HEALTH ALLIANCE EMPLOYER GROUP PLANS

State of Illinois

State of Illinois Participants

Plan Year 2014 Highlights (effective July 1, 2013, to June 30, 2014)

Outpatient Care

Copayment or Coinsurance

(Your Cost)

Physician Office Visits
Copayments apply to office visits with physicians, physician assistants, nurses and other mid-level providers. Other services obtained while in the office may require an additional copayment or coinsurance.

$18 per visit

Specialist Office Visits

Other services obtained while in the office may require an additional copayment or coinsurance.

$25 per visit

Be Healthy Preventive Services

Immunizations, adult and child annual physical exam, mammograms, PAP smears, cancer screenings and more. Age/frequency schedules apply.

$0 copayment

Routine Prenatal Care

$50 per pregnancy

Outpatient Surgery/Procedure

$225 per visit

Diagnostic Testing
X-rays, lab services

$0 each

Mental Health Care

$25 per visit

Substance Abuse Treatment

$25 per visit

Home Health Care
When prescribed by a Health Alliance physician and authorized by the Health Alliance Medical Management Department.

$25 per visit

Rehabilitation Services
Up to 60 visits combined per condition per plan year—includes short-term occupational, speech and physical therapy services.

$25 per visit

Emergency Care

Copayment or Coinsurance

(Your Cost)

Emergency Room

Lower of 50% or $225 per visit

Physician Care

$0 per visit

Ambulance
When medically necessary

$0 per trip

Inpatient Care

Copayment or Coinsurance

(Your Cost)

Hospitalization
Includes semi-private room, physician care, nursing care, operating room, anesthesia, lab services, X-rays, medical supplies and other medically necessary services.

$325 per admission

Maternity Care

$325 per admission

Mental Health Care

$325 per admission

Substance Abuse Treatment

$325 per admission

Extended Care/Rehabilitation Services
Up to 120 days combined per plan year—Extended Care refers to skilled nursing care received in an approved nursing facility. Rehabilitation Services include inpatient occupational, speech and physical therapy services.

$0 per stay

Other

Copayment or Coinsurance

(Your Cost)

Deductible
Per enrollee

Prescription Drugs (Including Specialty Drugs)†*

30-day supply retail copayment; 90-supply available at 2.5 times the one-month copayment for both retail and mail order.

$75

 

 

$8 Tier 1
$26 Tier 2
$50 Tier 3

Durable Medical Equipment

20% coinsurance 

Prosthetic Devices

20% coinsurance

Hearing Aids
every three years

All costs covered except:
$150 per exam
$600 maximum benefit for hearing aids

† Copayment, coinsurance and deductible payments for these services do not apply to the plan year out-of-pocket maximum.
* The Health Alliance Drug Formulary helps Health Alliance HMO members and their doctors choose drugs that give great results at low prices. Doctors and pharmacists meet monthly to keep the Drug Formulary up to date. Members who choose a brand-name drug after the release of a generic drug may pay the Tier 1 copayment plus the difference in cost between the brand-name and generic drugs. In some cases, your doctor may decide a Tier 3 drug is best. If he or she asks Health Alliance to review the drug and we approve, you will pay only the Tier 2 copayment.

Contract Year Out-of-Pocket Maximum

Your Maximum Cost

$3,000 per individual,
$6,000 per family

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