2020 large group plans - health alliance · mkt 2020 il grp dir sob hmo 80a 20 rx230 0120 hmo 80a...

2020 Large Group PlansIllinois

TM

Table of ContentsHMO 80A - HMO 1500C plansHMO 2000A - HMO 2500C plansHMO 3000A - HMO 3500C plansHMO 4000A - HMO 6000C plansHMO 7000B - HMO 8150H plansAll HMO HSA plans

POS 500A - POS 1500C plansPOS 2000A - POS 2500C plansPOS 3000A - POS 3500C plansPOS 4000A - POS 6000C plansPOS 7000B - POS 8150H plansAll POS HSA plans

All POSC+ plans

PPO 500A - PPO 1500C plansPPO 2000A - PPO 2500C plansPPO 3000A - PPO 3500C plansPPO 4000A - PPO 6000C plansPPO 7000B - PPO 8150H plansAll PPO HSA plans

Health 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 240,000 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 sales and medical management support. We partner with local health systems for true patient-focused care.

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.

QualityLearn more about everything you can give your employees.

Hometown Carewith

World-Class

Helping Your Employees Get and Stay HealthyWe support your employees through every step of care with these programs, included in their coverage at no extra cost.

• Health coaching for encouragement and support in making a healthy lifestyle change.• Care coordination when employees have critical medical need or a complex condition and need help navigating the healthcare system. We have doctors, nurses, social workers and others who are plugged in to both the health plan and healthcare providers.

• Care transitions for a smooth adjustment from hospital to home and any stays in between.• Medication management for help taking medications safely and getting the expected results.

These services are part of what makes Health Alliance more than just healthcare coverage. We’re part of your employees’ healthcare system and can help them in more ways than you might expect.

Employers can learn more about our health, wellness and work/life balance programs by talking with their Client Consultant or calling Client Support at 1-800-851-3379, ext. 28151.

For J.D. Power 2019 award information, visit jdpower.com/awards.

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.

Important InformationPlease keep in mind the following information when selecting the best plan for your group.• Plans with a variety of premium and deductible options• Plans designated with “HSA” can be paired with an employee health savings account.• Deductible and copayments/coinsurance, including for pharmacy coverage, all count toward your out-of-pocket maximum.

o Deductible—A set amount you pay before your plan starts helpingpayforyourmedicalcareorpharmacybenefits.

o Copayment—A set amount you pay when you use certain medical services covered by your plan.

o Coinsurance—A percentage of the cost you pay when you use certain medical services covered by your plan.

o Out-of-Pocket Maximum—The most you’ll pay out-of- pocket during your plan year. Once you reach this limit, Health Alliance pays 100 percent of covered expenses for the rest of the plan year. Please note that this is in-network only. Maximum Allowable Charges apply to out-of-network (so your costs for out-of-network services do not stop at the out-of-pocket maximum limit).

• The plans in this section have either an embedded or aggregate family deductible.

o With an embedded deductible, coverage kicks in for a member of your family as soon as he or she meets the individual deductible, even if the family deductible hasn’t been met.

o With an aggregate deductible, coverage kicks in for everyone after the family deductible is met. Even if one person meets his or her individual deductible, coverage won’t start until the family deductible is met.

• Preventive and wellness services include immunizations, adult and child annual physical exams, mammograms, Pap smears, cancer screenings and more. Age/frequency restrictions may apply.

Health Savings Account (HSA) An HSA is an account that lets employees set aside money tax-free for medical expenses. Employees can add money straight from a paycheck or add cash as they go, and they can change the contribution amount each month.

Key Points• The employee owns the HSA.• Both the employee and employer can

contribute.• The funds in an HSA never expire. Even if

employees leave their jobs or don’t spend the money in a given year, the money stays in the account.

• Employees can earn tax-free interest on their HSA savings.

What is an HSA plan?

HMO Plans

• Only HMO in-network care is covered, but at very affordable rates. Out-of-Network care is covered in urgent or emergency situations or when a referral or authorization is given.• Members choose a primary care provider (PCP) to coordinate all medical care.• For specialty care, a PCP gives a referral to an in-network specialist.• Women can select a Woman’s Principal Healthcare Provider (specializing in obstetrics, gynecology or family practice) in addition to a PCP.

