Sponsored and administered by: The National Alliance of Postal and
Federal Employees.
Who may enroll in this Plan: All eligible civilian
employees and annuitants who become members or associate members of the
National Alliance of Postal and Federal Employees (NAPFE).
To become
a member or associate member: At installations and subdivisions where there
is a NAPFE local, you may join as a regular or associate member. If there is no
local, or you
are an annuitant, you will automatically become an associate
member of the NAPFE.
Annuitants (retirees) may enroll in this plan.
Membership dues: $5.00 per month. Members will have the option of
paying dues on an annual or semi-annual basis. Dues paid on an annual basis on
or before March first of the
plan year will receive a 10% discount. NAPFE
will bill new associate members for annual dues when it receives notice of
enrollment. NAPFE will also bill continuing associate
members for the annual
membership.
Enrollment codes for this Plan:
1R1 Self Only 1R2 Self
and Family
RI 71-003
Alliance Health Benefit Plan 2001
http:// www.
ahbp. com
A fee-for-service plan with a preferred provider
organization
Forchangesin
benefits, see page 6. 1
1
Page 2 3
Introduction
........................................................................................................................................................................
4
Plain Language
...................................................................................................................................................................
4
Section 1. Facts about this fee-for-service
plan................................................................................................................
5
Section 2. How we change for 2001
.................................................................................................................................
6
Section 3. How you get care
.............................................................................................................................................
7
Identification cards
..........................................................................................................................................
7
Where you get covered care
............................................................................................................................
7
° Covered providers
..................................................................................................................................
7
° Covered Facilities
...............................................................................................................................
7-8
What you must do to get covered care
............................................................................................................
8
How to get approval for
...................................................................................................................................
9
° Your hospital stay (precertification)
......................................................................................................
9
° Other services
......................................................................................................................................
10
Section 4. Your costs for covered services
.....................................................................................................................
11
° Copayments
.........................................................................................................................................
11
° Deductible
............................................................................................................................................
11
° Coinsurance
.........................................................................................................................................
11
° Differences between our allowance and the
bill
.............................................................................
12-13
Your out-of-pocket maximum
.......................................................................................................................
14
When government facilities bill us
................................................................................................................
15
If we overpay you
..........................................................................................................................................
15
When you are age 65 or over and you do not have
Medicare .......................................................................
16
When you have Medicare
..............................................................................................................................
17
Section 5. Benefits
..........................................................................................................................................................
19
Overview
.......................................................................................................................................................
19
(a) Medical services and supplies provided by
physicians and other health care professionals ................. 20
(b) Surgical and anesthesia services provided by physicians and
other health care professionals .............. 31
(c)
Services provided by a hospital or other facility, and ambulance services
............................................ 38
(d)
Emergency services/ accidents
................................................................................................................
41
(e) Mental health and substance abuse benefits
...........................................................................................
43
(f) Prescription drug benefits
......................................................................................................................
47
(g) Special features
......................................................................................................................................
51
(h) Dental benefits
.......................................................................................................................................
52
(i) Non-FEHB benefits available to Plan members
.....................................................................................
54
Table of Contents
2001 Alliance Health Benefit Plan 2 Table of Contents 2
2 Page 3 4
Section 6. General exclusions Ñ things we don't
cover
............................................................................................
55
Section 7. Filing a claim for covered services
............................................................................................................
56
Section 8. The disputed claims process
.......................................................................................................................
58
Section 9. Coordinating benefits with other
coverage
................................................................................................
60
When you have other health coverage
.......................................................................................................
60
Original Medicare
.......................................................................................................................................
60
Medicare managed care plan
......................................................................................................................
63
TRICARE/ Workers Compensation/ Medicaid
......................................................................................
63-64
When other Government agencies are responsible
for your care ............................................................. 64
When others are responsible for injuries
...................................................................................................
64
Section 10. Definitions of terms we use in this
brochure
............................................................................................
65
Section 11. FEHB facts
.................................................................................................................................................
70
Coverage information
.................................................................................................................................
70
° No pre-existing condition limitation
................................................................................................
70
° Where you get information about enrolling in
the FEHB Program ............................................... 70
° Types of coverage available for you and your family
.................................................................... 70
° When benefits and premiums start
...................................................................................................
71
° Your medical and claims records are
confidential
............................................................................ 71
° When you retire
..................................................................................................................................
71
When you lose benefits
..............................................................................................................................
71
° When FEHB coverage ends
.......................................................................................................
71-72
° Spouse equity coverage
....................................................................................................................
72
° Temporary Continuation of Coverage (TCC)
..................................................................................
72
° Converting to individual coverage
...................................................................................................
72
° Getting a Certificate of Group Health Plan
Coverage .................................................................... 73
Inspector General Advisory
........................................................................................................................
73
Department of Defense/ FEHB Program Demonstration
Project
..................................................................................
74
INDEX............................................................................................................................................................................
77
Summary of High Option benefits
..........................................................................................................................
78-79
Rates
................................................................................................................................................................
Back cover
2001 Alliance Health Benefit Plan 3 Table of Contents 3
3 Page 4 5
2001 Alliance Health Benefit Plan 4 Introduction/ Plain Language
Introduction
The Alliance Health Benefit Plan 1628 11 th
Street NW
Washington, DC 20001
This brochure describes the benefits of
Alliance Health Benefit Plan under our contract CS 1164 with the Office of
Personnel Management (OPM), as authorized by the Federal Employees Health
Benefits law. This brochure is the
official statement of benefits. No oral
statement can modify or otherwise affect the benefits, limitations, and
exclusions of this brochure.
If you are enrolled in this Plan, you are entitled to the benefits described
in this brochure. If you are enrolled for Self and Family coverage, each
eligible family member is also entitled to these benefits. You do not have a
right to
benefits that were available before January 1, 2001, unless those
benefits are also shown in this brochure.
OPM negotiates benefits and rates
with each plan annually. Benefit changes are effective January 1, 2001, and are
summarized on page 6. Rates are shown at the end of
this brochure.
Plain Language
The President and Vice President are making
Governments's communication more responsive, accessible, and understandable to
the public by requiring agencies to use plain language. In response, a team of
health plan
representatives and OPM staff worked cooperatively to make this
brochure clearer. Except for necessary technical terms, we use common words.
"You" means the enrollee or family member, "we" means the
Alliance Health Benefit
Plan.
The plain language team reorganized the
brochure and the way we describe our benefits. When you compare this Plan with
other FEHB plans, you will find that the brochures have the same format and
similar information to make
comparisons easier.
If you have comments or
suggestions about how to improve this brochure, let us know. Visit OPM's
"Rate Us" feedback area at www. opm. gov/
insure or e-mail us at fehbwebcomments@ opm. gov or write to OPM at
Insurance
Planning and Evaluation Division, P. O. Box 436, Washington,
DC 20044-0436. 4
4 Page
5 6
2001 Alliance Health Benefit Plan 5 Section 1
Section 1.
Facts about this fee-for-service plan
This Plan is a fee-for-service
(FFS) plan. You can choose your own physicians, hospitals, and other health care
providers.
We reimburse you or your provider for your covered services, usually based on
a percentage of the amount we allow. The type and extent of covered services,
and the amount we allow, may be different from other plans. Read
brochures
carefully.
We also have Preferred Provider Organizations (PPO):
Our
fee-for-service plan offers services through a PPO. When you use our PPO
providers, you will receive covered services at reduced cost. Contact us for the
names of PPO providers and to verify their
continued participation. You
can also go to our web page, which you can
reach through the FEHB web site, www. opm. gov/ insure. Do not call OPM or
your agency for our provider directory.
PPO benefits apply only when you use a PPO provider. Provider networks may be
more extensive in some areas than others. We cannot guarantee the availability
of every speciality in all areas. If no PPO provider is available, or you
do
not use a PPO provider, the standard non-PPO benefits apply.
How we pay providers
This Plan has entered into an agreement with
First HealthÒ to use The First HealthÒ Network, a
Preferred Provider Organization (PPO). This is a group of doctors, hospitals and
other providers who have contracted with
First HealthÒ to
provide medical services at reduced cost. This PPO operates in 50 states, plus
Puerto Rico and the District of Columbia. Each time you need medical care you
have the choice to use a health care provider who
participates in the
network or one who doesn't.
When you use a PPO hospital, your benefits
increase from 70% after the $250 inpatient deductible to 90% after the $150
inpatient deductible. When you use a PPO doctor, your surgery benefits increase
to 90% after a $100 deductible
and your office visit benefits increase to
paid in full after a $15 copayment. Non-PPO benefits for both are 70% after a
$300 deductible. Precertification is required as explained on pages 9 and 10 for all inpatient hospitalizations. It is
your responsibility to complete this prior notification; however, your PPO
doctor may initiate precertification and will file your claims for you.
Note: PPO benefits are not payable when Alliance Health Benefit Plan is not the
primary
payer.
Patients' Bill of Rights
OPM requires that all FEHB Plans comply
with the Patients' Bill of Rights, recommended by the President's Advisory
Commission on Consumer Protection and Quality in the Health Care Industry. You may get information
about us, our networks, providers, and facilities. OPM's FEHB website (www.
opm. gov/ insure) lists the specific types of information that we must make
available to you. Some of the required information is listed below.
° Network providers must meet specific criteria including location,
medical speciality, professional skill and proper credentials
° Years in
existence ° Profit status
If you want more information about us, call 1/ 800-321-0347, or write to
Alliance Health Benefit Plan, 1628 11 th Street NW, Washington, DC 20001. You
may also contact us by fax at 202-939-6389 or visit our website at
http:// www. ahbp. com. 5
5
Page 6 7
2001 Alliance Health Benefit Plan 6 Section 2
Section 2. How we change for 2001
Program-wide changes
° The plain language team reorganized the brochure and the way we
describe our benefits. We hope this will make it easier for you to compare
plans.
° This year, the Federal Employees Health Benefits Program is
implementing network mental health and substance abuse parity. This means that
your coverage for mental health, substance abuse, medical, surgical, and
hospital
services from providers in our PPO network will be the same with
regard to deductibles, coinsurance, copays, and day and visit limitations when
you follow a treatment plan that we approve. Previously, we placed higher
patient
cost sharing and shorter day or visit limitations on mental health
and substance abuse services than we did on services to treat physical illness,
injury, or disease.
