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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)
$10Tier 1
$20Tier 2**
$40Tier 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.
 


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All contents © 2007 Health Alliance Medical Plans. All rights reserved. Every effort has been made to ensure that this information is accurate. It is not intended to replace the legal source. In case of any discrepancy between this information and the legal source, the legal source will govern in all cases.

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