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 HMO 80A 20 RX230 0120

HMO 80A 20 RX23001/01/2020 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: Not ApplicableFamily: Not Applicable

Plan Year Out-of-Pocket MaximumCombined medical and pharmacy expenses including deductible,coinsurance amounts and copays.

Single: $1,500Family: $3,000


Walk-in PatientServices

Annual Vision Exam $40 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% Not CoveredUrgent Care $50 per visit In Network Benefit AppliesVirtual Visits first 3 visits $0, then $25 Not Covered

EmergencyServices

Emergency Department Visit 20% In Network Benefit AppliesEmergency Ambulance

Transportation 20% In Network Benefit Applies

HospitalServices

Outpatient Surgery/Procedures* 20% Not CoveredInpatient Facility* 20% Not Covered

Mental Health/Substance Abuse

Outpatient Office Visits $25 per visit Not CoveredInpatient Facility* 20% Not Covered

Rehabilitative AndHabilitative Services

Physical Therapy 20% Not CoveredOccupational Therapy 20% Not Covered

Durable Medical Equipment 20% Not Covered

Diagnostic Services MRI and CT Scans 20% Not CoveredLaboratory and X-rays 20% Not Covered

MaternityInpatient newborn covered onmother’s policy up to 96 hours

Routine Prenatal Care 20% Not CoveredInpatient Maternity Facility* 20% Not CoveredInpatient Newborn Facility* 20% Not Covered

Preventive & 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 $7 Not Covered

Preferred Brand – Tier 3 $35 Not CoveredNon-Preferred Brand – Tier 4 $70 Not Covered

Specialty

Pharmacy/Medical

Preferred Specialty – Tier 5 $140 Not CoveredNon-Preferred Specialty– Tier 6 50% Not Covered




HMO 80A 20 RX23101/01/2020 Member Responsibility












EmergencyServices



HospitalServices











$0 Not Covered




Specialty

Pharmacy/Medical

Preferred Specialty – Tier 5 30% Not CoveredNon-Preferred Specialty– Tier 6 50% Not Covered



mkt 2020 IL GRP DIR SOB HMO 90B 20 RX230 0120

HMO 90B 20 RX23001/01/2020 Member Responsibility












EmergencyServices



HospitalServices











$0 Not Covered




Specialty

Pharmacy/Medical





HMO 90B 20 RX23101/01/2020 Member Responsibility












EmergencyServices



HospitalServices











$0 Not Covered




Specialty

Pharmacy/Medical





HMO 500A 20 RX230 Platinum01/01/2020 Member Responsibility



Single: $500Family: $1,000









EmergencyServices

Emergency Department Visit $150 per visit In Network Benefit AppliesEmergency Ambulance

Transportation $100 In Network Benefit Applies

HospitalServices

Outpatient Surgery/Procedures* Deductible, 20% Not CoveredInpatient Facility* Deductible, 20% Not Covered


Outpatient Office Visits $10 per visit Not CoveredInpatient Facility* Deductible, 20% Not Covered


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


Routine Prenatal Care Deductible, 20% Not CoveredInpatient Maternity Facility* Deductible, 20% Not CoveredInpatient Newborn Facility* Deductible, 20% Not Covered


$0 Not Covered




Specialty

Pharmacy/Medical

















EmergencyServices



HospitalServices











$0 Not Covered




Specialty

Pharmacy/Medical





HMO 1500B 20 RX230 Platinum01/01/2020 Member Responsibility












EmergencyServices



HospitalServices











$0 Not Covered




Specialty

Pharmacy/Medical

















EmergencyServices



HospitalServices











$0 Not Covered




Specialty

Pharmacy/Medical




mkt 2020 IL GRP DIR SOB HMO 1500C 20 RX230 0120

HMO 1500C 20 RX230 Platinum01/01/2020 Member Responsibility












EmergencyServices



HospitalServices











$0 Not Covered




Specialty

Pharmacy/Medical

















EmergencyServices



HospitalServices











$0 Not Covered




Specialty

Pharmacy/Medical




mkt 2020 IL GRP DIR SOB HMO 8150H 20 RX232 0120

HMO 8150H 20 RX232 Platinum01/01/2020 Member Responsibility









Annual Vision Exam Deductible, 0% Not CoveredPrimary Care Physician Office Visit $40 per visit Not Covered