° Many healthcare organizations have turned their attention this past
year to improving healthcare quality and patient safety. OPM asked all FEHB
plans to join them in this effort. You can find specific
information on our
patient safety activities by calling 1/ 800-225-4423, or checking out our website, www. ahbp. com. You can find out more about
patient safety on the OPM website, www. opm. gov/
insure. To improve your healthcare, take these
five
steps:
° Speak up if you have questions or concerns. ° Keep
a list of all the medicines you take.
° Make sure you get the results of
any test or procedure. ° Talk with your doctor and health care team about
your options if you need hospital care.
° Make sure you understand what
will happen if you need surgery.
° We clarified the language to show
that anyone who needs a mastectomy may choose to have the procedure performed on
an inpatient basis and remain in the hospital up to 48 hours after the
procedure. Previously, the
language referenced only women.
° North
Dakota is deleted from the list of states designated as medically underserved in
2001. See page 7 for information on medically underserved
areas.
Changes to this Plan
° Your share of the non-postal premium
will decrease 2% for Self Only or 5% for Self and Family.
° PPO
physician's office visit is increased from $10 per visit to $15 per visit.
° Preventive services for dental benefits are limited to 2 visits per
year.
° For non-PPO Mental Conditions Inpatient Care benefits, members
pay 30% coinsurance.
° For non-PPO Substance Abuse Inpatient Care
benefits, members pay 30% coinsurance.
Clarifications
° Covered providers also include Christian
Science Nurses and Christian Science Practitioners who are listed in the
Christian Science Journal.
° Covered facilities also include Christian Science Nursing Facilities
that are approved by the Commission for the Accreditation of Christian Science
Nursing Organizations/ Facilities, Inc..
° Home health services also
include services provided by a Christian Science Nurse who is listed in the
Christian Science Journal.
° Nursing services also include a Christian
Science Nurse who is listed in the Christian Science Journal. 6
6 Page 7 8
2001 Alliance Health Benefit Plan 7 Section 3
Section 3. How you get care
Identification cards We will send
you an identification (ID) card when you enroll. You should carry your ID card
with you at all times. You must
show it whenever you receive services from a
Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your
ID
card, use your copy of the Health Benefits Election Form, SF-2809, your
health benefits enrollment confirmation (for
annuitants), or your Employee
Express confirmation letter.
If you do not receive your ID card within 30
days after the effective date of your enrollment, or if you need replacement
cards, call us at 1/ 800-225-4423.
Where you get covered care You
can get care from any "covered provider" or "covered
facility." How much we pay Ñ and you payÑ depends on the
type of covered provider or facility you use. If you use our preferred
providers, you will pay less.
° Covered providers We consider the following to be covered
providers when they perform services within the scope of their license or
certification:
(1) a licensed doctor of medicine (M. D.), or a licensed
doctor of osteopathy (D. O.), and a licensed podiatrist practicing within the
scope of their license.
(2) other covered providers include: a
Chiropractor, Dentist, Optometrist, Clinical Psychologist, Clinical Social
Worker,
Nurse Midwife, Nurse Practitioner/ Clinical Specialist, Nurse
Anesthetist or Nursing School Administered Clinic. Charges for
Christian
Science Nurses and Christian Science Practitioners who are listed in the
Christian Science Journal will be covered
under this Plan the same as other
medical providers.
Medically underserved areas. Note: In medically
underserved areas, we cover any licensed medical practitioner for any
covered service performed within the scope of that license in states OPM
determines are "medically underserved." For 2001,
the states are:
Alabama, Idaho, Kentucky, Louisiana, Mississippi, Missouri, New Mexico, South
Carolina, South
Dakota, Utah, and Wyoming.
° Covered facilities
Covered facilities include:
° Birthing Center: A free
standing facility licensed or certified by the State in which it functions, or
Plan approved, which
offers comprehensive maternity care in a home-like
atmosphere.
° Hospice: A facility which provides short periods of stay for a
terminally ill person in a home-like setting for either direct
care or
respite. This facility may either be free-standing or affiliated with a
hospital. It must operate as an integral part
of the hospice care program. 7
7 Page 8 9
2001 Alliance Health Benefit Plan 8 Section 3
° Hospital: An institution licensed by the State or
conforming to the standards of, and accredited by, the
Joint Commission on
Accreditation of Health Care Organizations (JCAHO) providing inpatient
diagnostic and
therapeutic facilities for surgical and medical diagnosis,
treatment and care of injured and sick persons by or under
the supervision
of a staff of licensed doctors of medicine (M. D.), or licensed doctors of
osteopathy (D. O.). The
hospital must provide continuous 24-hour-a-day
professional registered nursing (R. N.) services and may
not be an Extended
Care Facility (other than an approved ECF); nursing home; a place for rest; an
institution for
exceptional children, the aged, drug addicts, or alcoholics;
or a custodial or domiciliary institution having the primary
purpose of
furnishing food, shelter, training, or non-medical personal services. This
definition includes college
infirmaries and Veterans Administration
Hospitals. This includes also Christian Science Nursing facilities that are
approved by the Commission for the Accreditation of Christian Science
Nursing Organizations/ Facilities, Inc.
What you must do to get covered care It depends on the kind of care
you want to receive. You can go to any physician you want, but we must approve
some
care in advance.
Transitional care: Speciality care: If you
have a chronic or disabling condition and lose access to your specialist because
we:
° terminate our contract with your specialist for other than cause; or
° drop out of the Federal Employees Health Benefits (FEHB) Program and
you enroll in another FEHB Plan.
you may be able to continue seeing your
specialist for up to 90 days after you receive notice of the change. Contact us
or,
if we drop out of the Program, contact your new plan.
If you are in
the second or third trimester of pregnancy and you lose access to your
specialist based on the above
circumstances, you can continue to see your
specialist until the end of your postpartum care, even if it is beyond the 90
days.
Hospital care. We pay for covered services from the effective date of
your enrollment. However, if you are in the
hospital when your enrollment in
our Plan begins, call our customer service department immediately at 1/
800-321-0347. 8
8 Page
9 10
2001 Alliance Health Benefit Plan
9 Section 3
If you changed from another FEHB plan to us, your
former plan will pay for the hospital stay until:
° You are discharged,
not merely moved to an alternative care center; or
° The day your
benefits from your former plan run out; or
° The 92 nd day after you
become a member of this Plan, whichever happens first.
These provisions apply only to benefits of the hospitalized person.
How to Get Approval for...
° Your hospital stay Precertification
is the process by which Ñ prior to your inpatient hospital admission
Ñ we evaluate the medical
necessity of your proposed stay and the
number of days required to treat your condition. Unless we are misled by the
information
given to us, we won't change our decision on medical necessity.
In most cases, your physician or hospital will take care of
precertification. Because you are still responsible for ensuring
that we are
asked to precertify your care, you should always ask your physician or hospital
whether they have contacted us.
Warning: We will reduce our benefits for the inpatient hospital stay
by $500 if no one contacts us for precertification. If the stay is not
medically necessary, we will not pay any benefits.
How to precertify
an admission: ° You, your representative, your doctor, or your hospital
must call us at 1/ 800-225-4423 at least 48 hours before admission.
° If you have an emergency due to a condition that you reasonably believe
puts your life in danger or could cause
serious damage to bodily function,
you, your representative, the doctor, or the hospital must telephone us within
two
business days following the day of the emergency admission, even if you
have been discharged from the hospital.
° Provide the following information:
° Enrollee's name and Plan
identification number;
° Patient's name, birth date, and phone number;
° Reason for hospitalization, proposed treatment, or surgery;
°
Name and phone number of admitting doctor;
° Name of hospital or
facility; and
° Number of planned days of confinement.
° We will
then tell the doctor and/ or hospital the number of approved inpatient days and
we will send written
confirmation of our decision to you, your doctor, and
the hospital. 9
9 Page
10 11
2001 Alliance Health Benefit
Plan 10 Section 3
Maternity care You do not need to
precertify a maternity admission for a routine delivery. However, if your
medical condition requires
you to stay more than 48 hours after a vaginal
delivery or 96 hours after a cesarean section, then your physician or the
hospital must contact us for precertification of additional days. Further,
if your baby stays after you are discharged, then your
physician or the
hospital must contact us for precertification of additional days for your baby.
If your hospital stay If your hospital stay Ñ including for
maternity care Ñ needs to be extended: needs to be extended, your
doctor or the hospital must ask us to
approve the additional days.
What happens when you ° When we precertified the admission but
you remained do not follow the in the hospital beyond the number of days
we approved
precertification rules and did not get the additional
days precertified, then:
°° for the part of the admission that was
medically necessary, we will pay inpatient benefits, but
°° for the part of the admission that was not medically necessary, we
will pay only medical services and supplies
otherwise payable on an
outpatient basis and will not pay inpatient benefits.
° If no one contacted us, we will decide whether the hospital stay was
medically necessary.
°° If we determine that the stay was medically
necessary, we will pay the inpatient charges, less the $500 penalty.
°° If we determine that it was not medically necessary for you to be
an inpatient, we will not pay inpatient hospital
benefits. We will only pay
for any covered medical supplies and services that are otherwise payable on an
outpatient basis.
° If we denied the precertification request, we
will not pay inpatient hospital benefits. We will only pay for any covered
medical supplies and services that are otherwise payable on an outpatient
basis.
Exceptions: You do not need precertification in these cases:
°
You are admitted to a hospital outside the United States or Puerto Rico.
° You have another group health insurance policy that is the primary
payer for the hospital stay.
° Your Medicare part A is the primary payer
for the hospital stay. Note: If you exhaust your Medicare hospital benefits
and do not want to use your Medicare lifetime reserve days, then we will
become the primary payer and you do need
precertification.
° Other services Some services require a referral,
precertification, or prior authorization.
° Right-sided heart
catheterization. 10
10 Page
11 12
Section 4. Your costs for
covered services
This is what you will pay out-of-pocket for your
covered care:
° Copayments A copayment is a fixed amount of money
you pay to the provider when you receive services.
Example: When you see your PPO physician you pay a copayment of $15 per
visit.
