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) |
$0 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 |
$200 per admission |
Mental Health Care
(up to 30 days per plan year) |
$200 per admission |
Substance Abuse Treatment
(up to 20 days per plan year) |
$200 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 |
Copayment (Your Cost) |
|
$3,000 per individual,
$6,000 per family |
† Copayment and coinsurance 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.
|
