 20% Not Covered
Diagnostic Services MRI and CT Scans Deductible, 20% Not CoveredLaboratory and X-rays Deductible, 20% Not Covered
MaternityInpatient newborn covered onmother’s policy up to 96 hours
Routine Prenatal Care Deductible, 20% Not CoveredInpatient Maternity Facility* Deductible, 20% Not CoveredInpatient Newborn Facility* Deductible, 20% Not Covered
Pediatric ServicesOffered to children upto age 19
Pediatric Dental Exam Refer to Delta Dental Materials Not CoveredPediatric Vision Exam $0 per exam Not Covered
Pediatric Vision Materials $0 per item Not CoveredPreventive & Wellness ServicesImmunizations, adult and child annual physical exams, mammograms,PAP smears, cancer screenings and more. Age/frequency schedules apply.
$0 Not Covered
Prescription Drugs Retail
Preferred Generic – Tier 1 $0 Not CoveredNon-Preferred Generic – Tier 2 $10 Not Covered
Preferred Brand – Tier 3 $35 Not CoveredNon-Preferred Brand – Tier 4 $70 Not Covered
Specialty
Pharmacy/Medical
Preferred Specialty – Tier 5 50% Not CoveredNon-Preferred Specialty– Tier 6 50% Not Covered
This is a brief summary of Health Alliance benefits and exclusions, which are subject to change.Please refer to your Health Alliance Policy for detailed information regarding this plan.
*Facility coverage only; physicians fees may apply
mkt 2020 IL GRP DIR SOB 2020 HMO 1000 Gold 0120
2020 HMO 1000 Gold Gold01/01/2020 Member Responsibility
Member Benefits In-Network Out-of-Network
Plan Year DeductibleIncludes Embedded Deductible. Members on this plan who meet theirindividual deductibles can use their coverage before the family deductibleis met.
Single: $1,000Family: $2,000
Single: Not ApplicableFamily: Not Applicable
Plan Year Out-of-Pocket MaximumCombined medical and pharmacy expenses including deductible,coinsurance amounts and copays.
Single: $7,500Family: $15,000
Single: Not ApplicableFamily: Not Applicable
Walk-in PatientServices
Annual Vision Exam $20 per exam Not CoveredPrimary Care Physician Office Visit $25 per visit Not Covered
Specialty Care Physician Office Visit $50 per visit Not CoveredAcupuncture $25 per visit Not Covered
Spinal Manipulations $50 per visit Not CoveredUrgent Care $50 per visit In Network Benefit AppliesVirtual Visits $0 visits 1-3, then $25 copay Not Covered
EmergencyServices
Emergency Department Visit $350 then 20% per visit In Network Benefit AppliesEmergency Ambulance
Transportation Deductible, 20% In Network Benefit Applies
HospitalServices
Outpatient Surgery/Procedures* Deductible, 20% Not CoveredInpatient Facility* Deductible, 20% Not Covered
Mental Health/Substance Abuse
Outpatient Office Visits $25 per visit Not CoveredInpatient Facility* Deductible, 20% Not Covered
Rehabilitative AndHabilitative Services
Physical Therapy Deductible, 20% Not CoveredOccupational Therapy Deductible, 20% Not Covered
Durable Medical Equipment Deductible, 20% Not Covered
Diagnostic Services MRI and CT Scans Deductible, 20% Not CoveredLaboratory and X-rays Deductible, 20% Not Covered
MaternityInpatient newborn covered onmother’s policy up to 96 hours
Routine Prenatal Care Deductible, 20% Not CoveredInpatient Maternity Facility* Deductible, 20% Not CoveredInpatient Newborn Facility* Deductible, 20% Not Covered
Pediatric ServicesOffered to children upto age 19
Pediatric Dental Exam Refer to Delta Dental Materials Not CoveredPediatric Vision Exam $0 per exam Not Covered
Pediatric Vision Materials $0 per item Not CoveredPreventive & Wellness ServicesImmunizations, adult and child annual physical exams, mammograms,PAP smears, cancer screenings and more. Age/frequency schedules apply.
$0 Not Covered
Prescription Drugs Retail
Preferred Generic – Tier 1 $0 Not CoveredNon-Preferred Generic – Tier 2 $10 Not Covered
Preferred Brand – Tier 3 $40 Not CoveredNon-Preferred Brand – Tier 4 $80 Not Covered
Specialty
Pharmacy/Medical
Preferred Specialty – Tier 5 50% Not CoveredNon-Preferred Specialty– Tier 6 50% Not Covered
This is a brief summary of Health Alliance benefits and exclusions, which are subject to change.Please refer to your Health Alliance Policy for detailed information regarding this plan.
*Facility coverage only; physicians fees may apply
mkt 2020 IL GRP DIR SOB 2020 HMO 2000 Gold 0120
2020 HMO 2000 Gold Gold01/01/2020 Member Responsibility
Member Benefits In-Network Out-of-Network
Plan Year DeductibleIncludes Embedded Deductible. Members on this plan who meet theirindividual deductibles can use their coverage before the family deductibleis met.
Single: $2,000Family: $4,000
Single: Not ApplicableFamily: Not Applicable
Plan Year Out-of-Pocket MaximumCombined medical and pharmacy expenses including deductible,coinsurance amounts and copays.
Single: $6,500Family: $13,000
Single: Not ApplicableFamily: Not Applicable
Walk-in PatientServices
Annual Vision Exam $20 per exam Not CoveredPrimary Care Physician Office Visit $25 per visit Not Covered
Specialty Care Physician Office Visit $50 per visit Not CoveredAcupuncture $25 per visit Not Covered
Spinal Manipulations $50 per visit Not CoveredUrgent Care $50 per visit In Network Benefit AppliesVirtual Visits $0 visits 1-3, then $25 copay Not Covered
EmergencyServices
Emergency Department Visit $350 then 10% per visit In Network Benefit AppliesEmergency Ambulance
Transportation Deductible, 10% In Network Benefit Applies
HospitalServices
Outpatient Surgery/Procedures* Deductible, 10% Not CoveredInpatient Facility* Deductible, 10% Not Covered
Mental Health/Substance Abuse
Outpatient Office Visits $25 per visit Not CoveredInpatient Facility* Deductible, 10% Not Covered
Rehabilitative AndHabilitative Services
Physical Therapy Deductible, 10% Not CoveredOccupational Therapy Deductible, 10% Not Covered
Durable Medical Equipment Deductible, 10% Not Covered
Diagnostic Services MRI and CT Scans Deductible, 10% Not CoveredLaboratory and X-rays Deductible, 10% Not Covered
MaternityInpatient newborn covered onmother’s policy up to 96 hours
Routine Prenatal Care Deductible, 10% Not CoveredInpatient Maternity Facility* Deductible, 10% Not CoveredInpatient Newborn Facility* Deductible, 10% Not Covered
Pediatric ServicesOffered to children upto age 19
Pediatric Dental Exam Refer to Delta Dental Materials Not CoveredPediatric Vision Exam $0 per exam Not Covered
Pediatric Vision Materials $0 per item Not CoveredPreventive & Wellness ServicesImmunizations, adult and child annual physical exams, mammograms,PAP smears, cancer screenings and more. Age/frequency schedules apply.
$0 Not Covered
Prescription Drugs Retail
Preferred Generic – Tier 1 $0 Not CoveredNon-Preferred Generic – Tier 2 $10 Not Covered
Preferred Brand – Tier 3 $40 Not CoveredNon-Preferred Brand – Tier 4 $80 Not Covered
Specialty
Pharmacy/Medical
Preferred Specialty – Tier 5 50% Not CoveredNon-Preferred Specialty– Tier 6 50% Not Covered
This is a brief summary of Health Alliance benefits and exclusions, which are subject to change.Please refer to your Health Alliance Policy for detailed information regarding this plan.
*Facility coverage only; physicians fees may apply
mkt 2020 IL GRP DIR SOB 2020 HMO 6500 Silver 0120
2020 HMO 6500 Silver Silver01/01/2020 Member Responsibility
Member Benefits In-Network Out-of-Network
Plan Year DeductibleIncludes Embedded Deductible. Members on this plan who meet theirindividual deductibles can use their coverage before the family deductibleis met.
Single: $6,500Family: $13,000
Single: Not ApplicableFamily: Not Applicable
Plan Year Out-of-Pocket MaximumCombined medical and pharmacy expenses including deductible,coinsurance amounts and copays.
Single: $8,150Family: $16,300
Single: Not ApplicableFamily: Not Applicable
Walk-in PatientServices
Annual Vision Exam $20 per exam Not CoveredPrimary Care Physician Office Visit $35 per visit Not Covered
Specialty Care Physician Office Visit $70 per visit Not CoveredAcupuncture $35 per visit Not Covered
Spinal Manipulations $70 per visit Not CoveredUrgent Care $70 per visit In Network Benefit AppliesVirtual Visits $0 visits 1-3, then $35 copay Not Covered
EmergencyServices
Emergency Department Visit Deductible, 20% In Network Benefit AppliesEmergency Ambulance
Transportation Deductible, 20% In Network Benefit Applies
HospitalServices
Outpatient Surgery/Procedures* Deductible, 20% Not CoveredInpatient Facility* Deductible, 20% Not Covered
Mental Health/Substance Abuse
Outpatient Office Visits $35 per visit Not CoveredInpatient Facility* Deductible, 20% Not Covered
Rehabilitative AndHabilitative Services
Physical Therapy Deductible, 20% Not CoveredOccupational Therapy Deductible, 20% Not Covered
Durable Medical Equipment Deductible, 20% Not Covered
Diagnostic Services MRI and CT Scans Deductible, 20% Not CoveredLaboratory and X-rays Deductible, 20% Not Covered
MaternityInpatient newborn covered onmother’s policy up to 96 hours
Routine Prenatal Care Deductible, 20% Not CoveredInpatient Maternity Facility* Deductible, 20% Not CoveredInpatient Newborn Facility* Deductible, 20% Not Covered
Pediatric ServicesOffered to children upto age 19
Pediatric Dental Exam Refer to Delta Dental Materials Not CoveredPediatric Vision Exam $0 per exam Not Covered
Pediatric Vision Materials $0 per item Not CoveredPreventive & Wellness ServicesImmunizations, adult and child annual physical exams, mammograms,PAP smears, cancer screenings and more. Age/frequency schedules apply.
$0 Not Covered
Prescription Drugs Retail
Preferred Generic – Tier 1 $0 Not CoveredNon-Preferred Generic – Tier 2 $15 Not Covered
Preferred Brand – Tier 3 $50 Not CoveredNon-Preferred Brand – Tier 4 $90 Not Covered
Specialty
Pharmacy/Medical
Preferred Specialty – Tier 5 50% Not CoveredNon-Preferred Specialty– Tier 6 50% Not Covered
POS
Structure• Coverage is determined at the point-of-service, dependent
on the provider chosen. When choosing a Health Alliance in-network provider, HMO-style benefits apply. When choosing an out-of-network provider, your costs may be higher, except in emergencies or when preauthorization is given.
• Members select a PCP to coordinate all medical care.
