Member Benefits In-Network Out-of-NetworkPlan Year Deductible
Plan Year Out-of-Pocket Maximum
Ambulatory Patient Services
Emergency Services
Hospitalization
Mental Health/Substance Abuse
Prescription Drugs
Rehabilitative and Habilitative Services
Diagnostic Services
Maternity
Pediatric Services
Combined medical and pharmacy expenses including deductible, coinsurance amounts and copays.
Offered to children up to age 19
Pediatric Dental Examx Pediatric Vision Exam
Pediatric Vision Materials
Outpatient Office Visits Outpatient Facility Visits
Inpatient Facility*
Outpatient Surgery/Procedures
Spinal ManipulationsUrgent Care Visits
Immunizations, adult and child annual physical exams, mammograms, PAP smears, cancer screenings and more. Age/frequency schedules apply.
Physical Therapy
Preventive & Wellness Services
Labratory and X-raysMRI and CT Scans
Routine Prenatal CareInpatient Maternity Facility*Inpatient Newborn Facility*
Inpatient Facility*
Occupational TherapyDurable Medical Equipment
Member Responsibility
Annual Vision ExamPrimary Care Physician Office Visits
Specialty Care Physician Office Visits
Emergency Department VisitsEmergency Ambulance Transportation
HMO 3000b Elite Network Silver SilverProduct Effective Date: 1/1/2016
Single: $ 3,000 Not ApplicableEmbedded Deductible Family: $ 6,000 Not Applicable
Single: $ 6,850 Not ApplicableFamily: $ 13,700 Not Applicable
$20 Not Covered$40 Not Covered$80 Not Covered$80 Not Covered$80 $80
deductible, 30% in-net deductible, 30%deductible, 30% in-net deductible, 30%
deductible, 30% Not Covereddeductible, 30% Not Covered
$40 Not Covereddeductible, 30% Not Covereddeductible, 30% Not Covered
RetailRxtra $0 Not Covered
Preferred Formulary/Generic - Tier 1 $10 Not CoveredPreferred Formulary/Brand - Tier 2 $40 Not Covered
Non-Preferred Formulary/Brand - Tier 3 $80 Not CoveredSpecialty
Preferred Formulary Specialty Pharmacy/Medical - Tier 4 $200 Not CoveredNon-Preferred Formulary Specialty Pharmacy/Medical - Tier 5 $300 Not Covered
Non-Formulary Specialty Pharmacy/Medical - Tier 6 50% Not Covered
deductible, 30% Not Covereddeductible, 30% Not Covereddeductible, 30% Not Covered
deductible, 30% Not Covereddeductible, 30% Not Covereddeductible, 30% Not Covered
Inpatient newborn covered on mother's policy up to 96 hours
deductible, 30% Not Covereddeductible, 30% Not Covered
$0 Not Covered$0 Not Covered$0 Not Covered
$0 Not Covered
*Facility coverage only; physician fees may apply.
An embedded deductible means two or more members have a separate individual deductible within the family deductible. This gives each member a chance to start receiving their benefits before the entire family meets the family deductible.
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.
mkt_1-2016_IL_IND_PUB_SOB_HMO_3000b_EliteNetwork_Silver_0315