° Deductible A deductible is a fixed amount of covered expenses
you must incur for certain covered services and supplies before we start
paying benefits for them. Copayments do not count toward any deductible.
° The calendar year deductible is $100 per person for PPO benefits and
$300 per person for Non-PPO benefits. Under a
family enrollment, the
deductible is satisfied for all family members when the combined covered
expenses applied to the
calendar year deductible for family members reach
$300 for PPO benefits and $900 for Non-PPO benefits.
° We also have separate deductibles for:
° There is a combined
annual $200 deductible per person for mail order and/ or retail prescription
drugs.
° There is a Non-PPO $500 deductible per person, per confinement for
inpatient care for mental conditions.
Note: If you change plans during open
season, you do not have to start a new deductible under your old plan between
January 1
and the effective date of your new plan. If you change plans at
another time during the year, you must begin a new deductible
under your new
plan.
° Coinsurance Coinsurance is the percentage of our allowance that
you must pay for your care. Coinsurance doesn't begin until you meet
your
deductible.
Example: You pay 10% of our allowance for office visits.
° 10% for PPO inpatient hospital room/ board, and other hospital
charges;
° 30% for non-PPO inpatient hospital room/ board, and other hospital
charges;
2001 Alliance Health Benefit Plan 11 Section 4 11
11 Page 12 13
2001 Alliance Health Benefit Plan 12 Section
4
° 10% for PPO inpatient and outpatient surgical benefits,
maternity benefits, and other medical benefits;
° 30% for non-PPO
inpatient and outpatient surgical benefits, maternity benefits, and other
medical benefits;
° 10% for PPO inpatient treatment of mental
conditions;
° 30% for non-PPO inpatient treatment of mental conditions;
° 10% for PPO doctors' visits for (inpatient) mental conditions;
° 50% for non-PPO doctors' visits (inpatient and outpatient) for mental
conditions;
° 10% for PPO inpatient treatment of substance abuse;
° 30% for
non-PPO inpatient treatment of substance abuse;
° 50% for non-PPO
outpatient treatment of substance abuse;
° 20% for skilled nursing
facility
Note: If your provider routinely waives (does not require you to
pay) your copayments, deductibles, or coinsurance, the provider
is
misstating the fee and may be violating the law. In this case, when we calculate
our share, we will reduce the provider's fee
by the amount waived.
For
example, if your physician ordinarily charges $100 for a service but routinely
waives your 30% coinsurance, the actual
charge is $70. We will pay $49 (70%
of the actual charge of $70).
° Differences between Our "Plan allowance" is the amount
we use to calculate our our allowance and payment for covered services.
Fee-for-service plans arrive at
the bill their allowances in
different ways, so their allowances vary. For more information about how we
determine our Plan allowance,
see the definition of Plan allowance in
Section 10.
Often, the provider's bill is more than a fee-for-service plan's allowance.
Whether or not you have to pay the difference
between our allowance and the
bill will depend on the provider you use. 12
12
Page 13 14
° PPO providers agree to limit what they will bill you. Because
of that, when you use a preferred provider, your
share of covered charges
consists only of your deductible and coinsurance. Here is an example: You see a
PPO physician
who charges $150, but our allowance is $100. If you have met
your deductible, you are only responsible for your
coinsurance. That is, you
just pay Ñ 10% of our $100 allowance ($ 10). Because of the agreement,
your PPO
physician will not bill you for the $50 difference between our
allowance and his bill.
° Non-PPO providers, on the other hand, have no agreement to limit
what they will bill you. When you use a non-PPO
provider, you will pay your
deductible and coinsurance Ñ plus any difference between our
allowance and charges on
the bill. Here is an example: You see a non-PPO
physician who charges $150 and our allowance is again $100. Because
you've
met your deductible, you are responsible for your coinsurance, so you pay 30% of
the $100 allowance ($ 30).
Plus, because there is no agreement between the
non-PPO physician and us, he can bill you for the $50 difference
between our
allowance and his bill.
The following table illustrates the examples of how much you have to pay
out-of-pocket for services from a PPO physician vs.
a non-PPO physician. The
table uses our example of a service for which the physician charges $150 and our
allowance is
$100. The table shows the amount you pay if you have met your
calendar year deductible.
EXAMPLE PPO physician Non-PPO physician
Physician's charge $150
$150
Our allowance We set it at: 100 We set it at: 100
We pay 90% of our
allowance: 90 70% of our allowance: 70
You owe: Coinsurance 10% of our
allowance: 10 30% of our allowance: 30
+Difference up to charge? No: 0 Yes: 50
TOTAL YOU PAY $10 $80
2001 Alliance Health Benefit Plan 13 Section 4 13
13 Page 14 15
2001 Alliance Health Benefit Plan 14 Section 4
Your
out-of-pocket maximum For those services with coinsurance, the Plan pays
100% of the for deductibles, coinsurance, plan allowance for the
remainder of the calendar year after the
and copayments calendar year
deductible is met when out-of-pocket expenses for coinsurance in that calendar
year exceed $2,000 under the PPO
benefit. The Plan pays 100% of the plan
allowance, if out-of-pocket expenses for the coinsurance in that calendar year
exceed
$3,000 under the non-PPO benefit. Any expenses incurred through PPO or
non-PPO benefits are applied toward both
catastrophic limits.
Out-of-pocket expenses for the purposes of this benefit are:
° The
$100 calendar year deductible for PPO benefits;
° The $300 calendar year
deductible for non-PPO benefits;
° The $150 PPO per admission inpatient
hospital copayment;
° The $250 non-PPO per admission inpatient hospital copayment;
°
The 10% you pay for PPO hospital, surgical, maternity and other medical
benefits;
° The 30% you pay for non-PPO hospital, surgical, maternity
and other medical benefits.
The following cannot be counted toward out-of-pocket expenses:
°
Expenses in excess of the plan allowance or maximum benefit limitations;
° Expenses for dental care;
° Any amounts you pay because
benefits have been reduced for non-compliance with the Plan's
cost containment
requirements (see pages 9-10);
° PPO office
visit copayments;
° Expenses for prescription drugs purchased through
retail or mail order program; and
° Expenses for skilled nursing facility confinements. 14
14 Page 15 16
2001 Alliance Health Benefit Plan 15 Section
4
Carryover If you changed to this Plan during open season from a
plan with a catastrophic protection benefit and the effective date of the
change was after January 1, any expenses that would have applied to that
plan's catastrophic protection benefit during the
prior year will be covered
by your old plan if they are for care you got in January before the effective
date of your coverage in
this Plan. If you have already met the covered
out-of-pocket maximum expense level in full, your old plan's catastrophic
protection benefit will continue to apply until the effective date. If you
have not met this expense in full, your old plan will first
apply your
covered out-of-pocket expenses until the prior year's catastrophic level is
reached and then apply the catastrophic
protection benefit to covered
out-of-pocket expenses incurred from that point until the effective date. The
old plan will pay
these covered expenses according to this year's benefits;
benefit changes are effective on January 1.
When government facilities Facilities of the Department of Veterans
Affairs, the Department bill us of Defense, and the Indian Health Service
are entitled to seek
reimbursement from us for certain services and supplies
they provide to you or a family member. They may not seek more
than their
governing laws allow.
If we overpay you We will make diligent efforts to recover benefit
payments we made in error but in good faith. We may reduce subsequent
benefit payments to offset overpayments. 15
15
Page 16 17
When
you are age 65 or over and you do not have Medicare
Under the FEHB law,
we must limit our payments for those benefits you would be entitled to if you
had Medicare. And, your physician and hospital must follow Medicare rules and
cannot bill you for more than they could bill you if
you had Medicare. The
following chart has more information about the limits.
If youÉ
° are age 65 or over, and
° do not have
Medicare Part A, Part B, or both; and
° have this Plan as an annuitant
or as a former spouse, or as a family member of an annuitant or former spouse;
and
° are not employed in a position that gives FEHB coverage. (Your
employing office can tell you if this applies.)
Then, for your inpatient hospital care,
° The law requires us
to base our payment on an amount Ñ the "equivalent Medicare
amount" Ñ set by Medicare's rules for what Medicare would pay, not
on the actual charge;
° You are responsible for your applicable deductibles, coinsurance or
copayments you owe under this Plan;
° You are not responsible for any
charges greater than the equivalent Medicare amount; we will show that amount on
the explanation of benefits; and
° The law prohibits a hospital from
collecting more than the Medicare equivalent amount.
And, for your physician care, the law requires us to base our payment
and your coinsurance onÉ
° an amount Ñ set by Medicare and
called the "Medicare approved amount," or
° the actual charge
if it is lower than the Medicare approved amount.
2001 Alliance Health Benefit Plan 16 Section 4 16
16 Page 17 18
If your Physician.... Then you are responsible
for...
Participates with Medicare or accepts your deductibles,
coinsurance, and copayments; Medicare assignment for the claim and
is a
member of our PPO network,
Participates with Medicare and is not in your
deductibles, coinsurance, copayments and our PPO network, any balance up to the
Medicare approved
amount;
Does not participate with Medicare, your
deductibles, coinsurance, copayments, and any balance up to 115% of the Medicare
approved amount
It is generally to your financial advantage to use a physician who
participates with Medicare. Such physicians are only permitted to collect up to
the Medicare approved amount.
Our explanation of benefits (EOB) form will
tell you how much the physician or hospital can collect from you. If your
physician or hospital tries to collect more than allowed by law, ask the
physician or hospital to reduce the
charges. If you have paid more than
allowed, ask for a refund. If you need further assistance, call us.
When you have the Original Medicare Plan We limit our payment to an
amount that supplements the benefits that Medicare would pay under Part A
(Hospital insurance) and Part B (Medical insurance), regardless of whether
Medicare pays. Note: We pay our
regular benefits for emergency services to
an institutional provider, such as a hospital, that does not
participate
with Medicare and is not reimbursed by Medicare.
If you are covered by Medicare Part B and it is primary, your out of pocket
costs for services both
Medicare Part B and we cover depend on whether your
physician accepts Medicare assignment for the claim.
° If your physician accepts Medicare assignment, then you pay nothing for
covered charges.
° If your physician does not accept Medicare
assignment, then you pay the difference between our
payment combined with
Medicare's payment and the charge.