• For in-network specialty care, a PCP gives a referral to an in-network specialist. Specialty care sought without a referral or out-of-network is covered at the lower benefit level.
• Women can select a Women’s Principal Health Care Provider (specializing in obstetrics, gynecology or family practice) in addition to a PCP.
Considerations• Staying in-network for care is vital to the cost effectiveness
of your POS plan. Our network is extensive and features premier providers.
• A PCP gives attention to members’ personalized, overall health and serves as their healthcare partner.
This is a brief summary of Health Alliance benefits and exclusions, which are subject to change.Please refer to your Health Alliance Policy for detailed information regarding this plan.
*Facility coverage only; physicians fees may apply
mkt 2020 IL GRP DIR SOB 2020 POS 1500 Gold 0120
2020 POS 1500 Gold Gold01/01/2020 Member Responsibility
Member Benefits In-Network Out-of-Network
Plan Year DeductibleIncludes Embedded Deductible. Members on this plan who meet theirindividual deductibles can use their coverage before the family deductibleis met.
Single: $1,500Family: $3,000
Single: $3,000Family: $6,000
Plan Year Out-of-Pocket MaximumCombined medical and pharmacy expenses including deductible,coinsurance amounts and copays.
Single: $7,500Family: $15,000
Single: $15,500Family: $31,000
Walk-in PatientServices
Annual Vision Exam $20 per exam Not CoveredPrimary Care Physician Office Visit $25 per visit Deductible, 50%
Specialty Care Physician Office Visit $50 per visit Deductible, 50%Acupuncture $25 per visit In Network Benefit Applies
Spinal Manipulations $50 per visit In Network Benefit AppliesUrgent Care $50 per visit In Network Benefit AppliesVirtual Visits $0 visits 1-3, then $25 copay Not Covered
EmergencyServices
Emergency Department Visit $350 then 20% per visit In Network Benefit AppliesEmergency Ambulance
Transportation Deductible, 20% In Network Benefit Applies
HospitalServices
Outpatient Surgery/Procedures* Deductible, 20% Deductible, 50%Inpatient Facility* Deductible, 20% Deductible, 50%
Mental Health/Substance Abuse
Outpatient Office Visits $25 per visit Deductible, 50%Inpatient Facility* Deductible, 20% Deductible, 50%
Rehabilitative AndHabilitative Services
Physical Therapy Deductible, 20% Deductible, 50%Occupational Therapy Deductible, 20% Deductible, 50%
Durable Medical Equipment Deductible, 20% Deductible, 50%
Diagnostic Services MRI and CT Scans Deductible, 20% Deductible, 50%Laboratory and X-rays Deductible, 20% Deductible, 50%
MaternityInpatient newborn covered onmother’s policy up to 96 hours
Routine Prenatal Care Deductible, 20% Deductible, 50%Inpatient Maternity Facility* Deductible, 20% Deductible, 50%Inpatient Newborn Facility* Deductible, 20% Deductible, 50%
Pediatric ServicesOffered to children upto age 19
Pediatric Dental Exam Refer to Delta Dental Materials Refer to Delta Dental MaterialsPediatric Vision Exam $0 per exam Deductible, 50%
Pediatric Vision Materials $0 per item In Network Benefit AppliesPreventive & Wellness ServicesImmunizations, adult and child annual physical exams, mammograms,PAP smears, cancer screenings and more. Age/frequency schedules apply.
$0 Deductible, 50%
Prescription Drugs Retail
Preferred Generic – Tier 1 $0 Deductible, 50%Non-Preferred Generic – Tier 2 $10 Deductible, 50%
Preferred Brand – Tier 3 $40 Deductible, 50%Non-Preferred Brand – Tier 4 $80 Deductible, 50%
Specialty
Pharmacy/Medical
Preferred Specialty – Tier 5 50% Deductible, 50%Non-Preferred Specialty– Tier 6 50% Deductible, 50%
This is a brief summary of Health Alliance benefits and exclusions, which are subject to change.Please refer to your Health Alliance Policy for detailed information regarding this plan.
*Facility coverage only; physicians fees may apply
mkt 2020 IL GRP DIR SOB 2020 POS 2000 Gold 0120
2020 POS 2000 Gold Gold01/01/2020 Member Responsibility
Member Benefits In-Network Out-of-Network
Plan Year DeductibleIncludes Embedded Deductible. Members on this plan who meet theirindividual deductibles can use their coverage before the family deductibleis met.
Single: $2,000Family: $4,000
Single: $4,000Family: $8,000
Plan Year Out-of-Pocket MaximumCombined medical and pharmacy expenses including deductible,coinsurance amounts and copays.
Single: $5,000Family: $10,000
Single: $16,500Family: $33,000
Walk-in PatientServices
Annual Vision Exam $20 per exam Not CoveredPrimary Care Physician Office Visit $25 per visit Deductible, 50%
Specialty Care Physician Office Visit $50 per visit Deductible, 50%Acupuncture $25 per visit In Network Benefit Applies
Spinal Manipulations $50 per visit In Network Benefit AppliesUrgent Care $50 per visit In Network Benefit AppliesVirtual Visits $0 visits 1-3, then $25 copay Not Covered
EmergencyServices
Emergency Department Visit $350 then 20% per visit In Network Benefit AppliesEmergency Ambulance
Transportation Deductible, 20% In Network Benefit Applies
HospitalServices
Outpatient Surgery/Procedures* Deductible, 20% Deductible, 50%Inpatient Facility* Deductible, 20% Deductible, 50%
Mental Health/Substance Abuse
Outpatient Office Visits $25 per visit Deductible, 50%Inpatient Facility* Deductible, 20% Deductible, 50%
Rehabilitative AndHabilitative Services
Physical Therapy Deductible, 20% Deductible, 50%Occupational Therapy Deductible, 20% Deductible, 50%
Durable Medical Equipment Deductible, 20% Deductible, 50%
Diagnostic Services MRI and CT Scans Deductible, 20% Deductible, 50%Laboratory and X-rays Deductible, 20% Deductible, 50%
MaternityInpatient newborn covered onmother’s policy up to 96 hours
Routine Prenatal Care Deductible, 20% Deductible, 50%Inpatient Maternity Facility* Deductible, 20% Deductible, 50%Inpatient Newborn Facility* Deductible, 20% Deductible, 50%
Pediatric ServicesOffered to children upto age 19
Pediatric Dental Exam Refer to Delta Dental Materials Refer to Delta Dental MaterialsPediatric Vision Exam $0 per exam Deductible, 50%
Pediatric Vision Materials $0 per item In Network Benefit AppliesPreventive & Wellness ServicesImmunizations, adult and child annual physical exams, mammograms,PAP smears, cancer screenings and more. Age/frequency schedules apply.
$0 Deductible, 50%
Prescription Drugs Retail
Preferred Generic – Tier 1 $0 Deductible, 50%Non-Preferred Generic – Tier 2 $10 Deductible, 50%
Preferred Brand – Tier 3 $40 Deductible, 50%Non-Preferred Brand – Tier 4 $80 Deductible, 50%
Specialty
Pharmacy/Medical
Preferred Specialty – Tier 5 50% Deductible, 50%Non-Preferred Specialty– Tier 6 50% Deductible, 50%
This is a brief summary of Health Alliance benefits and exclusions, which are subject to change.Please refer to your Health Alliance Policy for detailed information regarding this plan.
*Facility coverage only; physicians fees may apply
mkt 2020 IL GRP DIR SOB 2020 POS 2500 Gold 0120
2020 POS 2500 Gold Gold01/01/2020 Member Responsibility
Member Benefits In-Network Out-of-Network
Plan Year DeductibleIncludes Embedded Deductible. Members on this plan who meet theirindividual deductibles can use their coverage before the family deductibleis met.
Single: $2,500Family: $5,000
Single: $5,000Family: $10,000
Plan Year Out-of-Pocket MaximumCombined medical and pharmacy expenses including deductible,coinsurance amounts and copays.
Single: $6,000Family: $12,000
Single: $17,500Family: $35,000
Walk-in PatientServices
Annual Vision Exam $20 per exam Not CoveredPrimary Care Physician Office Visit $25 per visit Deductible, 50%
Specialty Care Physician Office Visit $50 per visit Deductible, 50%Acupuncture $25 per visit In Network Benefit Applies
Spinal Manipulations $50 per visit In Network Benefit AppliesUrgent Care $50 per visit In Network Benefit AppliesVirtual Visits $0 visits 1-3, then $25 copay Not Covered
EmergencyServices
Emergency Department Visit $350 then 20% per visit In Network Benefit AppliesEmergency Ambulance
Transportation Deductible, 20% In Network Benefit Applies
HospitalServices
Outpatient Surgery/Procedures* Deductible, 20% Deductible, 50%Inpatient Facility* Deductible, 20% Deductible, 50%
Mental Health/Substance Abuse
Outpatient Office Visits $25 per visit Deductible, 50%Inpatient Facility* Deductible, 20% Deductible, 50%
Rehabilitative AndHabilitative Services
Physical Therapy Deductible, 20% Deductible, 50%Occupational Therapy Deductible, 20% Deductible, 50%
Durable Medical Equipment Deductible, 20% Deductible, 50%
Diagnostic Services MRI and CT Scans Deductible, 20% Deductible, 50%Laboratory and X-rays Deductible, 20% Deductible, 50%
MaternityInpatient newborn covered onmother’s policy up to 96 hours
Routine Prenatal Care Deductible, 20% Deductible, 50%Inpatient Maternity Facility* Deductible, 20% Deductible, 50%Inpatient Newborn Facility* Deductible, 20% Deductible, 50%
Pediatric ServicesOffered to children upto age 19
Pediatric Dental Exam Refer to Delta Dental Materials Refer to Delta Dental MaterialsPediatric Vision Exam $0 per exam Deductible, 50%
Pediatric Vision Materials $0 per item In Network Benefit AppliesPreventive & Wellness ServicesImmunizations, adult and child annual physical exams, mammograms,PAP smears, cancer screenings and more. Age/frequency schedules apply.
$0 Deductible, 50%
Prescription Drugs Retail
Preferred Generic – Tier 1 $0 Deductible, 50%Non-Preferred Generic – Tier 2 $10 Deductible, 50%
Preferred Brand – Tier 3 $40 Deductible, 50%Non-Preferred Brand – Tier 4 $80 Deductible, 50%
Specialty
Pharmacy/Medical
Preferred Specialty – Tier 5 50% Deductible, 50%Non-Preferred Specialty– Tier 6 50% Deductible, 50%
This is a brief summary of Health Alliance benefits and exclusions, which are subject to change.Please refer to your Health Alliance Policy for detailed information regarding this plan.
*Facility coverage only; physicians fees may apply
mkt 2020 IL GRP DIR SOB 2020 POS 3000 Gold 0120
2020 POS 3000 Gold Gold01/01/2020 Member Responsibility
Member Benefits In-Network Out-of-Network
Plan Year DeductibleIncludes Embedded Deductible. Members on this plan who meet theirindividual deductibles can use their coverage before the family deductibleis met.
Single: $3,000Family: $6,000
Single: $6,000Family: $12,000
Plan Year Out-of-Pocket MaximumCombined medical and pharmacy expenses including deductible,coinsurance amounts and copays.