Spinal Manipulations Deductible, 0% Not CoveredUrgent Care $80 per visit In Network Benefit AppliesVirtual Visits first 3 visits $0, then $40 Not Covered

EmergencyServices

Emergency Department Visit Deductible, 0% In Network Benefit AppliesEmergency Ambulance

Transportation Deductible, 0% In Network Benefit Applies

HospitalServices











$0 Not Covered


Preferred Generic – Tier 1 Deductible, 0% Not CoveredNon-Preferred Generic – Tier 2 Deductible, 0% Not Covered

Preferred Brand – Tier 3 Deductible, 0% Not CoveredNon-Preferred Brand – Tier 4 Deductible, 0% Not Covered

Specialty

Pharmacy/Medical

Preferred Specialty – Tier 5 Deductible, 0% Not CoveredNon-Preferred Specialty– Tier 6 Deductible, 0% Not Covered



mkt 2020 IL GRP DIR SOB HSA 20 1500 HMO 80 RX233 AGG 0120

HSA 20 1500 HMO 80 RX233 AGG Platinum01/01/2020 Member Responsibility


Plan Year DeductibleIncludes Aggregate Deductible. Members on this plan must meet their familydeductible before anyone can use their coverage.







Annual Vision Exam Deductible, 20% Not CoveredPrimary Care Physician Office Visit Deductible, 20% Not Covered

Specialty Care Physician Office Visit Deductible, 20% Not CoveredAcupuncture Deductible, 20% Not Covered

Spinal Manipulations Deductible, 50% Not CoveredUrgent Care Deductible, 20% In Network Benefit AppliesVirtual Visits Deductible, 20% Not Covered

EmergencyServices



HospitalServices



Outpatient Office Visits Deductible, 20% Not CoveredInpatient Facility* Deductible, 20% Not Covered








$0 Not Covered




Specialty

Pharmacy/Medical




mkt 2020 IL GRP DIR SOB HSA 20 1500 HMO 100 RX232 AGG 0120

HSA 20 1500 HMO 100 RX232 AGG Platinum01/01/2020 Member Responsibility












EmergencyServices



HospitalServices











$0 Not Covered




Specialty

Pharmacy/Medical




mkt 2020 IL GRP DIR SOB HSA 20 2800 HMO 80 RX233 EMB 0120

HSA 20 2800 HMO 80 RX233 EMB Platinum01/01/2020 Member Responsibility












EmergencyServices



HospitalServices











$0 Not Covered




Specialty

Pharmacy/Medical

















EmergencyServices



HospitalServices











$0 Not Covered




Specialty

Pharmacy/Medical


POS Plans

• 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 or emergency situations).• Members select a primary care provider (PCP) to coordinate all medical care.• For in-network specialty care, a PCP gives a referral to an in-network specialist. Specialty care received without a referral or from an out-of-network provider is covered at the lower (indemnity) level.• Women can select a Woman’s Principal Healthcare Provider (specializing in obstetrics, gynecology or family practice) in addition to a PCP.



mkt 2020 IL GRP DIR SOB POS 500A 20 RX230 0120

POS 500A 20 RX230 Platinum01/01/2020 Member Responsibility









Annual Vision Exam $40 per exam Not CoveredPrimary Care Physician Office Visit $10 per visit Deductible, 40%

Specialty Care Physician Office Visit $25 per visit Deductible, 40%Acupuncture $10 per visit In Network Benefit Applies

Spinal Manipulations 50% In Network Benefit AppliesUrgent Care $25 per visit Deductible, 40%Virtual Visits first 3 visits $0, then $10 Not Covered