2001 Alliance Health Benefit Plan 17 Section 4 17
17 Page 18 19
Note: The physician who does not accept Medicare
assignment may not bill you for more than 115% of the amount Medicare
bases
its payments on, called the " limiting charge." The Medicare Summary
Notice (MSN) that Medicare will send you
will have more information about
the limiting charge. If your physician tries to collect more than allowed by
law, ask them to
reduce their charges. If they do not, report them to your
Medicare carrier who sent you the MSN form. Call us if you
need further
assistance.
When you have a Medicare A physician may ask you to sign a private
contract agreeing that Private Contract you can be billed directly for
service ordinarily covered by
Medicare. Should you sign an agreement,
Medicare will not pay any portion of the charges, and we will not increase our
payment. We will still limit our payment to the amount we would have paid
after Medicare's payment.
Please see Section 9, Coordinating benefits with other coverage, for more
information about how we coordinate benefits with
Medicare.
2001 Alliance Health Benefit Plan 18 Section 4 18
18 Page 19 20
Section 5. Benefits Ñ OVERVIEW
(See page 6 for how our benefits changed this year and pages 78-79 for a benefits summary.)
Note:
This benefits section is divided into subsections. Please read the important
things you should keep in mind at the beginning of each subsection. Also read
the General Exclusions in Section 6; they apply to the benefits in the
following subsections. To obtain claims forms, claims filing advice, or more
information about our benefits, contact us at 1/ 800-225-4423 or at our website
at www. ahbp. com.
(a) Medical services and supplies are provided by physicians and other health
care professionals ...................... 20-30
° Diagnostic and
treatment services ° Hearing services (testing, treatment, and supplies)
° Lab, X-ray, and other diagnostic tests ° Vision services (testing,
treatment, and supplies)
° Preventive care, adult ° Foot care ° Preventive care, children
° Orthopedic and prosthetic devices
° Maternity care ° Durable
medical equipment (DME) ° Family planning ° Home health services
° Infertility services ° Alternative treatments ° Allergy care
° Education classes and programs
° Treatment therapies °
Rehabilitative therapies
(b) Surgical and anesthesia services provided by physicians
and other health care professionals ......................... 31-37
° Surgical procedures ° Organ/ tissue transplants °
Reconstructive surgery ° Anesthesia
° Oral and maxillofacial surgery
(c) Services
provided by a hospital or other facility, and ambulance services
....................................................... 38-40
°
Inpatient hospital ° Hospice care ° Outpatient hospital or ambulatory
surgical center ° Ambulance
° Extended care benefits/ Skilled nursing care facility benefit
(d) Emergency services/ Accidents
............................................................................................................................
41-42
° Medical emergency ° Ambulance ° Accidental emergency
(e) Mental health and substance abuse benefits
.......................................................................................................
43-46
(f) Prescription drug benefits
....................................................................................................................................
47-50
(g) Special features
.........................................................................................................................................................
51
° Flexible Benefits Option ° 24 Hour Nurse
° Services for Deaf and Hearing Impaired ° High Risk Pregnancies
° Centers for Excellence for Transplants/ Heart/ Surgery/ Etc. °
Travel Benefit for organ transplants
(h) Dental benefits
.......................................................................................................................................................
52-53
(i) Non-FEHB benefits available to Plan members
........................................................................................................
54
SUMMARY OF
BENEFITS................................................................................................................................
78-79
2001 Alliance Health Benefit Plan 19 Section 5 19
19 Page 20 21
Here are some important things you should keep in
mind about these benefits:
° Please remember that all benefits are
subject to the definitions, limitations, and exclusions in this brochure and are
payable only when we determine they are
medically necessary.
° The
calendar year deductibles are: PPO $100 per person ($ 300 per family); Non-PPO
$300 per person ($ 900 per family). Calendar year deductibles apply
to
almost all benefits in this Section. We added "( No deductible)" to
show when a calendar year deductible does not apply.
° The non-PPO benefits are the standard benefits of this Plan. PPO
benefits apply only when you use a PPO provider. When no PPO provider is
available,
non-PPO benefits apply.
° Be sure to read Section 4,
Your costs for covered services for valuable information about how cost
sharing works, with special sections for members
who are age 65 or over.
Also read Section 9 about coordinating benefits with other coverage, including
with Medicare.
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Section 5 (a). Medical services and supplies provided by physicians and
other
health care professionals
Benefit Description You pay After the calendar year deductibleÉ
NOTE: The calendar year deductible applies to almost all benefits in this
Section. We say "No deductible" when it does not apply.
Diagnostic and treatment services
Professional services of
physicians
° In physician's office
Professional services of physicians
° In an urgent care center
° During a hospital stay
° In a skilled nursing facility
° Initial examination of newborn child covered under a family enrollment
° Second surgical opinion
° At home
PPO: $15 copayment
Non-PPO: 30% of the Plan allowance and any difference
between our allowance and
the billed amount
PPO: 10% of the Plan
allowance
Non-PPO: 30% of the Plan allowance and any difference between our
allowance and
the billed amount
2001 Alliance Health Benefit Plan 20 Section 5 (a) 20
20 Page 21 22
Lab, X-ray and other diagnostic tests You pay
Tests, such as
° Blood tests
° Urinalysis
°
Non-routine pap smears
° Pathology
° X-rays
°
Non-routine Mammograms
° CAT Scans/ MRI
° Ultrasound
°
Electrocardiograms and EEG
Preventive care, adults
Routine screenings, limited to:
°
Colorectal Cancer Screening, including
° Fecal occult blood test
annually for members age 40 and older
° Sigmoidoscopy, screening Ñ one every five years starting at age
50
Prostate Specific Antigen (PSA test) Ñ one annually for men age 40 and
older
Routine pap test Ñ one annually for women age 18 and older
Routine
mammogram Ñ covered for women age 35 and older, as follows:
°
From age 35 through 39, one during this five year period
° From age 40
through 64, one every calendar year
° At age 65 and older, one every two
consecutive calendar years
Preventive care, adults -Continued on next page.
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount
Note: If your PPO
provider uses a non-PPO lab or radiologist, we will pay non-PPO
benefits for
any lab and X-ray charges.
PPO: Nothing after office visit copayment
Non-PPO: 30% of the Plan
allowance and any difference between our allowance and
the billed amount
PPO: Nothing after office visit copayment
Non-PPO: 30% of the Plan
allowance and any difference between our allowance and
the billed amount
PPO: Nothing after office visit copayment
Non-PPO: 30% of the Plan
allowance and any difference between our allowance and
the billed amount
PPO: Nothing after office visit copayment
Non-PPO: 30% of the Plan allowance and any difference between our allowance
and
the billed amount
2001 Alliance Health Benefit Plan 21 Section 5 (a) 21
21 Page 22 23
2001 Alliance Health Benefit Plan 22 Section
5 (a)
Routine physical Ñ one annually every two years
Note:
The maximum PPO benefit is $150
Routine Immunizations, limited to:
° Tetanus-diphtheria (Td) booster Ñ once every 10 years, ages 19
and over (except as provided for under
Childhood immunizations)
°
Influenza/ Pneumococcal vaccines, annually, age 65 and over
Not Covered:
All charges
° Preventive medical care and services, including;
° Periodic checkups
° associated X-ray and lab test
° immunizations such as polio, flu, mumps and smallpox,
except as
shown under preventive care, adults and preventive care, children
Preventive care, children
° Childhood immunizations
recommended by the American Academy of Pediatrics for children under age 22
° For well-child care charges for routine examinations, immunizations and
care (to age 6) limited to 12 well
care visits.
° Sickle Cell
Screening Ñ for newborns for sickle cell anemia
° Examinations,
limited to:
° Examinations for amblyopia and strabismus Ñ limited
to one screening (ages 2 through 6)
° Examinations done on the day of the immunizations (through age 22)
Preventive care, adults -Continued You pay
PPO: $15 copayment (No deductible)
Non-PPO: All charges
PPO:
Nothing after office visit copayment
Non-PPO: 30% of the Plan allowance and
any difference between our allowance and the
billed amount
PPO: Nothing (No deductible)
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and
the billed amount
PPO: $15
copayment (No deductible)
Non-PPO: 30% of the Plan allowance and any difference between our allowance
and
the billed amount
PPO: $15 copayment (No deductible)
Non-PPO:
30% of the Plan allowance and any difference between our allowance and the
billed amount 22
22 Page
23 24
2001 Alliance Health Benefit Plan 23 Section 5 (a)
Maternity care You pay
Complete maternity (obstetrical) care,
such as:
° Prenatal care
° Delivery
° Postnatal care
Note: Here are some things to keep in mind:
° You do not need to
precertify your normal delivery; see page 10 for other
circumstances, such as extended stays for
you or your baby.
° You
may remain in the hospital up to 48 hours after a regular delivery and 96 hours
after a cesarean delivery. We will
cover an extended stay, if medically
necessary, but you must precertify.
° We cover routine nursery care of the newborn child during the covered
portion of the mother's maternity stay. We will
cover other care of an
infant who requires non-routine treatment if we cover the infant under a Self
and Family
enrollment.
° We pay hospitalization and surgeon services
(delivery) the same as for illness and injury. See Hospital benefits
(Section 5c) and Surgery benefits (Section 5b)
Not covered: Routine sonograms to determine fetal age, All charges
size or sex
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and
the billed amount 23
23 Page 24 25
2001 Alliance Health Benefit Plan 24 Section
5 (a)
Family planning You pay
° Voluntary sterilization
° Surgically implanted contraceptives
° Injectable contraceptive
drugs
° Intrauterine devices (IUDs)
Note: We cover contraceptive drugs in Section 5( f).
Not covered: Reversal of voluntary surgical sterilization, All charges
genetic counseling.
Infertility services
Diagnosis and treatment of infertility,
except as excluded.
Not covered: All charges
° Assisted reproductive technology (ART)
procedures, such as:
° artificial insemination
° in vitro
fertilization
° embryo transfer and GIFT
° intravaginal
insemination (IVI)
° intracervical insemination (ICI)
°
intrauterine insemination (IUI)
° Services and supplies related to ART
procedures.