Single: $6,000Family: $12,000
Single: $16,000Family: $32,000
Walk-in PatientServices
Annual Vision Exam $20 per exam Not CoveredPrimary Care Physician Office Visit $25 per visit Deductible, 40%
Specialty Care Physician Office Visit $50 per visit Deductible, 40%Acupuncture $25 per visit In Network Benefit Applies
Spinal Manipulations $50 per visit In Network Benefit AppliesUrgent Care $50 per visit In Network Benefit AppliesVirtual Visits $0 visits 1-3, then $25 copay Not Covered
EmergencyServices
Emergency Department Visit $350 then 10% per visit In Network Benefit AppliesEmergency Ambulance
Transportation Deductible, 10% In Network Benefit Applies
HospitalServices
Outpatient Surgery/Procedures* Deductible, 10% Deductible, 40%Inpatient Facility* Deductible, 10% Deductible, 40%
Mental Health/Substance Abuse
Outpatient Office Visits $25 per visit Deductible, 40%Inpatient Facility* Deductible, 10% Deductible, 40%
Rehabilitative AndHabilitative Services
Physical Therapy Deductible, 10% Deductible, 40%Occupational Therapy Deductible, 10% Deductible, 40%
Durable Medical Equipment Deductible, 10% Deductible, 40%
Diagnostic Services MRI and CT Scans Deductible, 10% Deductible, 40%Laboratory and X-rays Deductible, 10% Deductible, 40%
MaternityInpatient newborn covered onmother’s policy up to 96 hours
Routine Prenatal Care Deductible, 10% Deductible, 40%Inpatient Maternity Facility* Deductible, 10% Deductible, 40%Inpatient Newborn Facility* Deductible, 10% Deductible, 40%
Pediatric ServicesOffered to children upto age 19
Pediatric Dental Exam Refer to Delta Dental Materials Refer to Delta Dental MaterialsPediatric Vision Exam $0 per exam Deductible, 50%
Pediatric Vision Materials $0 per item In Network Benefit AppliesPreventive & Wellness ServicesImmunizations, adult and child annual physical exams, mammograms,PAP smears, cancer screenings and more. Age/frequency schedules apply.
$0 Deductible, 40%
Prescription Drugs Retail
Preferred Generic – Tier 1 $0 Deductible, 50%Non-Preferred Generic – Tier 2 $10 Deductible, 50%
Preferred Brand – Tier 3 $40 Deductible, 50%Non-Preferred Brand – Tier 4 $80 Deductible, 50%
Specialty
Pharmacy/Medical
Preferred Specialty – Tier 5 50% Deductible, 50%Non-Preferred Specialty– Tier 6 50% Deductible, 50%
This is a brief summary of Health Alliance benefits and exclusions, which are subject to change.Please refer to your Health Alliance Policy for detailed information regarding this plan.
*Facility coverage only; physicians fees may apply
mkt 2020 IL GRP DIR SOB 2020 POS 3500 Gold 0120
2020 POS 3500 Gold Gold01/01/2020 Member Responsibility
Member Benefits In-Network Out-of-Network
Plan Year DeductibleIncludes Embedded Deductible. Members on this plan who meet theirindividual deductibles can use their coverage before the family deductibleis met.
Single: $3,500Family: $7,000
Single: $7,000Family: $14,000
Plan Year Out-of-Pocket MaximumCombined medical and pharmacy expenses including deductible,coinsurance amounts and copays.
Single: $8,150Family: $16,300
Single: $19,500Family: $39,000
Walk-in PatientServices
Annual Vision Exam $20 per exam Not CoveredPrimary Care Physician Office Visit $25 per visit Deductible, 50%
Specialty Care Physician Office Visit $50 per visit Deductible, 50%Acupuncture $25 per visit In Network Benefit Applies
Spinal Manipulations $50 per visit In Network Benefit AppliesUrgent Care $50 per visit In Network Benefit AppliesVirtual Visits $0 visits 1-3, then $25 copay Not Covered
EmergencyServices
Emergency Department Visit $350 then 20% per visit In Network Benefit AppliesEmergency Ambulance
Transportation Deductible, 20% In Network Benefit Applies
HospitalServices
Outpatient Surgery/Procedures* Deductible, 20% Deductible, 50%Inpatient Facility* Deductible, 20% Deductible, 50%
Mental Health/Substance Abuse
Outpatient Office Visits $25 per visit Deductible, 50%Inpatient Facility* Deductible, 20% Deductible, 50%
Rehabilitative AndHabilitative Services
Physical Therapy Deductible, 20% Deductible, 50%Occupational Therapy Deductible, 20% Deductible, 50%
Durable Medical Equipment Deductible, 20% Deductible, 50%
Diagnostic Services MRI and CT Scans Deductible, 20% Deductible, 50%Laboratory and X-rays Deductible, 20% Deductible, 50%
MaternityInpatient newborn covered onmother’s policy up to 96 hours
Routine Prenatal Care Deductible, 20% Deductible, 50%Inpatient Maternity Facility* Deductible, 20% Deductible, 50%Inpatient Newborn Facility* Deductible, 20% Deductible, 50%
Pediatric ServicesOffered to children upto age 19
Pediatric Dental Exam Refer to Delta Dental Materials Refer to Delta Dental MaterialsPediatric Vision Exam $0 per exam Deductible, 50%
Pediatric Vision Materials $0 per item In Network Benefit AppliesPreventive & Wellness ServicesImmunizations, adult and child annual physical exams, mammograms,PAP smears, cancer screenings and more. Age/frequency schedules apply.
$0 Deductible, 50%
Prescription Drugs Retail
Preferred Generic – Tier 1 $0 Deductible, 50%Non-Preferred Generic – Tier 2 $10 Deductible, 50%
Preferred Brand – Tier 3 $40 Deductible, 50%Non-Preferred Brand – Tier 4 $80 Deductible, 50%
Specialty
Pharmacy/Medical
Preferred Specialty – Tier 5 50% Deductible, 50%Non-Preferred Specialty– Tier 6 50% Deductible, 50%
This is a brief summary of Health Alliance benefits and exclusions, which are subject to change.Please refer to your Health Alliance Policy for detailed information regarding this plan.
*Facility coverage only; physicians fees may apply
mkt 2020 IL GRP DIR SOB 2020 POS 3800 Silver 0120
2020 POS 3800 Silver Silver01/01/2020 Member Responsibility
Member Benefits In-Network Out-of-Network
Plan Year DeductibleIncludes Embedded Deductible. Members on this plan who meet theirindividual deductibles can use their coverage before the family deductibleis met.
Single: $3,800Family: $7,600
Single: $7,600Family: $15,200
Plan Year Out-of-Pocket MaximumCombined medical and pharmacy expenses including deductible,coinsurance amounts and copays.
Single: $8,150Family: $16,300
Single: $20,100Family: $40,200
Walk-in PatientServices
Annual Vision Exam $20 per exam Not CoveredPrimary Care Physician Office Visit $35 per visit Deductible, 50%
Specialty Care Physician Office Visit $70 per visit Deductible, 50%Acupuncture $35 per visit In Network Benefit Applies
Spinal Manipulations $70 per visit In Network Benefit AppliesUrgent Care $70 per visit In Network Benefit AppliesVirtual Visits $0 visits 1-3, then $35 copay Not Covered
EmergencyServices
Emergency Department Visit $400 per visit and Deductible then30% In Network Benefit Applies
Emergency AmbulanceTransportation Deductible, 30% In Network Benefit Applies
HospitalServices
Outpatient Surgery/Procedures* $400 per procedure and Deductiblethen 30% Deductible, 50%
Inpatient Facility* Deductible, 30% Deductible, 50%Mental Health/Substance Abuse
Outpatient Office Visits $35 per visit Deductible, 50%Inpatient Facility* Deductible, 30% Deductible, 50%
Rehabilitative AndHabilitative Services
Physical Therapy Deductible, 30% Deductible, 50%Occupational Therapy Deductible, 30% Deductible, 50%
Durable Medical Equipment Deductible, 30% Deductible, 50%
Diagnostic Services MRI and CT Scans Deductible, 30% Deductible, 50%Laboratory and X-rays Deductible, 30% Deductible, 50%
MaternityInpatient newborn covered onmother’s policy up to 96 hours
Routine Prenatal Care Deductible, 30% Deductible, 50%Inpatient Maternity Facility* Deductible, 30% Deductible, 50%Inpatient Newborn Facility* Deductible, 30% Deductible, 50%
Pediatric ServicesOffered to children upto age 19
Pediatric Dental Exam Refer to Delta Dental Materials Refer to Delta Dental MaterialsPediatric Vision Exam $0 per exam Deductible, 50%
Pediatric Vision Materials $0 per item In Network Benefit AppliesPreventive & Wellness ServicesImmunizations, adult and child annual physical exams, mammograms,PAP smears, cancer screenings and more. Age/frequency schedules apply.
$0 Deductible, 50%
Prescription Drugs Retail
Preferred Generic – Tier 1 $0 Deductible, 50%Non-Preferred Generic – Tier 2 $15 Deductible, 50%
Preferred Brand – Tier 3 $50 Deductible, 50%Non-Preferred Brand – Tier 4 $90 Deductible, 50%
Specialty
Pharmacy/Medical
Preferred Specialty – Tier 5 50% Deductible, 50%Non-Preferred Specialty– Tier 6 50% Deductible, 50%
This is a brief summary of Health Alliance benefits and exclusions, which are subject to change.Please refer to your Health Alliance Policy for detailed information regarding this plan.
*Facility coverage only; physicians fees may apply
mkt 2020 IL GRP DIR SOB 2020 POS 5500 Silver 0120
2020 POS 5500 Silver Silver01/01/2020 Member Responsibility
Member Benefits In-Network Out-of-Network
Plan Year DeductibleIncludes Embedded Deductible. Members on this plan who meet theirindividual deductibles can use their coverage before the family deductibleis met.
Single: $5,500Family: $11,000
Single: $11,000Family: $22,000
Plan Year Out-of-Pocket MaximumCombined medical and pharmacy expenses including deductible,coinsurance amounts and copays.