EmergencyServices



HospitalServices

Outpatient Surgery/Procedures* Deductible, 20% Deductible, 40%Inpatient Facility* Deductible, 20% Deductible, 40%


Outpatient Office Visits $10 per visit Deductible, 40%Inpatient Facility* Deductible, 20% Deductible, 40%


Physical Therapy Deductible, 20% Deductible, 40%Occupational Therapy Deductible, 20% Deductible, 40%

Durable Medical Equipment Deductible, 20% Deductible, 40%

Diagnostic Services MRI and CT Scans Deductible, 20% Deductible, 40%Laboratory and X-rays Deductible, 20% Deductible, 40%


Routine Prenatal Care Deductible, 20% Deductible, 40%Inpatient Maternity Facility* Deductible, 20% Deductible, 40%Inpatient Newborn Facility* Deductible, 20% Deductible, 40%


$0 Deductible, 40%


Preferred Generic – Tier 1 $0 Deductible, 50%Non-Preferred Generic – Tier 2 $7 Deductible, 50%

Preferred Brand – Tier 3 $35 Deductible, 50%Non-Preferred Brand – Tier 4 $70 Deductible, 50%

Specialty

Pharmacy/Medical

Preferred Specialty – Tier 5 $140 Deductible, 50%Non-Preferred Specialty– Tier 6 50% Deductible, 50%
















EmergencyServices



HospitalServices











$0 Deductible, 40%




Specialty

Pharmacy/Medical

Preferred Specialty – Tier 5 30% Deductible, 50%Non-Preferred Specialty– Tier 6 50% Deductible, 50%
















EmergencyServices



HospitalServices











$0 Deductible, 40%




Specialty

Pharmacy/Medical




mkt 2020 IL GRP DIR SOB POS 1500B 20 RX230 0120

POS 1500B 20 RX230 Platinum01/01/2020 Member Responsibility












EmergencyServices



HospitalServices











$0 Deductible, 40%




Specialty

Pharmacy/Medical

















EmergencyServices



HospitalServices











$0 Deductible, 40%




Specialty

Pharmacy/Medical




mkt 2020 IL GRP DIR SOB POS 1500C 20 RX230 0120

POS 1500C 20 RX230 Platinum01/01/2020 Member Responsibility












EmergencyServices



HospitalServices











$0 Deductible, 40%




Specialty

Pharmacy/Medical

















EmergencyServices



HospitalServices











$0 Deductible, 40%




Specialty

Pharmacy/Medical




mkt 2020 IL GRP DIR SOB POS 8150H 20 RX232 0120

POS 8150H 20 RX232 Platinum01/01/2020 Member Responsibility









Annual Vision Exam Deductible, 0% Not CoveredPrimary Care Physician Office Visit $40 per visit Deductible, 20%


Spinal Manipulations Deductible, 0% In Network Benefit AppliesUrgent Care $80 per visit Deductible, 20%Virtual Visits first 3 visits $0, then $40 Not Covered

EmergencyServices



HospitalServices











$0 Deductible, 20%


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%



mkt 2020 IL GRP DIR SOB HSA 20 1500 POS 80 RX233 AGG 0120

HSA 20 1500 POS 80 RX233 AGG Platinum01/01/2020 Member Responsibility









Annual Vision Exam Deductible, 20% Not CoveredPrimary Care Physician Office Visit Deductible, 20% Deductible, 40%

Specialty Care Physician Office Visit Deductible, 20% Deductible, 40%Acupuncture Deductible, 20% In Network Benefit Applies

Spinal Manipulations Deductible, 50% In Network Benefit AppliesUrgent Care Deductible, 20% Deductible, 40%Virtual Visits Deductible, 20% Not Covered

EmergencyServices



HospitalServices



Outpatient Office Visits Deductible, 20% Deductible, 40%Inpatient Facility* Deductible, 20% Deductible, 40%