Allergy care
Testing and treatment, including materials (such as
allergy serum)
Allergy injection PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan
allowance and any difference between our allowance and
the billed amount
Not covered: provocative food testing and sublingual allergy All charges
desensitization
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and
the billed amount
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and
the billed amount
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and
the billed amount 24
24 Page 25 26
2001 Alliance Health Benefit Plan 25 Section 5 (a)
°
Chemotherapy and radiation therapy
Note: High dose chemotherapy in
association with autologous bone marrow transplants is limited to those
transplants listed
on page 34.
° Dialysis Ñ Hemodialysis
and peritoneal dialysis
° Intravenous (IV) Infusion Therapy Ñ
Home IV and antibiotic therapy
° Respiratory and inhalation therapies
Rehabilitative therapies
Physical therapy, occupational therapy, and speech therapy provided by
a:
° qualified physical therapist;
° speech therapist; and
°
occupational therapist
Note: We only cover therapy to restore bodily
function or speech when there has been a total or partial loss of bodily
function or functional speech due to illness or injury and when a physician:
1) orders the care;
2) identifies the specific professional skills the
patient requires and the medical necessity for skilled services; and
3) indicates the length of time the service is needed.
Not covered:
All charges
° Exercise programs
° Speech therapy, physical therapy, and
occupational therapy
related to services, treatment, educational testing or
training
related to learning disabilities or developmental delays.
° Chelation therapy, except for acute arsenic, gold, lead, or
mercury poisoning.
° Massage therapy
Treatment therapies You pay
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our allowance
and
the billed amount
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and
the billed amount 25
25 Page 26 27
2001 Alliance Health Benefit Plan 26 Section
5 (a)
Hearing services (testing, treatment, and supplies) You pay
Testing only when necessitated by accidental injury PPO: 10% of the Plan
allowance
Non-PPO: 30% of the Plan allowance and any difference between our allowance
and
the billed amount
Not covered: All charges
° hearing
testing, except for accidental injury
° hearing aids, testing and
examinations for them
Vision services (testing, treatment, and supplies)
° One pair
of eyeglasses or contact lenses to correct an PPO: 10% of the Plan allowance
impairment directly caused by accidental ocular injury or
intraocular
surgery (such as for cataracts) Non-PPO: 30% of the Plan allowance and any
difference between our allowance and
Note: See Preventive care, children for
eye exams for children the billed amount
Not covered: All charges
° Eyeglasses or contact lenses and
examinations for them
° Eye exercise and orthoptics
° Radial
keratotomy and other refractive surgery 26
26
Page 27 28
Foot
care You pay
Routine foot care when you are under active treatment for a
PPO: $15 copayment and/ or 10% of the Plan metabolic or peripheral vascular
disease, such as diabetes. allowance
See orthopedic and prosthetic devices for information on Non-PPO: 30% of the
Plan allowance and podiatric shoe inserts. any difference between our allowance
and
the billed amount
Not covered: All charges
° Cutting,
trimming or removal of corns, calluses, or the
free edge of toenails, and
similar routine treatment of
conditions of the foot, except as stated above
° Treatment of weak, strained or flat feet or bunions or
spurs;
and of any instability, imbalance or subluxation of the foot (unless the
treatment is by open cutting surgery)
Orthopedic and prosthetic devices
° Artificial limbs and eyes;
stump hose PPO: 10% of the Plan allowance
° Externally worn breast prostheses and surgical bras, Non-PPO: 30% of
the Plan allowance and including necessary replacements following a mastectomy
any difference between our allowance and
the billed amount ° Internal
prosthetic devices, such as artificial joints,
pacemakers, cochlear
implants, and surgically implanted breast implants following mastectomy.
Note: Internal prosthetic devices are paid as hospital benefits; See Section
5 (c) for payment information.
Insertion of the device is paid as surgery,
see Section 5 (b).
Not Covered: All charges
° Orthopedic and
corrective shoes
° Arch supports
° Foot orthotics
° Heel
pads and heel cups
° Lumbosacral supports
° Corsets, trusses,
elastic stockings, support hose, and other supportive devices
2001 Alliance Health Benefit Plan 27 Section 5 (a) 27
27 Page 28 29
Durable medical equipment (DME) You pay
Durable medical equipment (DME) is equipment and supplies that:
1. Are prescribed by your attending physician (i. e., the physician who is
treating your illness or injury);
2. Are medically necessary;
3. Are
primarily and customarily used only for a medical purpose;
4. Are generally useful only to a person with an illness or injury;
5.
Are designed for prolonged use; and
6. Serve a specific therapeutic purpose
in the treatment of an illness or injury.
We cover rental or purchase, at our option, including repair and adjustment,
of durable medical equipment, such as
oxygen and dialysis equipment. Under
this benefit, we also cover:
° Hospital beds;
° Wheelchairs, to include medically necessary
motorized wheelchairs;
° Iron lung;
° Certain types of traction equipment;
°
Oxygen and rental of equipment for its administration;
° Crutches; and
° Walkers.
Note: Call us at 1/ 800-225-4423 as soon as your physician prescribes this
equipment. We arrange with a health care
provider to rent or sell you
durable medical equipment at discounted rates and will tell you more about this
service
when you call.
Not covered: All charges
° exercise
equipment
° whirlpool baths
° sun-lamps
° heating pads
° air conditioners
° humidifiers, dehumidifiers, and purifiers
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount
2001 Alliance Health Benefit Plan 28 Section 5 (a) 28
28 Page 29 30
Home health services You pay
Nursing services:
° 240 units
annually up to $15 per unit when rendered by a:
° Registered Nurse (R.
N.), a licensed practical nurse (L. P. N.) , or a Christian Science Nurse who is
listed in
the Christian Science Journal
Note: One private duty nursing unit consist
of up to one hour of private duty nursing care.
Home health care services:
° 60 home health visits per calendar year
up to a maximum plan payment of $40 per visit when:
° A home health care visit consists of;
° Less than an 8-hour
shift of nursing care; or
° One therapy session; or
° One social
worker visit; or
° Less than an 8-hour shift by a home health aide.
° Covered home health care services are:
° Nursing care provided
on a part-time basis (less than an 8-hour shift) by:
a) a registered nurse (RN); or
b) a licensed practical nurse (LPN); or
c) a Christian science nurse
° Physical, occupational or speech therapy provided by a licensed
therapist;
° Services of a licensed social worker (but not more than 2 visits);
° Home health aide services provided on a part-time basis (less than an
8-hour shift) that;
a) are performed by a home health aide under the
supervision of a registered nurse (RN); and
b) consist mainly of medical
care and therapy provided solely for the care of the patient.
Note: The home health care services must be furnished:
° by a home
health care agency ( or by visiting nurses where services of a home health care
agency are not
available);
° in accordance with a home health
care plan, see definition on page 67; and
° in the patient's home
Not covered: All charges
° Nursing
care requested by, or for the convenience of, the
patient or the patient's
family
° Nursing care primarily for hygiene, feeding, exercising,
moving
the patient, homemaking, companionship or giving
oral medication.
PPO: all charges after $15 per unit with the maximum of 240 units
Non-PPO: all charges after $15 per unit with the maximum of 240 units
PPO: (No deductible) all charges after we pay $40 per day
Non-PPO: (No
deductible) all charges after we pay $40 per day
2001 Alliance Health Benefit Plan 29 Section 5 (a) 29
29 Page 30 31
Alternative treatments You pay
Acupuncture
Ñ by a doctor of medicine or osteopathy for: PPO: 10% of the Plan
allowance
° anesthesia when used as an anesthetic agent for covered Non-PPO: 30% of
the Plan allowance and surgery any difference between our allowance and
the
billed amount
Chiropractor Ñ The Plan pays a maximum of $225 per
person PPO: 10% of the Plan allowance annually for outpatient services provided:
Non-PPO: 30% of the Plan allowance and ° by a licensed chiropractor any
difference between our allowance and
the billed amount Note: No other
services of a chiropractor are covered under
any other provision of this
Plan.
Educational classes and programs
Coverage is limited to:
° Cardiac rehabilitation program Ñ Outpatient visits must consist
of outpatient cardiac rehabilitative exercise, education,
and counseling
when:
° patient has been diagnosed as having angina pectoris (chest
pain); or
° patient has been hospitalized for a diagnosed myocardial infarction
(heart attack); or
° coronary surgery.
Note: Services must be
provided by an approved hospital-based or hospital-coordinated cardiac
rehabilitation program.
° Smoking Cessation Ñ Up to $100 for one smoking PPO: all charges
after benefits stop at $100 cessation program per member per lifetime, including
all related expenses such as drugs. Non-PPO: all charges after benefits stop
at $100
PPO: 30% of the Plan allowance
Non-PPO: 50% of the Plan allowance and any
difference between our allowance and
the billed amount
2001 Alliance Health Benefit Plan 30 Section 5 (a) 30
30 Page 31 32
2001 Alliance Health Benefit Plan 31 Section
5 (b)
Here are some important things you should keep in mind about
these benefits:
° Please remember that all benefits are subject to
the definitions, limitations, and exclusions in this brochure and are payable
only when we determine they are
medically necessary.
° The calendar
year deductibles are: PPO $100 per person ($ 300 per family); Non-PPO: $300 per
person ($ 900 per family). Calendar year deductibles apply
to almost all benefits in this section. We added "No deductible" to
show when a calendar year deductible does not apply.
° The non-PPO benefits are the standard benefits of this Plan. PPO
benefits apply only when you use a PPO provider. When no PPO provider is
available,
non-PPO benefits apply.
° Be sure to read Section 4,
Your costs for covered services for valuable information about how cost
sharing works, with special sections for members
who are age 65 or over. Also read Section 9 about coordinating benefits with
other coverage, including with Medicare.
° The amounts listed below are for the charges billed by a physician or
other health care professional for your surgical care. Look in Section 5( c) for
charges associated with the facility (i. e. hospital, surgical center, etc.)
° YOU MUST GET PRECERTIFICATION OF SOME SURGICAL PROCEDURES. Please
refer to the precertification information shown in
Section 3 to be sure which services require precertification.
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Section 5 (b). Surgical and anesthesia services provided by physicians and
other health care professionals
Benefit Description You pay After the calendar year deductibleÉ
NOTE: The calendar year deductible applies to almost all benefits in this
Section. We say "No deductible" when it does not apply.