Single: $8,150Family: $16,300
Single: $23,500Family: $47,000
Walk-in PatientServices
Annual Vision Exam $20 per exam Not CoveredPrimary Care Physician Office Visit $35 per visit Deductible, 50%
Specialty Care Physician Office Visit $70 per visit Deductible, 50%Acupuncture $35 per visit In Network Benefit Applies
Spinal Manipulations $70 per visit In Network Benefit AppliesUrgent Care $70 per visit In Network Benefit AppliesVirtual Visits $0 visits 1-3, then $35 copay Not Covered
EmergencyServices
Emergency Department Visit Deductible, 20% In Network Benefit AppliesEmergency Ambulance
Transportation Deductible, 20% In Network Benefit Applies
HospitalServices
Outpatient Surgery/Procedures* Deductible, 20% Deductible, 50%Inpatient Facility* Deductible, 20% Deductible, 50%
Mental Health/Substance Abuse
Outpatient Office Visits $35 per visit Deductible, 50%Inpatient Facility* Deductible, 20% Deductible, 50%
Rehabilitative AndHabilitative Services
Physical Therapy Deductible, 20% Deductible, 50%Occupational Therapy Deductible, 20% Deductible, 50%
Durable Medical Equipment Deductible, 20% Deductible, 50%
Diagnostic Services MRI and CT Scans Deductible, 20% Deductible, 50%Laboratory and X-rays Deductible, 20% Deductible, 50%
MaternityInpatient newborn covered onmother’s policy up to 96 hours
Routine Prenatal Care Deductible, 20% Deductible, 50%Inpatient Maternity Facility* Deductible, 20% Deductible, 50%Inpatient Newborn Facility* Deductible, 20% Deductible, 50%
Pediatric ServicesOffered to children upto age 19
Pediatric Dental Exam Refer to Delta Dental Materials Refer to Delta Dental MaterialsPediatric Vision Exam $0 per exam Deductible, 50%
Pediatric Vision Materials $0 per item In Network Benefit AppliesPreventive & Wellness ServicesImmunizations, adult and child annual physical exams, mammograms,PAP smears, cancer screenings and more. Age/frequency schedules apply.
$0 Deductible, 50%
Prescription Drugs Retail
Preferred Generic – Tier 1 $0 Deductible, 50%Non-Preferred Generic – Tier 2 $15 Deductible, 50%
Preferred Brand – Tier 3 $50 Deductible, 50%Non-Preferred Brand – Tier 4 $90 Deductible, 50%
Specialty
Pharmacy/Medical
Preferred Specialty – Tier 5 50% Deductible, 50%Non-Preferred Specialty– Tier 6 50% Deductible, 50%
This is a brief summary of Health Alliance benefits and exclusions, which are subject to change.Please refer to your Health Alliance Policy for detailed information regarding this plan.
*Facility coverage only; physicians fees may apply
mkt 2020 IL GRP DIR SOB 2020 POS HSA 2000 Gold 0120
2020 POS HSA 2000 Gold Gold01/01/2020 Member Responsibility
Member Benefits In-Network Out-of-Network
Plan Year DeductibleIncludes Aggregate Deductible. Members on this plan must meet their familydeductible before anyone can use their coverage.
Single: $2,000Family: $4,000
Single: $4,000Family: $8,000
Plan Year Out-of-Pocket MaximumCombined medical and pharmacy expenses including deductible,coinsurance amounts and copays.
Single: $3,750Family: $7,500
Single: $11,500Family: $23,000
Walk-in PatientServices
Annual Vision Exam Deductible, 0% Not CoveredPrimary Care Physician Office Visit Deductible, 0% Deductible, 30%
Specialty Care Physician Office Visit Deductible, 0% Deductible, 30%Acupuncture Deductible, 0% In Network Benefit Applies
Spinal Manipulations Deductible, 0% In Network Benefit AppliesUrgent Care Deductible, 0% In Network Benefit AppliesVirtual Visits Deductible, 0% Not Covered
EmergencyServices
Emergency Department Visit Deductible, 0% In Network Benefit AppliesEmergency Ambulance
Transportation Deductible, 0% In Network Benefit Applies
HospitalServices
Outpatient Surgery/Procedures* Deductible, 0% Deductible, 30%Inpatient Facility* Deductible, 0% Deductible, 30%
Mental Health/Substance Abuse
Outpatient Office Visits Deductible, 0% Deductible, 30%Inpatient Facility* Deductible, 0% Deductible, 30%
Rehabilitative AndHabilitative Services
Physical Therapy Deductible, 0% Deductible, 30%Occupational Therapy Deductible, 0% Deductible, 30%
Durable Medical Equipment Deductible, 0% Deductible, 30%
Diagnostic Services MRI and CT Scans Deductible, 0% Deductible, 30%Laboratory and X-rays Deductible, 0% Deductible, 30%
MaternityInpatient newborn covered onmother’s policy up to 96 hours
Routine Prenatal Care Deductible, 0% Deductible, 30%Inpatient Maternity Facility* Deductible, 0% Deductible, 30%Inpatient Newborn Facility* Deductible, 0% Deductible, 30%
Pediatric ServicesOffered to children upto age 19
Pediatric Dental Exam Refer to Delta Dental Materials Refer to Delta Dental MaterialsPediatric Vision Exam $0 per exam Deductible, 50%
Pediatric Vision Materials Deductible, $0 per item In Network Benefit AppliesPreventive & Wellness ServicesImmunizations, adult and child annual physical exams, mammograms,PAP smears, cancer screenings and more. Age/frequency schedules apply.
$0 Deductible, 30%
Prescription Drugs Retail
Preferred Generic – Tier 1 Deductible, $0 Deductible, 50%Non-Preferred Generic – Tier 2 Deductible, $10 Deductible, 50%
Preferred Brand – Tier 3 Deductible, 20% Deductible, 50%Non-Preferred Brand – Tier 4 Deductible, 30% Deductible, 50%
Specialty
Pharmacy/Medical
Preferred Specialty – Tier 5 Deductible, 40% Deductible, 50%Non-Preferred Specialty– Tier 6 Deductible, 50% Deductible, 50%
This is a brief summary of Health Alliance benefits and exclusions, which are subject to change.Please refer to your Health Alliance Policy for detailed information regarding this plan.
*Facility coverage only; physicians fees may apply
mkt 2020 IL GRP DIR SOB 2020 POS HSA 2800 Gold 0120
2020 POS HSA 2800 Gold Gold01/01/2020 Member Responsibility
Member Benefits In-Network Out-of-Network
Plan Year DeductibleIncludes Embedded Deductible. Members on this plan who meet theirindividual deductibles can use their coverage before the family deductibleis met.
Single: $2,800Family: $5,600
Single: $5,600Family: $11,200
Plan Year Out-of-Pocket MaximumCombined medical and pharmacy expenses including deductible,coinsurance amounts and copays.
Single: $3,500Family: $7,000
Single: $13,100Family: $26,200
Walk-in PatientServices
Annual Vision Exam Deductible, 0% Not CoveredPrimary Care Physician Office Visit Deductible, 0% Deductible, 30%
Specialty Care Physician Office Visit Deductible, 0% Deductible, 30%Acupuncture Deductible, 0% In Network Benefit Applies
Spinal Manipulations Deductible, 0% In Network Benefit AppliesUrgent Care Deductible, 0% In Network Benefit AppliesVirtual Visits Deductible, 0% Not Covered
EmergencyServices
Emergency Department Visit Deductible, 0% In Network Benefit AppliesEmergency Ambulance
Transportation Deductible, 0% In Network Benefit Applies
HospitalServices
Outpatient Surgery/Procedures* Deductible, 0% Deductible, 30%Inpatient Facility* Deductible, 0% Deductible, 30%
Mental Health/Substance Abuse
Outpatient Office Visits Deductible, 0% Deductible, 30%Inpatient Facility* Deductible, 0% Deductible, 30%
Rehabilitative AndHabilitative Services
Physical Therapy Deductible, 0% Deductible, 30%Occupational Therapy Deductible, 0% Deductible, 30%
Durable Medical Equipment Deductible, 0% Deductible, 30%
Diagnostic Services MRI and CT Scans Deductible, 0% Deductible, 30%Laboratory and X-rays Deductible, 0% Deductible, 30%
MaternityInpatient newborn covered onmother’s policy up to 96 hours
Routine Prenatal Care Deductible, 0% Deductible, 30%Inpatient Maternity Facility* Deductible, 0% Deductible, 30%Inpatient Newborn Facility* Deductible, 0% Deductible, 30%
Pediatric ServicesOffered to children upto age 19
Pediatric Dental Exam Refer to Delta Dental Materials Refer to Delta Dental MaterialsPediatric Vision Exam $0 per exam Deductible, 50%
Pediatric Vision Materials Deductible, $0 per item In Network Benefit AppliesPreventive & Wellness ServicesImmunizations, adult and child annual physical exams, mammograms,PAP smears, cancer screenings and more. Age/frequency schedules apply.
$0 Deductible, 30%
Prescription Drugs Retail
Preferred Generic – Tier 1 Deductible, $0 Deductible, 50%Non-Preferred Generic – Tier 2 Deductible, $10 Deductible, 50%
Preferred Brand – Tier 3 Deductible, 20% Deductible, 50%Non-Preferred Brand – Tier 4 Deductible, 30% Deductible, 50%
Specialty
Pharmacy/Medical
Preferred Specialty – Tier 5 Deductible, 40% Deductible, 50%Non-Preferred Specialty– Tier 6 Deductible, 50% Deductible, 50%
This is a brief summary of Health Alliance benefits and exclusions, which are subject to change.Please refer to your Health Alliance Policy for detailed information regarding this plan.
*Facility coverage only; physicians fees may apply
mkt 2020 IL GRP DIR SOB 2020 POS HSA 3000 Silver 0120
2020 POS HSA 3000 Silver Silver01/01/2020 Member Responsibility
Member Benefits In-Network Out-of-Network
Plan Year DeductibleIncludes Embedded Deductible. Members on this plan who meet theirindividual deductibles can use their coverage before the family deductibleis met.
Single: $3,000Family: $6,000
Single: $6,000Family: $12,000
Plan Year Out-of-Pocket MaximumCombined medical and pharmacy expenses including deductible,coinsurance amounts and copays.
Single: $6,750Family: $13,500
Single: $16,000Family: $32,000
Walk-in PatientServices
Annual Vision Exam Deductible, 10% Not CoveredPrimary Care Physician Office Visit Deductible, 10% Deductible, 40%
Specialty Care Physician Office Visit Deductible, 10% Deductible, 40%Acupuncture Deductible, 10% In Network Benefit Applies
Spinal Manipulations Deductible, 10% In Network Benefit AppliesUrgent Care Deductible, 10% In Network Benefit AppliesVirtual Visits Deductible, 10% Not Covered
EmergencyServices
Emergency Department Visit Deductible, 10% In Network Benefit AppliesEmergency Ambulance
Transportation Deductible, 10% In Network Benefit Applies
HospitalServices
Outpatient Surgery/Procedures* Deductible, 10% Deductible, 40%Inpatient Facility* Deductible, 10% Deductible, 40%
Mental Health/Substance Abuse
Outpatient Office Visits Deductible, 10% Deductible, 40%Inpatient Facility* Deductible, 10% Deductible, 40%
Rehabilitative AndHabilitative Services
Physical Therapy Deductible, 10% Deductible, 40%Occupational Therapy Deductible, 10% Deductible, 40%
Durable Medical Equipment Deductible, 10% Deductible, 40%
Diagnostic Services MRI and CT Scans Deductible, 10% Deductible, 40%Laboratory and X-rays Deductible, 10% Deductible, 40%
MaternityInpatient newborn covered onmother’s policy up to 96 hours
Routine Prenatal Care Deductible, 10% Deductible, 40%Inpatient Maternity Facility* Deductible, 10% Deductible, 40%Inpatient Newborn Facility* Deductible, 10% Deductible, 40%
Pediatric ServicesOffered to children upto age 19
Pediatric Dental Exam Refer to Delta Dental Materials Refer to Delta Dental MaterialsPediatric Vision Exam $0 per exam Deductible, 50%
Pediatric Vision Materials Deductible, $0 per item In Network Benefit AppliesPreventive & Wellness ServicesImmunizations, adult and child annual physical exams, mammograms,PAP smears, cancer screenings and more. Age/frequency schedules apply.
