|
PCY = per calendar year |
|
Plan Name |
Balance 1000 |
Balance 1500 |
Balance 2500 |
Balance 5000 |
|
Name of Network |
Alliant Plus
In-Network and Out-of Network Providers |
Annual Deductible
Per individual PCY;
the maximum deductible
per family equals 3 times
the individual amount
the deductible applies to all expenses unless otherwise specified |
$1,000 |
$1,500 |
$2,500 |
$5,000 |
Annual Coinsurance Maximum
Per
individual PCY;
the maximum coinsurance per family
equals 3 times the individual
amount; once the coinsurance maximum is met, services are covered
in full |
$4,000 |
$6,000 |
$8,000 |
$10,000 |
Out-of-Pocket Limit
Per
individual PCY;
includes annual
deductible and coinsurance maximum; the maximum out-of-pocket per
family equals 3 times the individual amount; once the out-of-pocket
limit is
met, services are covered in full |
$5,000 |
$6,500 |
$10,500 |
$15,000 |
|
Lifetime Maximum |
$2 million per individual |
|
Office Visits |
100% paid after $30 copay per visit
In-Network
No deductible
Out-of-Network
Paid after deductible satisfied |
Preventive Care
No
deductible
For children and
adults, including physicals and immunizations, as established in Group
Health's preventive care schedule |
100% paid after $30 copay
per visit
In-Network
no maximum benefit
Out-of-Network
$300 per person/$600 per family maximum benefit PCY |
Manipulative Therapy
10 visits limit PCY |
Paid same as "Office
Visits" |
Acupuncture
In-Network: 8 visits limit PCY
Out-of-Network: no limit |
Paid same as "Office
Visits" |
Naturopathy
In-Network: 3 visits limit PCY
Out-of-Network: no limit |
Paid same as "Office
Visits" |
Maternity Care - Outpatient
Prenatal and
postpartum visits |
Paid
same as "Office Visits" |
Not
covered |
Mental Health Services -
Outpatient
- 12 visits limit PCY |
Paid same as "Office
Visits" |
|
 |
|
PCY = per calendar year |
|
Plan Name |
Balance 1000 |
Balance 1500 |
Balance 2500 |
Balance 5000 |
|
Name of Network |
Alliant Plus
In-Network and Out-of Network Providers |
Lab & X-Ray Services
Outpatient services |
100% paid
In-Network
No deductible
Out-of-Network
Paid after deductible satisfied |
Rehabilitation Services - Outpatient
Outpatient physical,
occupational, and restorative speech-therapy services combined; 60
visits limit PCY |
80% |
70% |
60% |
50% |
Hospital Care - Inpatient
Hospital
room and board; inpatient surgery; anesthesia; intensive and coronary
care; laboratory tests; radiology services; drugs while in hospital |
80% |
70% |
60% |
50% |
Maternity Care - Inpatient
Delivery & associated hospital care |
80% |
70% |
Not
covered |
Mental Health Services -
Inpatient
- 12 days limit PCY |
80% |
70% |
60% |
50% |
Rehabilitation Services - Inpatient
Inpatient
physical, occupational, and restorative speech-therapy services
combined; 30 days limit PCY |
80% |
70% |
60% |
50% |
Prescription Drugs - Outpatient
No deductible
Drugs and medicines that
require a prescription, including injectables,
contraceptive drugs, devices and supplies. Mental health drugs are
excluded from coverage.
Up to 30 day supply per copay |
You pay the
copay shown below
$10 generic in-network
$15 generic out-of-network
30% brand-name
50% non-formulary
$3,000 annual benefit maximum
Mail order (in-network only):
$5 discount
for
30 day supply |
Not covered |
Ambulance Services
Emergency ground/air transportation |
80% |
70% |
60% |
50% |
Ambulance Services
Non-emergency ground/air
interfacility transfer |
In-Network
80% for Group
Health-initiated transfers, except
hospital-to-hospital transfers
covered in full
Out-of-Network
80% |
In-Network
70%
for Group Health-initiated transfers, except
hospital-to-hospital
transfers covered in full
Out-of-Network
70% |
In-Network
60% for Group
Health-initiated transfers, except
hospital-to-hospital transfers
covered in full
Out-of-Network
60% |
In-Network
50% for Group
Health-initiated transfers,
except
hospital-to-hospital transfers covered in full
Out-of-Network
50% |
|
|
|
PCY = per calendar year |
|
Plan Name |
Balance 1000 |
Balance 1500 |
Balance 2500 |
Balance 5000 |
|
Name of Network |
Alliant Plus
In-Network and Out-of Network Providers |
Chemical Dependency Treatment - Inpatient
Limited to
acute detoxification only |
80% |
70% |
60% |
50% |
Chemical Dependency Treatment - Outpatient
Limited to
diagnostic evaluation only |
80% |
70% |
60% |
50% |
Devices, Equipment & Supplies
(for home use)
Durable medical equipment,
orthopedic appliances, ostomy supplies, prosthetic devices, etc. |
50%
Maximum benefit is $2,500 PCY for all except
ostomy supplies and prosthetics;
maximum benefit PCY for ostomy supplies/prosthetics is $20,000 |
Emergency Care
In-Network
$100 copay per incident |
80% |
70% |
60% |
50% |
Emergency Care
Out-of-Network
$150 copay per incident |
80% |
70% |
60% |
50% |
Hearing Exams
(routine)
To
determine hearing loss |
Paid same as "Office
Visits" |
Home Health Care
No visit limit |
80% |
70% |
60% |
50% |
|
Hospice |
100% |
Organ Transplant
Six month benefit waiting
period |
Covered subject to
your applicable cost share up to $250,000
lifetime maximum (including
organ acquisition, matching, and donor costs
up to $50,000) |
|
|
|
PCY = per calendar year |
|
Plan Name |
Balance 1000 |
Balance 1500 |
Balance 2500 |
Balance 5000 |
|
Name of Network |
Alliant Plus
In-Network and Out-of Network Providers |
Skilled Nursing Facility Care
60 days limit PCY |
80% |
70% |
60% |
50% |
Tobacco Cessation Sessions
Individual/group sessions |
In-network only:
100%
No deductible |
Tobacco Cessation Pharmacy
Approved
pharmacy products |
In-network only:
100% when prescribed as part of a Group Health-designated tobacco
cessation program and dispensed through the Group Health mail order
service |
Vision Care - Eye Exam
No deductible
Routine exam limited to
one visit
every
12 months |
In-Network
100% after $30 copay
Out-of-Network
100% up to $30 reimbursement |
Vision Care - Hardware
No deductible |
100% to $200
maximum benefit
every 12 months |
|
Work-Related Conditions |
Covered as for any
other condition (limited to partners, proprietors or corporate
officers who are not covered by a Workers' Compensation Act or other
similar law) |
|
Pre-Existing Conditions |
A pre-existing
condition is one for which there has been
diagnosis, treatment (including the use of prescribed drugs), or
medical advice within the six month period prior to the effective date
of coverage or a condition for which symptoms existed within the six
month period prior to the date of coverage and for which a prudent
person would have ordinarily sought treatment.
Pre-existing
conditions will not be
covered until a member has been continuously enrolled under this plan
for 9 (nine) months. In some cases, Group Health will apply credit for
pre-existing conditions if the person enrolling has been covered by a
prior group or individual health benefit plan that is considered
"creditable" coverage (i.e., a plan that had benefits as good or
better than this plan), at any time during the 63 (sixty-three) day
period immediately preceding the receipt date of the application. |
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