Surgical procedures
° Operative procedures
° Treatment
of fractures, including casting
° Normal pre-and post-operative care by
a surgeon
° Correction of amblyopia and strabismus
° Endoscopy
procedure
° Biopsy procedure
° Electroconvulsive therapy
Surgical procedures Ñ Continued on next page.
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and
the billed amount 31
31 Page 32 33
Surgical procedures Ñ Continued
You pay
° Removal of tumors and cysts
° Correction of
congenital anomalies (See Reconstructive surgery)
° Surgical treatment of morbid obesity Ñ a condition in which an
individual weighs 100 pounds or 100% over
his or her normal weight according
to current underwriting standards; eligible members must be age 18 or over
° Insertion of internal prosthetic devices. See 5( a) Ñ Orthopedic
braces and prosthetic devices for device
coverage information
°
Voluntary sterilization, Norplant (a surgically implanted contraceptive), and
intrauterine devices (IUDs)
° Treatment of burns
° Assistant surgeons Ñ we cover up to
20% of our allowance for the surgeon's charge
When multiple or bilateral surgical procedures performed during the same
operative session add time or complexity
to patient care, our benefits are
° For the primary procedure
° PPO: 90% of the Plan allowance
° Non-PPO: 70% of the reasonable and customary charge
° For the secondary procedure( s):
° PPO: 90% of one-half of the
Plan allowance
° Non-PPO: 70% of one-half of the reasonable and
customary charge
Note: Multiple and bilateral surgical procedures performed through the same
incision are "incidental" to the primary
surgery. That is, the
procedure would not add time or complexity to patient care. We do not pay extra
for incidental
procedures.
Not covered: All charges
°
Reversal of voluntary sterilization
° Services of a standby surgeon,
except during angioplasty
or other high risk procedures when we determine
standbys are medically necessary
° Routine treatment of conditions of the foot; see Foot care
PPO: 10% of the Plan allowance
Non-PP0: 30% of the Plan allowance and any
difference between our allowance and the
billed amount.
PPO: 10% of the Plan allowance for the primary procedure; 10% of one-half of
the
Plan allowance for the secondary procedure( s) and 10% of one-quarter of
the Plan allowance
for procedure( s) thereafter.
Non-PPO: 30% of the
Plan allowance for the primary procedure and 30% of one-half of the
Plan
allowance for the secondary procedure( s) and 30% of one-quarter of the Plan
allowance
for procedure( s) thereafter and any difference between our
allowance and the billed amount
2001 Alliance Health Benefit Plan 32 Section 5 (b) 32
32 Page 33 34
Reconstructive surgery You pay
°
Surgery to correct a functional defect
° Surgery to correct a condition caused by injury or illness if:
° the condition produced a major effect on the member's appearance and
° the condition can reasonably be expected to be corrected by such
surgery
° Surgery to correct a condition that existed at or from birth and is a
significant deviation from the common form
or norm. Examples of congenital
anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks;
and
webbed fingers and toes.
° All stages of breast reconstruction
surgery following a mastectomy, such as:
° surgery to produce a symmetrical appearance on the other breast;
° treatment of any physical complication, such as lymphedemas;
°
breast prostheses; and surgical bras and replacements (see Prosthetic devices
for coverage)
Note: We pay for internal breast prostheses as hospital benefits.
Note:
If you need a mastectomy, you may choose to have the procedure performed on an
inpatient basis and remain in the
hospital up to 48 hours after the
procedure.
Not covered: All charges
° Cosmetic surgery Ñ
any surgical procedure (or any portion
of a procedure) performed primarily
to improve physical
appearance through change in bodily form, except repair
of accidental injury.
° Surgeries related to sexual transformations or sexual dysfunction.
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and
the billed amount
2001 Alliance Health Benefit Plan 33 Section 5 (b) 33
33 Page 34 35
Oral surgical procedures, limited to:
°
Reduction of fractures of the jaw or facial bones ° Surgical correction of
cleft lip, cleft palate or severe
functional malocclusion ° Removal of stones from salivary ducts
°
Excision of leukoplakia or malignancies ° Excision of cysts and incision of
abscesses when done as
independent procedures ° Other surgical
procedures that do not involve the teeth or
their supporting structures
Not covered: All charges
° Oral implants and transplants
° Procedures that involve the teeth or their supporting
structures
(such as the periodontal membrane, gingiva and alveolar bone)
Organ/ tissue transplants
Limited to:
° Cornea ° Heart
° Heart/ lung ° Kidney
° Kidney/ Pancreas ° Liver
° Lung: Single Ñ only for the following end-stage pulmonary
diseases: primary fibrosis, primary pulmonary hypertension,
or emphysema;
Double Ñ only for patients with cystic fibrosis
° Pancreas (when
condition is not treatable by use of insulin therapy)
° Allogeneic bone
marrow transplants Ñ only for patients with Acute leukemia, Advanced
Hodgkins lymphoma,
Advanced non-Hodgkin's lymphoma, Advanced neuroblastoma
(limited to children over age one),
Aplastic anemia, Chronic myelogenous
leukemia, Infantile malignant osteopetrosis, Severe combined immunodeficiency,
Thalassemia major, and Wiskott-Aldrich syndrome ° Autologous bone marrow
transplants Ñ (autologous stem
cell and autologous peripheral stem
cell support) for Acute lymphocytic or non-lymphocytic leukemia, Advance
Hodgkin's lymphoma, Advanced non-Hodgkin's lymphoma, Advanced neuroblastoma,
Testicular, Mediastinal,
Retroperitoneal, and Ovarian germ cell tumors,
Breast cancer, Multiple myeloma, and Epithelial ovarian cancer.
Oral and maxillofacial surgery You pay
2001 Alliance Health Benefit Plan 34 Section 5 (b)
PPO: 10%
of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference
between our allowance and the
billed amount
The First HealthÒ National Transplant Program: 10% of the Plan
allowance
PPO: 20% of the Plan allowance
Non-PPO: 30% of the Plan
allowance and the difference between our allowance and the
billed amount.
Organ/ tissue transplants -Continued on next page. 34
34 Page 35 36
2001 Alliance Health Benefit Plan 35 Section
5 (b)
Organ/ tissue transplants Ñ Continued You
pay
First HealthÒ National Transplant Program
° Covered
Transplant Services:
° Pre-transplant evaluation;
° Organ
procurement;
° Transplant procedures and associated hospitalization;
° Transplant-related follow-up care provided by the designated
transplant hospital for up to 1 year;
° Pharmacy costs provided by the First HealthÒ National
Transplant Program for immunosuppressant and other
transplant-related
medications while hospitalized;
° Donor expenses, if not covered under
any other plan;
° Transplant-related services provided by the First
HealthÒ National Transplant Program facility that are associated
with the transplant events listed above, including laboratory and other
diagnostic services;
° Physician services related to the transplant events listed above
° Travel and lodging benefit:
° If the recipient lives more than
100 miles from a designated transplant facility, the Plan will provide an
allowance for pre-approved travel and lodging expenses up to $10,000 per
transplant. The allowance will not be
subject to the calendar year
deductible or coinsurance. The allowance will provide coverage of reasonable
travel
and temporary lodging expenses for the recipient and one companion
(two companions if the recipient is a minor).
Covered travel and lodging
expenses will be established by the Plan's case manager during the
precertification
process. Travel and lodging to a designated facility for
the pre-transplant evaluation is covered under this benefit
even if the
transplant is not eventually certified as medically necessary.
Organ/ tissue transplants Ñ Continued on next page.
The First HealthÒ National Transplant Program: 10% of the Plan
allowance
PPO: 20% of the Plan allowance
Non-PPO: 30% of the Plan
allowance and the difference between our allowance and the
billed amount. 35
35 Page 36 37
Organ/ tissue transplants Ñ Continued
You pay
PPO benefitÑ not designated as National Transplant
Program:
° If you do not use a First HealthÒ National
Transplant Program facility, but you do use a PPO facility, 80%
benefits will be applied to your expenses. Total benefit payments, including
donor expenses, the transplant
procedure itself, and transplant-related
follow-up care for one year at the transplant facility will be limited to a
maximum payment of $150,000 for a liver transplant and $100,000 for any
other transplant. The travel and lodging
allowance will not be available.
Charges incurred for prescription drugs and follow-up care outside of the
transplant facility/ hospital will not be counted toward this maximum.
Note: Cornea and pancreas transplants are not available through the First
HealthÒ National Transplant Program;
therefore, the Travel/
Lodging benefit is not available.
Precertification: ° In order to
receive benefits for the transplants listed
above, you are required to call
First HealthÒ OnCall at 1/ 800-225-4423 as soon as the need for a
transplant is
discussed with your physician. When you call, it will be
necessary to provide the program with all information
needed to complete the
review. In order to receive the highest level of benefits, all
transplant-related services
must be received at one of the designated
hospitals within the First HealthÒ National Transplant Program.
All covered transplant benefits, including pre-transplant evaluation
expenses (even if the transplant does not
occur) will be provided by the
Plan.
° If you do not follow the procedures required by the First
HealthÒ National Transplant Program, the Plan's
co-payment will
be reduced to the PPO or non-PPO benefit level for all related covered
physician/ hospital
expenses, after any applicable deductible. Also, no
coverage will be provided for transportation or lodging
and meal expenses if
a transplant procedure is not performed at a First HealthÒ
National Transplant
Program facility. The penalty assessed when you do
not follow the procedures required by the First HealthÒ
National Transplant Program does not apply toward your out-of-pocket
maximum.
Organ/ tissue transplants Ñ Continued on next page.
The First HealthÒ National Transplant Program: 10% of the Plan
allowance
PPO: 20% of the Plan allowance
Non-PPO: 30% of the Plan
allowance and the difference between our allowance and the
billed amount.
2001 Alliance Health Benefit Plan 36 Section 5 (b) 36
36 Page 37 38
Organ/ tissue transplants Ñ Continued
You pay
Limitations: (See above)
° For the purposes of
the maximum total payment, charges from doctors and hospitals while the patient
is confined
in a transplant facility will be counted toward the maximum. Charges incurred
for prescription drugs and
follow-up care outside of the transplant
facility/ hospital will not be counted toward this maximum.