$0 Deductible, 40%
Prescription Drugs Retail
Preferred Generic – Tier 1 Deductible, $0 Deductible, 50%Non-Preferred Generic – Tier 2 Deductible, $10 Deductible, 50%
Preferred Brand – Tier 3 Deductible, 20% Deductible, 50%Non-Preferred Brand – Tier 4 Deductible, 30% Deductible, 50%
Specialty
Pharmacy/Medical
Preferred Specialty – Tier 5 Deductible, 40% Deductible, 50%Non-Preferred Specialty– Tier 6 Deductible, 50% Deductible, 50%
This is a brief summary of Health Alliance benefits and exclusions, which are subject to change.Please refer to your Health Alliance Policy for detailed information regarding this plan.
*Facility coverage only; physicians fees may apply
mkt 2020 IL GRP DIR SOB 2020 POS HSA 3500 Silver 0120
2020 POS HSA 3500 Silver Silver01/01/2020 Member Responsibility
Member Benefits In-Network Out-of-Network
Plan Year DeductibleIncludes Embedded Deductible. Members on this plan who meet theirindividual deductibles can use their coverage before the family deductibleis met.
Single: $3,500Family: $7,000
Single: $7,000Family: $14,000
Plan Year Out-of-Pocket MaximumCombined medical and pharmacy expenses including deductible,coinsurance amounts and copays.
Single: $6,750Family: $13,500
Single: $19,500Family: $39,000
Walk-in PatientServices
Annual Vision Exam Deductible, 20% Not CoveredPrimary Care Physician Office Visit Deductible, 20% Deductible, 50%
Specialty Care Physician Office Visit Deductible, 20% Deductible, 50%Acupuncture Deductible, 20% In Network Benefit Applies
Spinal Manipulations Deductible, 20% In Network Benefit AppliesUrgent Care Deductible, 20% In Network Benefit AppliesVirtual Visits Deductible, 20% Not Covered
EmergencyServices
Emergency Department Visit Deductible, 20% In Network Benefit AppliesEmergency Ambulance
Transportation Deductible, 20% In Network Benefit Applies
HospitalServices
Outpatient Surgery/Procedures* Deductible, 20% Deductible, 50%Inpatient Facility* Deductible, 20% Deductible, 50%
Mental Health/Substance Abuse
Outpatient Office Visits Deductible, 20% Deductible, 50%Inpatient Facility* Deductible, 20% Deductible, 50%
Rehabilitative AndHabilitative Services
Physical Therapy Deductible, 20% Deductible, 50%Occupational Therapy Deductible, 20% Deductible, 50%
Durable Medical Equipment Deductible, 20% Deductible, 50%
Diagnostic Services MRI and CT Scans Deductible, 20% Deductible, 50%Laboratory and X-rays Deductible, 20% Deductible, 50%
MaternityInpatient newborn covered onmother’s policy up to 96 hours
Routine Prenatal Care Deductible, 20% Deductible, 50%Inpatient Maternity Facility* Deductible, 20% Deductible, 50%Inpatient Newborn Facility* Deductible, 20% Deductible, 50%
Pediatric ServicesOffered to children upto age 19
Pediatric Dental Exam Refer to Delta Dental Materials Refer to Delta Dental MaterialsPediatric Vision Exam $0 per exam Deductible, 50%
Pediatric Vision Materials Deductible, $0 per item In Network Benefit AppliesPreventive & Wellness ServicesImmunizations, adult and child annual physical exams, mammograms,PAP smears, cancer screenings and more. Age/frequency schedules apply.
$0 Deductible, 50%
Prescription Drugs Retail
Preferred Generic – Tier 1 Deductible, $0 Deductible, 50%Non-Preferred Generic – Tier 2 Deductible, $10 Deductible, 50%
Preferred Brand – Tier 3 Deductible, 20% Deductible, 50%Non-Preferred Brand – Tier 4 Deductible, 30% Deductible, 50%
Specialty
Pharmacy/Medical
Preferred Specialty – Tier 5 Deductible, 40% Deductible, 50%Non-Preferred Specialty– Tier 6 Deductible, 50% Deductible, 50%
This is a brief summary of Health Alliance benefits and exclusions, which are subject to change.Please refer to your Health Alliance Policy for detailed information regarding this plan.
*Facility coverage only; physicians fees may apply
mkt 2020 IL GRP DIR SOB 2020 POS HSA 5000 Bronze 0120
2020 POS HSA 5000 Bronze Bronze01/01/2020 Member Responsibility
Member Benefits In-Network Out-of-Network
Plan Year DeductibleIncludes Embedded Deductible. Members on this plan who meet theirindividual deductibles can use their coverage before the family deductibleis met.
Single: $5,000Family: $10,000
Single: $10,000Family: $20,000
Plan Year Out-of-Pocket MaximumCombined medical and pharmacy expenses including deductible,coinsurance amounts and copays.
Single: $6,750Family: $13,500
Single: $22,500Family: $45,000
Walk-in PatientServices
Annual Vision Exam Deductible, 20% Not CoveredPrimary Care Physician Office Visit Deductible, 20% Deductible, 50%
Specialty Care Physician Office Visit Deductible, 20% Deductible, 50%Acupuncture Deductible, 20% In Network Benefit Applies
Spinal Manipulations Deductible, 20% In Network Benefit AppliesUrgent Care Deductible, 20% In Network Benefit AppliesVirtual Visits Deductible, 20% Not Covered
EmergencyServices
Emergency Department Visit Deductible, 20% In Network Benefit AppliesEmergency Ambulance
Transportation Deductible, 20% In Network Benefit Applies
HospitalServices
Outpatient Surgery/Procedures* Deductible, 20% Deductible, 50%Inpatient Facility* Deductible, 20% Deductible, 50%
Mental Health/Substance Abuse
Outpatient Office Visits Deductible, 20% Deductible, 50%Inpatient Facility* Deductible, 20% Deductible, 50%
Rehabilitative AndHabilitative Services
Physical Therapy Deductible, 20% Deductible, 50%Occupational Therapy Deductible, 20% Deductible, 50%
Durable Medical Equipment Deductible, 20% Deductible, 50%
Diagnostic Services MRI and CT Scans Deductible, 20% Deductible, 50%Laboratory and X-rays Deductible, 20% Deductible, 50%
MaternityInpatient newborn covered onmother’s policy up to 96 hours
Routine Prenatal Care Deductible, 20% Deductible, 50%Inpatient Maternity Facility* Deductible, 20% Deductible, 50%Inpatient Newborn Facility* Deductible, 20% Deductible, 50%
Pediatric ServicesOffered to children upto age 19
Pediatric Dental Exam Refer to Delta Dental Materials Refer to Delta Dental MaterialsPediatric Vision Exam $0 per exam Deductible, 50%
Pediatric Vision Materials Deductible, $0 per item In Network Benefit AppliesPreventive & Wellness ServicesImmunizations, adult and child annual physical exams, mammograms,PAP smears, cancer screenings and more. Age/frequency schedules apply.
$0 Deductible, 50%
Prescription Drugs Retail
Preferred Generic – Tier 1 Deductible, $0 Deductible, 50%Non-Preferred Generic – Tier 2 Deductible, $10 Deductible, 50%
Preferred Brand – Tier 3 Deductible, 20% Deductible, 50%Non-Preferred Brand – Tier 4 Deductible, 30% Deductible, 50%
Specialty
Pharmacy/Medical
Preferred Specialty – Tier 5 Deductible, 40% Deductible, 50%Non-Preferred Specialty– Tier 6 Deductible, 50% Deductible, 50%
This is a brief summary of Health Alliance benefits and exclusions, which are subject to change.Please refer to your Health Alliance Policy for detailed information regarding this plan.
*Facility coverage only; physicians fees may apply
mkt 2020 IL GRP DIR SOB 2020 POS HSA 6750 Bronze 0120
2020 POS HSA 6750 Bronze Bronze01/01/2020 Member Responsibility
Member Benefits In-Network Out-of-Network
Plan Year DeductibleIncludes Embedded Deductible. Members on this plan who meet theirindividual deductibles can use their coverage before the family deductibleis met.
Single: $6,750Family: $13,500
Single: $13,500Family: $27,000
Plan Year Out-of-Pocket MaximumCombined medical and pharmacy expenses including deductible,coinsurance amounts and copays.
Single: $6,750Family: $13,500
Single: $21,000Family: $42,000
Walk-in PatientServices
Annual Vision Exam Deductible, 0% Not CoveredPrimary Care Physician Office Visit Deductible, 0% Deductible, 30%
Specialty Care Physician Office Visit Deductible, 0% Deductible, 30%Acupuncture Deductible, 0% In Network Benefit Applies
Spinal Manipulations Deductible, 0% In Network Benefit AppliesUrgent Care Deductible, 0% In Network Benefit AppliesVirtual Visits Deductible, 0% Not Covered
EmergencyServices
Emergency Department Visit Deductible, 0% In Network Benefit AppliesEmergency Ambulance
Transportation Deductible, 0% In Network Benefit Applies
HospitalServices
Outpatient Surgery/Procedures* Deductible, 0% Deductible, 30%Inpatient Facility* Deductible, 0% Deductible, 30%
Mental Health/Substance Abuse
Outpatient Office Visits Deductible, 0% Deductible, 30%Inpatient Facility* Deductible, 0% Deductible, 30%
Rehabilitative AndHabilitative Services
Physical Therapy Deductible, 0% Deductible, 30%Occupational Therapy Deductible, 0% Deductible, 30%
Durable Medical Equipment Deductible, 0% Deductible, 30%
Diagnostic Services MRI and CT Scans Deductible, 0% Deductible, 30%Laboratory and X-rays Deductible, 0% Deductible, 30%
MaternityInpatient newborn covered onmother’s policy up to 96 hours
Routine Prenatal Care Deductible, 0% Deductible, 30%Inpatient Maternity Facility* Deductible, 0% Deductible, 30%Inpatient Newborn Facility* Deductible, 0% Deductible, 30%
Pediatric ServicesOffered to children upto age 19
Pediatric Dental Exam Refer to Delta Dental Materials Refer to Delta Dental MaterialsPediatric Vision Exam $0 per exam Deductible, 50%
Pediatric Vision Materials Deductible, $0 per item In Network Benefit AppliesPreventive & Wellness ServicesImmunizations, adult and child annual physical exams, mammograms,PAP smears, cancer screenings and more. Age/frequency schedules apply.
