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Health Alliance Illinois Privacy Notice 
Health Alliance HMO Privacy Notice |
| Outpatient Care |
Copayment (Your Cost) |
Physician Office Visits
Includes periodic physicals, routine office visits,
immunizations and inoculations and pediatric care. Copayments apply to office
visits with physicians, physician assistants, nurses and other mid-level
providers.
|
$15 per visit |
| Routine Prenatal Care |
$50 per pregnancy |
| Outpatient Surgery/Procedure |
$150 per visit |
Diagnostic Testing
X-rays, lab services
|
$0 each |
Mental Health Care
up to 20 visits per plan year
|
$20 per visit |
Substance Abuse Treatment
up to 20 visits per plan year
|
$20 per visit |
Home Health Care
when prescribed by a Health Alliance physician and authorized by the Health
Alliance Medical Management Department
|
$15 per visit |
Rehabilitation Services
up to 60 visits combined per condition per plan year-includes short-term
occupational, speech and physical therapy services.
|
$0 per visit |
| Emergency Care |
Copayment (Your Cost) |
| Emergency Room |
lower of 50% or $200 per visit |
| Physician Care |
$0 per visit |
Ambulance
when medically necessary
|
$0 per trip |
| Inpatient Care |
Copayment (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)
|
$250 per admission |
| Maternity Care |
$250 per admission |
Mental Health Care
up to 30 days per plan year
|
$250 per admission |
Substance Abuse Treatment
up to 20 days per plan year
|
$250 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 (Your Cost) |
Prescription Drugs†*
per 30-day supply
|
| $10 |
Tier 1 |
| $20 |
Tier 2** |
| $40 |
Tier 3 |
|
| Durable Medical Equipment† |
20% |
| Prosthetic Devices |
$0 |
| Contract Year Out-of-Pocket Maximum |
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| Your Maximum Cost |
$3,000 per individual,
$6,000 per family |
† Copayment, coinsurance and deductible payments
for these services do not apply to the plan year out-of-pocket maximum.
* Health Alliance HMO
members only.
**
If generic is available, you pay the $10 Tier 1 copayment plus the difference
between the retail cost of the Tier 2 drug and the Tier 1 drug.
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