Note: If the Plan cannot refer a member in need of a transplant to a First
HealthÒ National Transplant Program facility, the
$100,000/$
150,000 maximum will not apply.
Treatment for breast cancer, multiple
myeloma, and epithelial ovarian cancer may be provided in a National Cancer
Institute
(NCI) or National Institute of Health (NIH) approved clinical
trial at a Plan-designated center of excellence and if approved
by the
Plan's medical director in accordance with the Plan's protocols.
Note: We cover related medical and hospital expenses of the donor when we
cover the recipient.
Not covered: All charges ° Services, supplies,
drugs and aftercare for, or related to,
artificial or non-human organ
implants or transplants;
° Services that are considered experimental/
investigational or not medically necessary;
° Expenses for services which are specifically excluded under
the
Medical Expenses Not Covered section of this Plan; and ° Transplants not
listed as covered
Anesthesia
Professional services provided in Ñ °
Hospital (inpatient)
Professional services provided in Ñ ° Hospital outpatient
department
° Skilled nursing facility ° Ambulatory surgical center
° Office
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount
PPO: 10% of the
Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our allowance
and the
billed amount
Note: If your PPO provider uses a non-PPO
anesthesiologist, we will pay non-PPO benefits
for the anesthesia charges
2001 Alliance Health Benefit Plan 37 Section 5 (b) 37
37 Page 38 39
Here are some important things you should keep in
mind about these benefits:
° Please remember that all your benefits
are subject to the definitions, limitations, and exclusions in this brochure and
are payable only when we
determine they are medically necessary.
°
Unlike Sections (a) and (b), in this section the calendar year deductibles apply
to only a few benefits. In that case we added "( calendar year deductibles
apply)"
° The non-PPO benefits are the standard benefits of this
Plan. PPO benefits apply only when you use a PPO provider. When no PPO provider
is available,
non-PPO benefits apply.
° When you use a PPO hospital, keep in mind
that the professionals who provide services to you in the hospital, such as
radiologists, emergency room
physicians, anesthesiologists, and pathologists, may not all be preferred
providers. If they are not, they will be paid by this Plan as non-PPO providers.
° Be sure to read Section 4, Your costs for covered services for
valuable information about how cost sharing works, with special sections for
members
who are age 65 or over. Also read Section 9 about coordinating
benefits with other coverage, including with Medicare.
° The amounts listed below are for the charges billed by the facility (i.
e. hospital or surgical center) or ambulance service for your surgery or care.
Any costs
associated with the professional charge (i. e. physicians, etc.)
are in Section 5 (a) or (b).
° YOU MUST GET PRECERTIFICATION OF HOSPITAL STAYS; FAILURE TO DO SO
WILL RESULT IN A MINIMUM $500
PENALTY. Please refer to the
precertification information in Section 3 to be sure which services require
precertification.
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Section 5 (c). Services provided by a hospital or other facility, and
ambulance services
Benefit Description You pay
NOTE: The calendar year deductible applies
ONLY when we say below: "calendar year deductible applies".
Inpatient Hospital
Room and board, such as
° ward,
semiprivate, or intensive care accommodations;
° general nursing care;
and
° meals and special diets.
NOTE: We only cover a private room when you must be isolated to prevent
contagion. Otherwise, we will pay the hospital's
average charge for
semiprivate accommodations. If the hospital only has private rooms, we base our
payment on the average
semiprivate rate of the most comparable hospital in
the area.
NOTE: When the non-PPO hospital bills a flat rate, we prorate the
charge to determine how to pay them, as follows: 30% room and
board and 70%
other charges.
Inpatient hospital Ñ Continued on next page.
PPO: $150 per admission and 10% of the
covered charges
Non-PPO: $250 per admission and 30% of the
covered charges
Note: If you use a PPO provider and a PPO
facility, we may still pay
non-PPO benefits if
you receive treatment from a radiologist,
pathologist or anesthesiologist who is not a PPO
provider
2001 Alliance Health Benefit Plan 38 Section 5 (c) 38
38 Page 39 40
Other hospital services and supplies, such as: (see
above) ° Operating, recovery, maternity, and other treatment rooms
°
Prescribed drugs and medicines ° Diagnostic laboratory tests and X-rays
° Blood or blood plasma, if not donated or replaced ° Dressings,
splints, casts, and sterile tray services
° Medical supplies and
equipment, including oxygen ° Anesthetics, including nurse anesthetist
services
° Take home items ° Medical supplies, appliances, medical
equipment, and any
covered items billed by a hospital for use at home (Note:
calendar year deductible applies.)
NOTE: We base payment on whether the facility or a health care professional
bills for the services or supplies. For example, when
the hospital bills for
its nurse anesthetists' services, we pay Hospital benefits and when the
anesthesiologist bills, we pay
surgery benefits.
Not covered: All
charges
° Any part of a hospital admission that is not medically
necessary (see definition), such as when you do not need acute hospital
inpatient (overnight) care, but could receive
care in some other setting without adversely affecting your
condition
or the quality of your medical care. Note: In this event, we pay benefits for
services and supplies other than
room and board and in-hospital physician care at the level
they would
have been covered if provided in an alternative setting
° Custodial care; see definition. ° Non-covered facilities, such
as nursing homes, extended care
facilities, schools, rest homes, places for
the aged,
convalescent homes, residential treatment facilities, and any
place that is not a hospital
° Personal comfort items, such as telephone, television, barber
services, guest meals and beds
° Private nursing care
Outpatient hospital or ambulatory surgical center
°
Operating, recovery, and other treatment rooms ° Prescribed drugs and
medicines
° Diagnostic laboratory tests, X-rays, and pathology services °
Administration of blood, blood plasma, and other biologicals
° Blood and
blood plasma, if not donated or replaced ° Pre-surgical testing
°
Dressings, casts, and sterile tray services ° Medical supplies, including
oxygen
° Anesthetics and anesthesia service
Outpatient hospital
or ambulatory surgical center Ñ Continued on next page.
Inpatient hospital Ñ Continued You pay
PPO;
10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the billed
amount
2001 Alliance Health Benefit Plan 39 Section 5 (c) 39
39 Page 40 41
PPO: Nothing until Plan allowance stops at $4,500
Non-PPO: Nothing until Plan allowance stops at $4,500
PPO: 10% of the Plan allowance (calendar year deductible applies)
Non-PPO: 30% of the Plan allowance and any difference between our allowance
and the
billed amount (calendar year deductible applies)
Outpatient hospital or ambulatory surgical center Ñ
Continued You pay
NOTE: Ñ We cover hospital
services and supplies related to (see above) dental procedures when necessitated
by a non-dental physical
impairment. We do not cover the dental procedures.
Not covered: all services not listed All charges
Extended care benefits/ Skilled nursing care facility benefits
Skilled nursing facility (SNF): We cover semiprivate room, PPO: 20% of the
Plan allowance board, services, supplies in a SNF for up to 60 days confinement
when: Non-PPO: 20% of the Plan allowance 1) you are admitted within 14 days
from a precertified hospital
stay of at least 3 consecutive days; and 2) you
are admitted for the same condition as the hospital stay;
and 3) your
skilled nursing care is supervised by a physician and
provided by an R. N.,
L. P. N., or L. V. N.; and 4) SNF care is medically appropriate.
Hospice care
Hospice is a coordinated program of maintenance and
supportive care for the terminally ill provided by a medically
supervised team under the direction of a Plan approved independent hospice
administration.
° We pay $4,500 per lifetime for inpatient and outpatient services.
Not covered: All charges ° Bereavement counseling
° Funeral
arrangements
° Pastoral counseling ° Financial or legal counseling
° Homemaker or caretaker services
Ambulance
°
Local professional ambulance service when medically appropriate
2001 Alliance Health Benefit Plan 40 Section 5 (c) 40
40 Page 41 42
Benefit Description You pay After the calendar year
deductibleÉ
NOTE: The calendar year deductible applies to almost all
benefits in this Section. We say "No deductible" when it does not
apply.
Accidental injury
If you receive care for your accidental injury
within 72 hours, we cover:
° Non-surgical physician services and supplies ° Related outpatient
hospital services
Note: We pay Hospital benefits if you are admitted.
If you receive care
for your accidental injury after 72 hours, we cover:
° Non-surgical physician services and supplies ° Surgical care
Note: We pay Hospital benefits if you are admitted.
Here are some important things to keep in mind about these benefits:
° Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure.
° The calendar year deductibles are: PPO $100 per person ($ 300 per
family); Non-PPO $300 per person ($ 900 per family). Calendar year deductibles
apply
to almost all benefits in this Section. We added "( No
deductible)" to show when a calendar year deductible does not apply.
° The non-PPO benefits are the standard benefits of this Plan. PPO
benefits apply only when you use a PPO provider. When no PPO provider is
available,
non-PPO benefits apply.
° Be sure to read Section 4,
Your costs for covered services for valuable information about how cost
sharing works, with special sections for members
who are age 65 or over. Also read Section 9 about coordinating benefits with
other coverage, including with Medicare.
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Section 5 (d). Emergency services/ accidents
What is a medical emergency? A medical emergency is the sudden and
unexpected onset of a condition or an injury that you believe endangers
your
life or could result in serious injury or disability, and requires immediate
medical or surgical care. Some problems are emergencies because, if not treated
promptly, they might become more serious, examples include
deep cuts and
broken bones. Others are emergencies because they are potentially life
threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or
sudden inability to breathe. There are many other acute conditions
that we
may determine are medical emergencies Ñ what they all have in common is
the need for quick action.
What is an accidental injury? An
accidental injury is a bodily injury sustained solely through violent, external,
and accidental means, such as
broken bones, animal bites, poisonings and dental care required as a result
of accidental injury to sound natural teeth.
PPO: Nothing (No deductible)
Non-PPO: Only the difference between our
allowance and the billed amount
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount
2001 Alliance Health Benefit Plan 41 Section 5 (d) 41
41 Page 42 43
PPO: $25 copayment
Non-PPO: $25 copayment and the
difference between our allowance and the billed amount
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and the
billed amount
Medical emergency You pay
Outpatient medical or surgical services
and supplies in an emergency room.
Care in a physician's office PPO: $15 and/ or 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our allowance
and the
billed amount.