$0 Deductible, 30%
Prescription Drugs Retail
Preferred Generic – Tier 1 Deductible, 0% Deductible, 50%Non-Preferred Generic – Tier 2 Deductible, 0% Deductible, 50%
Preferred Brand – Tier 3 Deductible, 0% Deductible, 50%Non-Preferred Brand – Tier 4 Deductible, 0% Deductible, 50%
Specialty
Pharmacy/Medical
Preferred Specialty – Tier 5 Deductible, 0% Deductible, 50%Non-Preferred Specialty– Tier 6 Deductible, 0% Deductible, 50%
• Coverage is determined at the point of service, dependent on the provider chosen. When choosing an in-network provider, HMO-style benefitsapply.Whenchoosinganout-of-network provider,indemnitybenefitsapply(exceptinurgent oremergencysituations).• Membersselectaprimarycareprovider(PCP)to coordinate all medical care.• Forin-networkspecialtycare,aPCPgivesareferral to an in-network specialist. Specialty care received withoutareferralorfromanout-of-networkprovider iscoveredatthelower(indemnity)level.• WomencanselectaWoman’sPrincipalHealthcare Provider(specializinginobstetrics,gynecologyor familypractice)inadditiontoaPCP.
POSC
This is a brief summary of Health Alliance benefits and exclusions, which are subject to change.Please refer to your Health Alliance Policy for detailed information regarding this plan.
*Facility coverage only; physicians fees may apply
mkt 2020 IL GRP DIR SOB 2020 POSC 0 Gold 0120
2020 POSC 0 Gold Gold01/01/2020 Member Responsibility
Member Benefits In-Network Out-of-Network
Plan Year DeductibleIncludes Embedded Deductible. Members on this plan who meet theirindividual deductibles can use their coverage before the family deductibleis met.
Single: $0Family: $0
Single: $1,000Family: $2,000
Plan Year Out-of-Pocket MaximumCombined medical and pharmacy expenses including deductible,coinsurance amounts and copays.
Single: $8,150Family: $16,300
Single: $13,500Family: $27,000
Walk-in PatientServices
Annual Vision Exam $20 per exam Not CoveredPrimary Care Physician Office Visit $25 per visit Deductible, 50%
Specialty Care Physician Office Visit $50 per visit Deductible, 50%Acupuncture $25 per visit In Network Benefit Applies
Chiropractic Services $50 per visit In Network Benefit AppliesUrgent Care $50 per visit In Network Benefit AppliesVirtual Visits $0 visits 1-3, then $25 copay Not Covered
EmergencyServices
Emergency Department Visit $500 per visit, then 35% In Network Benefit AppliesEmergency Ambulance
Transportation 35% In Network Benefit Applies
HospitalServices
Outpatient Surgery/Procedures* $1,000 per procedure, then 35% Deductible, 50%Inpatient Facility* $1,000 per stay, then 35% Deductible, 50%
Mental Health/Substance Abuse
Outpatient Office Visits $25 per visit Deductible, 50%Inpatient Facility* $1,000 per stay, then 35% Deductible, 50%
Rehabilitative AndHabilitative Services
Physical Therapy 35% Deductible, 50%Occupational Therapy 35% Deductible, 50%
Durable Medical Equipment 35% Deductible, 50%
Diagnostic Services MRI and CT Scans $1,000 per test, then 35% Deductible, 50%Laboratory and X-rays 35% Deductible, 50%
MaternityInpatient newborn covered onmother’s policy up to 96 hours
Routine Prenatal Care 35% Deductible, 50%Inpatient Maternity Facility* $1,000 per stay, then 35% Deductible, 50%Inpatient Newborn Facility* $1,000 per stay, then 35% Deductible, 50%
Pediatric ServicesOffered to children upto age 19
Pediatric Dental Exam Refer to Delta Dental Materials Refer to Delta Dental MaterialsPediatric Vision Exam $0 per exam Deductible, 50%
Pediatric Vision Materials $0 per item In Network Benefit AppliesPreventive & Wellness ServicesImmunizations, adult and child annual physical exams, mammograms,PAP smears, cancer screenings and more. Age/frequency schedules apply.
$0 Deductible, 50%
Prescription Drugs Retail
Preferred Generic – Tier 1 $0 Deductible, 50%Non-Preferred Generic – Tier 2 $10 Deductible, 50%
Preferred Brand – Tier 3 $40 Deductible, 50%Non-Preferred Brand – Tier 4 $80 Deductible, 50%
Specialty
Pharmacy/Medical
Preferred Specialty – Tier 5 50% Deductible, 50%Non-Preferred Specialty– Tier 6 50% Deductible, 50%
This is a brief summary of Health Alliance benefits and exclusions, which are subject to change.Please refer to your Health Alliance Policy for detailed information regarding this plan.
*Facility coverage only; physicians fees may apply
mkt 2020 IL GRP DIR SOB 2020 POSC 500 Gold 0120
2020 POSC 500 Gold Gold01/01/2020 Member Responsibility
Member Benefits In-Network Out-of-Network
Plan Year DeductibleIncludes Embedded Deductible. Members on this plan who meet theirindividual deductibles can use their coverage before the family deductibleis met.
Single: $500Family: $1,000
Single: $1,000Family: $2,000
Plan Year Out-of-Pocket MaximumCombined medical and pharmacy expenses including deductible,coinsurance amounts and copays.
Single: $8,150Family: $16,300
Single: $13,500Family: $27,000
Walk-in PatientServices
Annual Vision Exam $20 per exam Not CoveredPrimary Care Physician Office Visit $25 per visit Deductible, 50%
Specialty Care Physician Office Visit $50 per visit Deductible, 50%Acupuncture $25 per visit In Network Benefit Applies
Spinal Manipulations $50 per visit In Network Benefit AppliesUrgent Care $50 per visit In Network Benefit AppliesVirtual Visits $0 visits 1-3, then $25 copay Not Covered
EmergencyServices
Emergency Department Visit $500 per visit and Deductible then30% In Network Benefit Applies
Emergency AmbulanceTransportation Deductible, 30% In Network Benefit Applies
HospitalServices
Outpatient Surgery/Procedures* $1,000 per procedure and Deductiblethen 30% Deductible, 50%
Inpatient Facility* $1,000 per stay and Deductible then30% Deductible, 50%
Mental Health/Substance Abuse
Outpatient Office Visits $25 per visit Deductible, 50%
Inpatient Facility* $1,000 per stay and Deductible then30% Deductible, 50%
Rehabilitative AndHabilitative Services
Physical Therapy Deductible, 30% Deductible, 50%Occupational Therapy Deductible, 30% Deductible, 50%
Durable Medical Equipment Deductible, 30% Deductible, 50%
Diagnostic Services MRI and CT Scans $1,000 per test and Deductible then30% Deductible, 50%
Laboratory and X-rays Deductible, 30% Deductible, 50%
MaternityInpatient newborn covered onmother’s policy up to 96 hours
Routine Prenatal Care Deductible, 30% Deductible, 50%
Inpatient Maternity Facility* $1,000 per stay and Deductible then30% Deductible, 50%
Inpatient Newborn Facility* $1,000 per stay and Deductible then30% Deductible, 50%
Pediatric ServicesOffered to children upto age 19
Pediatric Dental Exam Refer to Delta Dental Materials Refer to Delta Dental MaterialsPediatric Vision Exam $0 per exam Deductible, 50%
Pediatric Vision Materials $0 per item In Network Benefit AppliesPreventive & Wellness ServicesImmunizations, adult and child annual physical exams, mammograms,PAP smears, cancer screenings and more. Age/frequency schedules apply.
$0 Deductible, 50%
Prescription Drugs Retail
Preferred Generic – Tier 1 $0 Deductible, 50%Non-Preferred Generic – Tier 2 $10 Deductible, 50%
Preferred Brand – Tier 3 $40 Deductible, 50%Non-Preferred Brand – Tier 4 $80 Deductible, 50%
Specialty
Pharmacy/Medical
Preferred Specialty – Tier 5 50% Deductible, 50%Non-Preferred Specialty– Tier 6 50% Deductible, 50%
This is a brief summary of Health Alliance benefits and exclusions, which are subject to change.Please refer to your Health Alliance Policy for detailed information regarding this plan.
*Facility coverage only; physicians fees may apply
mkt 2020 IL GRP DIR SOB 2020 POSC 2750 Silver 0120
2020 POSC 2750 Silver Silver01/01/2020 Member Responsibility
Member Benefits In-Network Out-of-Network
Plan Year DeductibleIncludes Embedded Deductible. Members on this plan who meet theirindividual deductibles can use their coverage before the family deductibleis met.
Single: $2,750Family: $5,500
Single: $5,500Family: $11,000
Plan Year Out-of-Pocket MaximumCombined medical and pharmacy expenses including deductible,coinsurance amounts and copays.
Single: $8,150Family: $16,300
Single: $18,000Family: $36,000
Walk-in PatientServices
Annual Vision Exam $20 per exam Not CoveredPrimary Care Physician Office Visit $35 per visit Deductible, 50%
Specialty Care Physician Office Visit $70 per visit Deductible, 50%Acupuncture $35 per visit In Network Benefit Applies
Spinal Manipulations $70 per visit In Network Benefit AppliesUrgent Care $70 per visit In Network Benefit AppliesVirtual Visits $0 visits 1-3, then $35 copay Not Covered
EmergencyServices
Emergency Department Visit $400 per visit and Deductible then30% In Network Benefit Applies
Emergency AmbulanceTransportation Deductible, 30% In Network Benefit Applies
HospitalServices
Outpatient Surgery/Procedures* $400 per procedure and Deductiblethen 30% Deductible, 50%
Inpatient Facility* Deductible, 30% Deductible, 50%Mental Health/Substance Abuse
Outpatient Office Visits $35 per visit Deductible, 50%Inpatient Facility* Deductible, 30% Deductible, 50%
Rehabilitative AndHabilitative Services
Physical Therapy Deductible, 30% Deductible, 50%Occupational Therapy Deductible, 30% Deductible, 50%
Durable Medical Equipment Deductible, 30% Deductible, 50%
Diagnostic Services MRI and CT Scans Deductible, 30% Deductible, 50%Laboratory and X-rays Deductible, 30% Deductible, 50%
MaternityInpatient newborn covered onmother’s policy up to 96 hours
Routine Prenatal Care Deductible, 30% Deductible, 50%Inpatient Maternity Facility* Deductible, 30% Deductible, 50%Inpatient Newborn Facility* Deductible, 30% Deductible, 50%
Pediatric ServicesOffered to children upto age 19
Pediatric Dental Exam Refer to Delta Dental Materials Refer to Delta Dental MaterialsPediatric Vision Exam $0 per exam Deductible, 50%
Pediatric Vision Materials $0 per item In Network Benefit AppliesPreventive & Wellness ServicesImmunizations, adult and child annual physical exams, mammograms,PAP smears, cancer screenings and more. Age/frequency schedules apply.
$0 Deductible, 50%
Prescription Drugs Retail
Preferred Generic – Tier 1 $0 Deductible, 50%Non-Preferred Generic – Tier 2 $15 Deductible, 50%
Preferred Brand – Tier 3 $60 Deductible, 50%Non-Preferred Brand – Tier 4 Deductible, 30% Deductible, 50%
Specialty
Pharmacy/Medical
Preferred Specialty – Tier 5 Deductible, 30% Deductible, 50%Non-Preferred Specialty– Tier 6 Deductible, 30% Deductible, 50%
PPO
Structure• PPO members can see any provider, but they’ll get
the greatest out-of-pocket savings when staying in-network.