$0 Deductible, 40%




Specialty

Pharmacy/Medical




mkt 2020 IL GRP DIR SOB HSA 20 1500 POS 100 RX232 AGG 0120

HSA 20 1500 POS 100 RX232 AGG Platinum01/01/2020 Member Responsibility












EmergencyServices



HospitalServices











$0 Deductible, 20%




Specialty

Pharmacy/Medical




mkt 2020 IL GRP DIR SOB HSA 20 2800 POS 80 RX233 EMB 0120

HSA 20 2800 POS 80 RX233 EMB Platinum01/01/2020 Member Responsibility












EmergencyServices



HospitalServices











$0 Deductible, 40%




Specialty

Pharmacy/Medical

















EmergencyServices



HospitalServices











$0 Deductible, 20%




Specialty

Pharmacy/Medical

















EmergencyServices



HospitalServices











$0 Deductible, 40%




Specialty

Pharmacy/Medical

















EmergencyServices



HospitalServices











$0 Deductible, 20%




Specialty

Pharmacy/Medical


POSC+ Plans

• The POSC, one of our most popular plan designs in the past, has been reworked and brought up to date in the new POSC+ plans.• 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 or emergency situations).• Members select a primary care provider (PCP) to coordinate all medical care.• For in-network specialty care, a PCP gives a referral to an in-network specialist. Specialty care received without a referral or from an out-of-network provider is covered at the lower (indemnity) level.• Women can select a Woman’s Principal Healthcare Provider (specializing in obstetrics, gynecology or family practice) in addition to a PCP.



mkt 2020 IL GRP DIR SOB POSC+ 250F 20 100 RX230 0120

POSC+ 250F 20 100 RX230 Platinum01/01/2020 Member Responsibility












EmergencyServices



HospitalServices

Outpatient Surgery/Procedures* $500 per procedure Deductible, 20%Inpatient Facility* $500 per stay Deductible, 20%


Outpatient Office Visits $25 per visit Deductible, 20%Inpatient Facility* $500 per stay Deductible, 20%




Diagnostic Services MRI and CT Scans $500 per service Deductible, 20%Laboratory and X-rays Deductible, 0% Deductible, 20%


Routine Prenatal Care Deductible, 0% Deductible, 20%Inpatient Maternity Facility* $500 per stay Deductible, 20%Inpatient Newborn Facility* $500 per stay Deductible, 20%


$0 Deductible, 20%




Specialty

Pharmacy/Medical




mkt 2020 IL GRP DIR SOB POSC+ 250G 20 80 RX231 0120

POSC+ 250G 20 80 RX231 Platinum01/01/2020 Member Responsibility












EmergencyServices



HospitalServices











$0 Deductible, 40%




Specialty

Pharmacy/Medical

















EmergencyServices



HospitalServices











$0 Deductible, 40%




Specialty

Pharmacy/Medical

















EmergencyServices



HospitalServices











$0 Deductible, 20%




Specialty

Pharmacy/Medical

















EmergencyServices



HospitalServices











$0 Deductible, 40%




Specialty

Pharmacy/Medical

















EmergencyServices



HospitalServices











$0 Deductible, 20%




Specialty

Pharmacy/Medical




mkt 2020 IL GRP DIR SOB POSC+ 1000D 20 80 RX230 0120

POSC+ 1000D 20 80 RX230 Platinum01/01/2020 Member Responsibility












EmergencyServices



HospitalServices

Outpatient Surgery/Procedures* $1,000 per procedure Deductible, 40%Inpatient Facility* $1,000 per stay Deductible, 40%


Outpatient Office Visits $10 per visit Deductible, 40%Inpatient Facility* $1,000 per stay Deductible, 40%






Routine Prenatal Care Deductible, 20% Deductible, 40%Inpatient Maternity Facility* $1,000 per stay Deductible, 40%Inpatient Newborn Facility* $1,000 per stay Deductible, 40%