• Members are not required to select a primary care physician (PCP) to coordinate care.
• Health Alliance does not require PPO members to get a referral for specialty care, although some physician practices may require it.
Considerations• Health Alliance has a strong network of top-notch
doctors, hospitals, clinics and pharmacies throughout Illinois.
This is a brief summary of Health Alliance benefits and exclusions, which are subject to change.Please refer to your Health Alliance Policy for detailed information regarding this plan.
*Facility coverage only; physicians fees may apply
mkt 2020 IL GRP DIR SOB 2020 PPO 1500 Gold 0120
2020 PPO 1500 Gold Gold01/01/2020 Member Responsibility
Member Benefits In-Network Out-of-Network
Plan Year DeductibleIncludes Embedded Deductible. Members on this plan who meet theirindividual deductibles can use their coverage before the family deductibleis met.
Single: $1,500Family: $3,000
Single: $3,000Family: $6,000
Plan Year Out-of-Pocket MaximumCombined medical and pharmacy expenses including deductible,coinsurance amounts and copays.
Single: $7,500Family: $15,000
Single: $15,500Family: $31,000
Walk-in PatientServices
Annual Vision Exam $20 per exam Not CoveredPrimary Care Physician Office Visit $25 per visit Deductible, 50%
Specialty Care Physician Office Visit $50 per visit Deductible, 50%Acupuncture $25 per visit In Network Benefit Applies
Spinal Manipulations $50 per visit In Network Benefit AppliesUrgent Care $50 per visit In Network Benefit AppliesVirtual Visits $0 visits 1-3, then $25 copay Not Covered
EmergencyServices
Emergency Department Visit $350 then 20% per visit In Network Benefit AppliesEmergency Ambulance
Transportation Deductible, 20% In Network Benefit Applies
HospitalServices
Outpatient Surgery/Procedures* Deductible, 20% Deductible, 50%Inpatient Facility* Deductible, 20% Deductible, 50%
Mental Health/Substance Abuse
Outpatient Office Visits $25 per visit Deductible, 50%Inpatient Facility* Deductible, 20% Deductible, 50%
Rehabilitative AndHabilitative Services
Physical Therapy Deductible, 20% Deductible, 50%Occupational Therapy Deductible, 20% Deductible, 50%
Durable Medical Equipment Deductible, 20% Deductible, 50%
Diagnostic Services MRI and CT Scans Deductible, 20% Deductible, 50%Laboratory and X-rays Deductible, 20% Deductible, 50%
MaternityInpatient newborn covered onmother’s policy up to 96 hours
Routine Prenatal Care Deductible, 20% Deductible, 50%Inpatient Maternity Facility* Deductible, 20% Deductible, 50%Inpatient Newborn Facility* Deductible, 20% Deductible, 50%
Pediatric ServicesOffered to children upto age 19
Pediatric Dental Exam Refer to Delta Dental Materials Refer to Delta Dental MaterialsPediatric Vision Exam $0 per exam Deductible, 50%
Pediatric Vision Materials $0 per item In Network Benefit AppliesPreventive & Wellness ServicesImmunizations, adult and child annual physical exams, mammograms,PAP smears, cancer screenings and more. Age/frequency schedules apply.
$0 Deductible, 50%
Prescription Drugs Retail
Preferred Generic – Tier 1 $0 Deductible, 50%Non-Preferred Generic – Tier 2 $10 Deductible, 50%
Preferred Brand – Tier 3 $40 Deductible, 50%Non-Preferred Brand – Tier 4 $80 Deductible, 50%
Specialty
Pharmacy/Medical
Preferred Specialty – Tier 5 50% Deductible, 50%Non-Preferred Specialty– Tier 6 50% Deductible, 50%
This is a brief summary of Health Alliance benefits and exclusions, which are subject to change.Please refer to your Health Alliance Policy for detailed information regarding this plan.
*Facility coverage only; physicians fees may apply
mkt 2020 IL GRP DIR SOB 2020 PPO 3500 Gold 0120
2020 PPO 3500 Gold Gold01/01/2020 Member Responsibility
Member Benefits In-Network Out-of-Network
Plan Year DeductibleIncludes Embedded Deductible. Members on this plan who meet theirindividual deductibles can use their coverage before the family deductibleis met.
Single: $3,500Family: $7,000
Single: $7,000Family: $14,000
Plan Year Out-of-Pocket MaximumCombined medical and pharmacy expenses including deductible,coinsurance amounts and copays.
Single: $8,150Family: $16,300
Single: $19,500Family: $39,000
Walk-in PatientServices
Annual Vision Exam $20 per exam Not CoveredPrimary Care Physician Office Visit $25 per visit Deductible, 50%
Specialty Care Physician Office Visit $50 per visit Deductible, 50%Acupuncture $25 per visit In Network Benefit Applies
Spinal Manipulations $50 per visit In Network Benefit AppliesUrgent Care $50 per visit In Network Benefit AppliesVirtual Visits $0 visits 1-3, then $25 copay Not Covered
EmergencyServices
Emergency Department Visit $350 then 20% per visit In Network Benefit AppliesEmergency Ambulance
Transportation Deductible, 20% In Network Benefit Applies
HospitalServices
Outpatient Surgery/Procedures* Deductible, 20% Deductible, 50%Inpatient Facility* Deductible, 20% Deductible, 50%
Mental Health/Substance Abuse
Outpatient Office Visits $25 per visit Deductible, 50%Inpatient Facility* Deductible, 20% Deductible, 50%
Rehabilitative AndHabilitative Services
Physical Therapy Deductible, 20% Deductible, 50%Occupational Therapy Deductible, 20% Deductible, 50%
Durable Medical Equipment Deductible, 20% Deductible, 50%
Diagnostic Services MRI and CT Scans Deductible, 20% Deductible, 50%Laboratory and X-rays Deductible, 20% Deductible, 50%
MaternityInpatient newborn covered onmother’s policy up to 96 hours
Routine Prenatal Care Deductible, 20% Deductible, 50%Inpatient Maternity Facility* Deductible, 20% Deductible, 50%Inpatient Newborn Facility* Deductible, 20% Deductible, 50%
Pediatric ServicesOffered to children upto age 19
Pediatric Dental Exam Refer to Delta Dental Materials Refer to Delta Dental MaterialsPediatric Vision Exam $0 per exam Deductible, 50%
Pediatric Vision Materials $0 per item In Network Benefit AppliesPreventive & Wellness ServicesImmunizations, adult and child annual physical exams, mammograms,PAP smears, cancer screenings and more. Age/frequency schedules apply.
$0 Deductible, 50%
Prescription Drugs Retail
Preferred Generic – Tier 1 $0 Deductible, 50%Non-Preferred Generic – Tier 2 $10 Deductible, 50%
Preferred Brand – Tier 3 $40 Deductible, 50%Non-Preferred Brand – Tier 4 $80 Deductible, 50%
Specialty
Pharmacy/Medical
Preferred Specialty – Tier 5 50% Deductible, 50%Non-Preferred Specialty– Tier 6 50% Deductible, 50%
This is a brief summary of Health Alliance benefits and exclusions, which are subject to change.Please refer to your Health Alliance Policy for detailed information regarding this plan.
*Facility coverage only; physicians fees may apply
mkt 2020 IL GRP DIR SOB 2020 PPO 3800 Silver 0120
2020 PPO 3800 Silver Silver01/01/2020 Member Responsibility
Member Benefits In-Network Out-of-Network
Plan Year DeductibleIncludes Embedded Deductible. Members on this plan who meet theirindividual deductibles can use their coverage before the family deductibleis met.
Single: $3,800Family: $7,600
Single: $7,600Family: $15,200
Plan Year Out-of-Pocket MaximumCombined medical and pharmacy expenses including deductible,coinsurance amounts and copays.
Single: $8,150Family: $16,300
Single: $20,100Family: $40,200
Walk-in PatientServices
Annual Vision Exam $20 per exam Not CoveredPrimary Care Physician Office Visit $35 per visit Deductible, 50%
Specialty Care Physician Office Visit $70 per visit Deductible, 50%Acupuncture $35 per visit In Network Benefit Applies
Spinal Manipulations $70 per visit In Network Benefit AppliesUrgent Care $70 per visit In Network Benefit AppliesVirtual Visits $0 visits 1-3, then $35 copay Not Covered
EmergencyServices
Emergency Department Visit $400 per visit and Deductible then30% In Network Benefit Applies
Emergency AmbulanceTransportation Deductible, 30% In Network Benefit Applies
HospitalServices
Outpatient Surgery/Procedures* $400 per procedure and Deductiblethen 30% Deductible, 50%
Inpatient Facility* Deductible, 30% Deductible, 50%Mental Health/Substance Abuse
Outpatient Office Visits $35 per visit Deductible, 50%Inpatient Facility* Deductible, 30% Deductible, 50%
Rehabilitative AndHabilitative Services
Physical Therapy Deductible, 30% Deductible, 50%Occupational Therapy Deductible, 30% Deductible, 50%
Durable Medical Equipment Deductible, 30% Deductible, 50%
Diagnostic Services MRI and CT Scans Deductible, 30% Deductible, 50%Laboratory and X-rays Deductible, 30% Deductible, 50%
MaternityInpatient newborn covered onmother’s policy up to 96 hours
Routine Prenatal Care Deductible, 30% Deductible, 50%Inpatient Maternity Facility* Deductible, 30% Deductible, 50%Inpatient Newborn Facility* Deductible, 30% Deductible, 50%
Pediatric ServicesOffered to children upto age 19
Pediatric Dental Exam Refer to Delta Dental Materials Refer to Delta Dental MaterialsPediatric Vision Exam $0 per exam Deductible, 50%
Pediatric Vision Materials $0 per item In Network Benefit AppliesPreventive & Wellness ServicesImmunizations, adult and child annual physical exams, mammograms,PAP smears, cancer screenings and more. Age/frequency schedules apply.
$0 Deductible, 50%
Prescription Drugs Retail
Preferred Generic – Tier 1 $0 Deductible, 50%Non-Preferred Generic – Tier 2 $15 Deductible, 50%
Preferred Brand – Tier 3 $50 Deductible, 50%Non-Preferred Brand – Tier 4 $90 Deductible, 50%
Specialty
Pharmacy/Medical
Preferred Specialty – Tier 5 50% Deductible, 50%Non-Preferred Specialty– Tier 6 50% Deductible, 50%
This is a brief summary of Health Alliance benefits and exclusions, which are subject to change.Please refer to your Health Alliance Policy for detailed information regarding this plan.
*Facility coverage only; physicians fees may apply
mkt 2020 IL GRP DIR SOB 2020 PPO HSA 2800 Gold 0120
2020 PPO HSA 2800 Gold Gold01/01/2020 Member Responsibility
Member Benefits In-Network Out-of-Network
Plan Year DeductibleIncludes Embedded Deductible. Members on this plan who meet theirindividual deductibles can use their coverage before the family deductibleis met.
Single: $2,800Family: $5,600
Single: $5,600Family: $11,200
Plan Year Out-of-Pocket MaximumCombined medical and pharmacy expenses including deductible,coinsurance amounts and copays.
Single: $3,500Family: $7,000
Single: $13,100Family: $26,200
Walk-in PatientServices
Annual Vision Exam Deductible, 0% Not CoveredPrimary Care Physician Office Visit Deductible, 0% Deductible, 30%
Specialty Care Physician Office Visit Deductible, 0% Deductible, 30%Acupuncture Deductible, 0% In Network Benefit Applies
Spinal Manipulations Deductible, 0% In Network Benefit AppliesUrgent Care Deductible, 0% In Network Benefit AppliesVirtual Visits Deductible, 0% Not Covered
EmergencyServices
Emergency Department Visit Deductible, 0% In Network Benefit AppliesEmergency Ambulance
Transportation Deductible, 0% In Network Benefit Applies
HospitalServices
Outpatient Surgery/Procedures* Deductible, 0% Deductible, 30%Inpatient Facility* Deductible, 0% Deductible, 30%
Mental Health/Substance Abuse
Outpatient Office Visits Deductible, 0% Deductible, 30%Inpatient Facility* Deductible, 0% Deductible, 30%
Rehabilitative AndHabilitative Services
Physical Therapy Deductible, 0% Deductible, 30%Occupational Therapy Deductible, 0% Deductible, 30%
Durable Medical Equipment Deductible, 0% Deductible, 30%
Diagnostic Services MRI and CT Scans Deductible, 0% Deductible, 30%Laboratory and X-rays Deductible, 0% Deductible, 30%
MaternityInpatient newborn covered onmother’s policy up to 96 hours
Routine Prenatal Care Deductible, 0% Deductible, 30%Inpatient Maternity Facility* Deductible, 0% Deductible, 30%Inpatient Newborn Facility* Deductible, 0% Deductible, 30%
Pediatric ServicesOffered to children upto age 19
Pediatric Dental Exam Refer to Delta Dental Materials Refer to Delta Dental MaterialsPediatric Vision Exam $0 per exam Deductible, 50%
Pediatric Vision Materials Deductible, $0 per item In Network Benefit AppliesPreventive & Wellness ServicesImmunizations, adult and child annual physical exams, mammograms,PAP smears, cancer screenings and more. Age/frequency schedules apply.
$0 Deductible, 30%
Prescription Drugs Retail
Preferred Generic – Tier 1 Deductible, $0 Deductible, 50%Non-Preferred Generic – Tier 2 Deductible, $10 Deductible, 50%
Preferred Brand – Tier 3 Deductible, 20% Deductible, 50%Non-Preferred Brand – Tier 4 Deductible, 30% Deductible, 50%
Specialty
Pharmacy/Medical
Preferred Specialty – Tier 5 Deductible, 40% Deductible, 50%Non-Preferred Specialty– Tier 6 Deductible, 50% Deductible, 50%
This is a brief summary of Health Alliance benefits and exclusions, which are subject to change.Please refer to your Health Alliance Policy for detailed information regarding this plan.
*Facility coverage only; physicians fees may apply
mkt 2020 IL GRP DIR SOB 2020 PPO HSA 5000 Bronze 0120
2020 PPO HSA 5000 Bronze Bronze01/01/2020 Member Responsibility
Member Benefits In-Network Out-of-Network
Plan Year DeductibleIncludes Embedded Deductible. Members on this plan who meet theirindividual deductibles can use their coverage before the family deductibleis met.
Single: $5,000Family: $10,000
Single: $10,000Family: $20,000
Plan Year Out-of-Pocket MaximumCombined medical and pharmacy expenses including deductible,coinsurance amounts and copays.
Single: $6,750Family: $13,500
Single: $22,500Family: $45,000
Walk-in PatientServices
Annual Vision Exam Deductible, 20% Not CoveredPrimary Care Physician Office Visit Deductible, 20% Deductible, 50%
Specialty Care Physician Office Visit Deductible, 20% Deductible, 50%Acupuncture Deductible, 20% In Network Benefit Applies
Spinal Manipulations Deductible, 20% In Network Benefit AppliesUrgent Care Deductible, 20% In Network Benefit AppliesVirtual Visits Deductible, 20% Not Covered
EmergencyServices
Emergency Department Visit Deductible, 20% In Network Benefit AppliesEmergency Ambulance
Transportation Deductible, 20% In Network Benefit Applies
HospitalServices
Outpatient Surgery/Procedures* Deductible, 20% Deductible, 50%Inpatient Facility* Deductible, 20% Deductible, 50%
Mental Health/Substance Abuse
Outpatient Office Visits Deductible, 20% Deductible, 50%Inpatient Facility* Deductible, 20% Deductible, 50%
Rehabilitative AndHabilitative Services
Physical Therapy Deductible, 20% Deductible, 50%Occupational Therapy Deductible, 20% Deductible, 50%
Durable Medical Equipment Deductible, 20% Deductible, 50%
Diagnostic Services MRI and CT Scans Deductible, 20% Deductible, 50%Laboratory and X-rays Deductible, 20% Deductible, 50%
MaternityInpatient newborn covered onmother’s policy up to 96 hours
Routine Prenatal Care Deductible, 20% Deductible, 50%Inpatient Maternity Facility* Deductible, 20% Deductible, 50%Inpatient Newborn Facility* Deductible, 20% Deductible, 50%
Pediatric ServicesOffered to children upto age 19
Pediatric Dental Exam Refer to Delta Dental Materials Refer to Delta Dental MaterialsPediatric Vision Exam $0 per exam Deductible, 50%
Pediatric Vision Materials Deductible, $0 per item In Network Benefit AppliesPreventive & Wellness ServicesImmunizations, adult and child annual physical exams, mammograms,PAP smears, cancer screenings and more. Age/frequency schedules apply.
$0 Deductible, 50%
Prescription Drugs Retail
Preferred Generic – Tier 1 Deductible, $0 Deductible, 50%Non-Preferred Generic – Tier 2 Deductible, $10 Deductible, 50%
Preferred Brand – Tier 3 Deductible, 20% Deductible, 50%Non-Preferred Brand – Tier 4 Deductible, 30% Deductible, 50%
Specialty
Pharmacy/Medical
Preferred Specialty – Tier 5 Deductible, 40% Deductible, 50%Non-Preferred Specialty– Tier 6 Deductible, 50% Deductible, 50%
cmp-nondiscrim15MED-0719
DISCRIMINATION IS AGAINST THE LAW Health Alliance complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Health Alliance does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. Health Alliance: • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
o Qualified sign language interpreters o Written information in other formats (large print audio, accessible electronic formats, other formats)
• Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages
If you need these services, contact customer service. If you believe that Health Alliance has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Health Alliance Medicare, Member Services, 3310 Fields South Drive, Champaign, IL 61822 or 411 N. Chelan Avenue, Wenatchee, WA 98801, telephone for members in Illinois, Indiana, Iowa and Ohio: 1-800-965-4022; telephone for members in Washington: 1-877-750-3350 TTY: 711, fax: 217-902-9705, [email protected]. You can file a grievance in person or by mail, fax or email. If you need help filing a grievance, Member Services is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, TTY: 1-800-537-7697. Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. ATENCIÓN: Si habla Español, servicios de asistencia lingüística, de forma gratuita, están disponibles para usted. IA,
IL, IN, OH: Llame 1-800-965-4022, WA Llame: 1-877-750-3350 (TTY: 711). 注意:如果你講中文,語言協助服務,免費的,都可以給你。IA, IL, IN, OH: 呼叫 1-800-965-4022, WA: 呼叫
1-877-750-3350(TTY: 711)。 UWAGA: Jeśli mówić Polskie, usługi pomocy języka, bezpłatnie, są dostępne dla Ciebie. IA, IL, IN, OH: Zadzwoń
1-800-965-4022, WA: Zadzwoń 1-877-750-3350 (TTY: 711). Chú ý: Nếu bạn nói Tiếng Việt, các dịch vụ hỗ trợ ngôn ngữ, miễn phí, có sẵn cho bạn. IA, IL, IN, OH: Gọi
1-800-965-4022, WA: Gọi 1-877-750-3350 (TTY: 711). 주의 : 당신이한국어, 무료 언어 지원 서비스를 말하는 경우 사용할 수 있습니다. 1-800-965-4022 IA, IL, IN, OH: 전화 WA: 1-877-750-3350 전화 (TTY: 711).
ВНИМАНИЕ: Если вы говорите русский, вставки услуги языковой помощи, бесплатно, доступны для вас. IA, IL, IN, OH: Вызов 1-800-965-4022, WA: Вызов 1-877-750-3350 (TTY: 711).
Pansin: Kung magsalita ka Tagalog, mga serbisyo ng tulong sa wika, nang walang bayad, ay magagamit sa iyo. IA, IL, IN, OH: Tumawag 1-800-965-4022, WA: Tumawag 1-877-750-3350 (TTY: 711).
، والیة واشنطن: 4022-965-800-1إذا كنت تتكلم العربیة، فإن خدمات المساعدة اللغویة متوفرة لك مجاناً. إیلینوي، إندیانا، أوھایو: اتصل بالرقم : انتباه )711(إذا كنت تعاني من الصمم أو صعوبة في السمع فاتصل على الرقم 3350-750-877-1اتصل بالرقم:
Aufmerksamkeit: Wenn Sie Deutsch sprechen, Sprachassistenzdienste sind kostenlos, zur Verfügung. IA, IL, IN, OH: Anruf 1-800-965-4022, WA: Anruf 1-877-750-3350 (TTY: 711).
ATTENTION: Si vous parlez français, les services d'assistance linguistique, gratuitement, sont à votre disposition. IA, IL, IN, OH: Appelez 1-800-965-4022, WA: Appelez 1-877-750-3350 (TTY: 711).
ધ્યાન: તમે વાત તો �જુરાતી, ભાષા સહાય સેવાઓ, મફત, તમારા માટ� ઉપલબ્ધ છે. IA, IL, IN, OH: કૉલ 1-800-965-4022,
WA: કૉલ 1-877-750-3350 (TTY: 711). 注意:あなたは、日本語 、無料で言語支援サービスを、話す場合は、あなたに利用可能です。
1-800-965-4022 IA, IL, IN, OH: コール 1-877-750-3350 WA: コール(TTY: 711)。 LET OP: Als je spreekt pennsylvania nederlandse, taalkundige bijstand diensten, gratis voor u beschikbaar zijn. IA, IL,
IN, OH: Bel 1-800-965-4022, WA: Bel 1-877-750-3350 (TTY: 711). УВАГА: Якщо ви говорите український, вставки послуги мовної допомоги, безкоштовно, доступні для вас. IA,
IL, IN, OH: Виклик 1-800-965-4022, WA: Виклик 1-877-750-3350 (TTY: 711). ATTENZIONE: Se si parla italiano, servizi di assistenza linguistica, a titolo gratuito, sono a vostra disposizione. IA, IL, IN, OH: Chiamare 1-800-965-4022, WA: Chiamare 1-877-750-3350 (TTY: 711).
grp-sgbwbkltsIL-0619