$0 Deductible, 40%




Specialty

Pharmacy/Medical




mkt 2020 IL GRP DIR SOB POSC+ 1000D 20 100 RX230 0120

POSC+ 1000D 20 100 RX230 Platinum01/01/2020 Member Responsibility












EmergencyServices



HospitalServices











$0 Deductible, 20%




Specialty

Pharmacy/Medical




mkt 2020 IL GRP DIR SOB POSC+ 1000E 20 80 RX231 0120

POSC+ 1000E 20 80 RX231 Platinum01/01/2020 Member Responsibility












EmergencyServices



HospitalServices











$0 Deductible, 40%




Specialty

Pharmacy/Medical




mkt 2020 IL GRP DIR SOB POSC+ 1000E 20 100 RX231 0120

POSC+ 1000E 20 100 RX231 Platinum01/01/2020 Member Responsibility












EmergencyServices



HospitalServices











$0 Deductible, 20%




Specialty

Pharmacy/Medical


PPO Plans

• 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 provider (PCP) to coordinate care.• Health Alliance does not require PPO members to get a referral for specialty care, although some provider practices may require it.



mkt 2020 IL GRP DIR SOB PPO 500A 20 RX230 0120

PPO 500A 20 RX230 Platinum01/01/2020 Member Responsibility









Annual Vision Exam $40 per exam Deductible, 40%Primary Care Physician Office Visit $10 per visit Deductible, 40%



EmergencyServices



HospitalServices











$0 Deductible, 40%




Specialty

Pharmacy/Medical

















EmergencyServices



HospitalServices











$0 Deductible, 40%




Specialty

Pharmacy/Medical




mkt 2020 IL GRP DIR SOB PPO 1500B 20 RX230 0120

PPO 1500B 20 RX230 Platinum01/01/2020 Member Responsibility












EmergencyServices



HospitalServices











$0 Deductible, 40%




Specialty

Pharmacy/Medical

















EmergencyServices



HospitalServices











$0 Deductible, 40%




Specialty

Pharmacy/Medical




mkt 2020 IL GRP DIR SOB PPO 1500C 20 RX230 0120

PPO 1500C 20 RX230 Platinum01/01/2020 Member Responsibility












EmergencyServices



HospitalServices











$0 Deductible, 40%




Specialty

Pharmacy/Medical

















EmergencyServices



HospitalServices











$0 Deductible, 40%




Specialty

Pharmacy/Medical




mkt 2020 IL GRP DIR SOB PPO 8150H 20 RX232 0120

PPO 8150H 20 RX232 Platinum01/01/2020 Member Responsibility









Annual Vision Exam Deductible, 0% Deductible, 20%Primary Care Physician Office Visit $40 per visit Deductible, 20%


Spinal Manipulations Deductible, 0% In Network Benefit AppliesUrgent Care $80 per visit Deductible, 20%Virtual Visits first 3 visits $0, then $40 Not Covered

EmergencyServices



HospitalServices











$0 Deductible, 20%




Specialty

Pharmacy/Medical




mkt 2020 IL GRP DIR SOB HSA 20 1500 PPO 80 RX233 AGG 0120

HSA 20 1500 PPO 80 RX233 AGG Platinum01/01/2020 Member Responsibility









Annual Vision Exam Deductible, 20% Deductible, 40%Primary Care Physician Office Visit Deductible, 20% Deductible, 40%



EmergencyServices



HospitalServices











$0 Deductible, 40%




Specialty

Pharmacy/Medical




mkt 2020 IL GRP DIR SOB HSA 20 1500 PPO 100 RX232 AGG 0120

HSA 20 1500 PPO 100 RX232 AGG Platinum01/01/2020 Member Responsibility












EmergencyServices



HospitalServices











$0 Deductible, 20%




Specialty

Pharmacy/Medical




mkt 2020 IL GRP DIR SOB HSA 20 2800 PPO 80 RX233 EMB 0120

HSA 20 2800 PPO 80 RX233 EMB Platinum01/01/2020 Member Responsibility












EmergencyServices



HospitalServices











$0 Deductible, 40%




Specialty

Pharmacy/Medical

















EmergencyServices



HospitalServices











$0 Deductible, 20%




Specialty

Pharmacy/Medical

















EmergencyServices



HospitalServices











$0 Deductible, 40%




Specialty

Pharmacy/Medical

















EmergencyServices



HospitalServices











$0 Deductible, 20%




Specialty

Pharmacy/Medical


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).

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