Ambulance
Professional ambulance
service
Note: If hospital treatment requiring special equipment is necessary but not
locally available, the Plan covers transportation
within the United States
and Canada by professional ambulance, railroad, or scheduled commercial airlines
to the nearest hospital
equipped to furnish the treatment.
Note: See 5
(c) for non-emergency service.
Not covered: All charges
°
Transportation necessary to obtain the services of a doctor
or any other
practitioner
2001 Alliance Health Benefit Plan 42 Section 5 (d) 42
42 Page 43 44
Parity
Beginning in 2001, all FEHB plans' mental health and
substance abuse benefits will achieve "parity" with other benefits.
This means that we will provide mental
health and substance abuse benefits differently than in the past.
You may
now choose to get Out-of-Network (same as before) or In-Network (new in
2001). When you receive In-Network care, you must get our approval for
services and follow a treatment plan we approve. If you do, cost-sharing and
limitations for In-Network mental health and substance abuse benefits will be no
greater than for similar benefits for other illnesses and conditions.
Here are some important things to keep in mind about these benefits:
° All benefits are subject to the definitions, limitations, and
exclusions in this brochure.
° The calendar year deductibles or, for facility care, the inpatient
deductibles apply to almost all benefits in this section. We added "( No
deductible)" to
show when a deductible does not apply.
° Be
sure to read Section 4, Your cost for covered services for valuable
information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
°
YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the instructions
after the benefits descriptions below.
° In-Network mental health and substance abuse benefits are below, then
Out-of-Network benefits begin on page 45.
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2001 Alliance Health Benefit Plan 43 Section 5 (e)
Section 5 (e). Mental health and substance abuse benefits
Benefit
Description You pay After the calendar year deductibleÉ
NOTE: The
calendar year deductible applies to almost all benefits in this Section. We say
"No deductible" when it does not apply.
In-Network benefits
All diagnostic and treatment services
contained in a treatment plan that we approve. The treatment plan may include
services,
drugs, and supplies described elsewhere in this brochure.
Note:
In-Network benefits are payable only when we determine the care is clinically
appropriate to treat your condition and only
when you receive the care as
part of a treatment plan that we approve.
In-Network benefits Ñ Continued on next page.
Your cost sharing responsibilities are no greater than for other illnesses or
conditions. 43
43 Page
44 45
° Professional services, including individual or group therapy $15 per
visit by providers such as psychiatrists, psychologists, or clinical
social
workers
° Medication management
° Diagnostic tests 10% of the
Plan allowance
° Services provided by a hospital or other facility $150
per admission copayment and 10% of the Plan allowance
° Services in approved alternative care settings such as partial
hospitalization, half-way house, residential treatment,
full-day
hospitalization, facility based intensive outpatient treatment
Not covered: Services we have not approved. All charges.
Note: OPM
will base its review of disputes about treatment plans on the treatment plan's
clinical appropriateness. OPM
will generally not order us to pay or provide
one clinically
appropriate treatment plan in favor of another.
Preauthorization To be eligible to receive these enhanced mental
health and substance abuse benefits you must follow your treatment plan and all
of our
network authorization processes:
° Pre-certification: The
medical necessity of your admission to a hospital or other covered facility must
be precertified for you to
receive full Plan benefits. Emergency admissions
must be reported within two business days following the day of the admission
even if
you have been discharged. Otherwise, the
benefits payable will be reduced by $500. See page 9 for details.
° You may obtain a provider directory by calling 1/ 800-321-0347.
° Outpatient approval procedures: Covered outpatient services for
treatment of mental conditions or substance abuse require
pre-certification.
Pre-certification is required when treatment continues beyond 2 visits per
person, per calendar year.
Special transition benefit If a mental health or substance abuse
professional provider is treating you under our plan as of January 1, 2001, you
will be eligible for
continued coverage with your provider for up to 90 days
under the following conditions:
In-Network benefits Ñ Continued You pay
2001 Alliance Health Benefit Plan 44 Section 5 (e) 44
44 Page 45 46
° If your mental health or substance abuse
professional provider with whom you are currently in treatment leaves the plan
at our request for
other than cause, or
° If changes to this plan's
benefit structure for 2001 cause your out-of-pocket costs for your
out-of-network provider to be greater than they
were in contract year 2000.
If these conditions apply to you, we will allow you reasonable time to
transfer your care to a network mental health or substance abuse
professional provider. During the transitional period, you may continue to
see your treating provider and will not pay any more out-of-pocket
than you
did in the year 2000 for services. This transitional period will begin with our
notice to you of the change in coverage and will end 90
days after you
receive our notice. If we write to you before October 1, 2000, the 90-day period
ends before January 1 and this transitional
benefit does not apply.
Network limitation If you do not obtain and follow an approved
treatment plan, we will provide only out-of-network benefits.
Out-of-Network benefits You pay
Inpatient and outpatient
professional services to treat mental conditions.
Inpatient and outpatient professional services to treat substance abuse
conditions.
Inpatient care to treat mental conditions includes ward or
semiprivate accommodations and other hospital charges
Inpatient care to treat substance abuse includes room and board and ancillary
charges for confinement in a treatment facility for
rehabilitative treatment
of alcoholism or substance abuse
Not covered out-of-network: All charges
° Services by pastoral and
marital counselors
° Treatment for learning disabilities and mental
retardation
° Services rendered or billed by schools, residential
treatment
centers or halfway houses or members of their staffs
Out-of-network benefits Ñ Continued on next page.
30% of our allowance and any difference between our allowance and the billed
amount
for up to 45 visits; all charges after 45 visits
50% of our
allowance and any difference between our allowance and the billed amount
and all charges after the $4000 maximum
After a $500 deductible per
admission to a non-PPO hospital, 30% of charges for up to 45
days per
calendar year; all charges after 45 days
30% of Plan allowance and any difference between our allowance and the billed
amount
and all charges after maximum benefit of $4000
In-Network benefits Ñ Continued
2001 Alliance Health Benefit Plan 45 Section 5 (e) 45
45 Page 46 47
Out-of-Network benefits Ñ Continued
Lifetime maximum Out-of-Network inpatient care for the treatment
of alcoholism and drug abuse is limited to a 60-day maximum per lifetime.
Precertification The medical necessity of your admission to a hospital
or other covered facility must be precertified for you to receive these
Out-of-Network
benefits. Emergency admissions must be reported within two
business days following the day of admission even if you have been discharged.
Otherwise, the benefits will be reduced by $500. See Section 3 for details.
See these sections of the brochure for more valuable information about these
benefits:
° Section 3, How you get care, for information about
catastrophic protection for these benefits.
° Section 7, Filing a
claim for covered services, for information about submitting out-of-network
claims.
2001 Alliance Health Benefit Plan 46 Section 5 (e) 46
46 Page 47 48
Here are some important things to keep in mind about these benefits:
° We cover prescribed drugs and medications,
as described in the chart beginning on page 49.
° All benefits are subject to definitions, limitations, and exclusions in
this brochure and are payable only when we determine they are medically
necessary.
° The combined annual prescription drug deductible is
$200 per person for prescriptions filled through the retail and/ or mail order
service program.
° Be sure to read Section 4, Your costs for covered services for
valuable information about how cost sharing works, with special sections for
members
who are age 65 or over. Also read Section 9 about coordinating
benefits with other coverage, including with Medicare.
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2001 Alliance Health Benefit Plan 47 Section 5 (f)
Section 5 (f). Prescription drug benefits
° Who can write
your prescription. A licensed physician or licensed dentist must write the
prescription.
° Where you can obtain them. You may fill the
prescription at a pharmacy participating in the network, a non-network pharmacy,
or by mail. We pay a higher level of benefits when you use a
network
pharmacy.
° Network Pharmacy Benefit. After satisfying your combined annual
$200 per person prescription drug deductible, you pay a $10 copay for the
initial prescription for up to a 30 day supply of
medication (as prescribed
by your doctor) and $10 each for the first and second refills. After that, for
the third and any subsequent refills, your cost increases to 50% of Alliance's
negotiated price
for medications.
° Mail Service Pharmacy Program. After satisfying your combined
annual $200 per person prescription drug deductible, you pay 20% of the covered
charges per generic medication or per
brand name medication. To order by
mail, send your prescriptions to Merck Medco Rx Services, Post Office Box
650322, Dallas, TX 75265-0322
° Non-Network Pharmacy Benefit. After satisfying your combined
annual $200 per person prescription drug deductible, you pay a $10 copay per
prescription or refill, for the initial 30 day
supply and two refills. The
third and subsequent refills will require you to pay 50% of the cost of the
prescription drug. You will also be responsible for any charges in excess of the
participating
pharmacy charges. You must pay the full amount of the
prescription drug and file a claim with First Health Rx as indicated below.
Prescription drug benefits Ñ Continued on next page. 47
47 Page 48 49
Prescription drugs benefits Ñ
Continued
° We use a formulary. We administer an open
formulary. If your physician believes a name brand product is necessary or there
is no
generic available, your physician may prescribe a name brand drug from
a formulary list. This list of name brand drugs is a preferred list
of drugs
that we selected to meet patient needs at a lower cost. You may call for the
list.
° These are the dispensing limitations. For participating and
non-participating pharmacies, the dispensing limit is a 30 day supply. For
mail order the dispensing limit is a 90 day supply with the initial mail
order prescription being limited to a 45 day supply.
° Refilling your prescription. To be sure you never run short of
your prescription medication, you should re-order on or after the refill date
indicated on the refill slip or when you have fewer than 14 days of
medication left. Refills sent in prior to scheduled or authorized refill
will not be filled.
° When you have to file a claim. If a participating pharmacy is
not available where you reside or if you do not use your prescription drug
identification card, you must pay in full for your medication, obtain a
prescription drug receipt and submit a claim to: Alliance Health
Benefit
Plan, Prescription Drug Program, First Health Rx, Post Office Box 22410, Tucson,
AZ 85734. Reimbursement will be based on Plan
cost had you used a
participating pharmacy. The Alliance's cost represents a negotiated fee. The
actual cost to Alliance may be less
than the retail price, so your
reimbursement may be less.
Prescription drug benefits begin on next page.
2001 Alliance Health Benefit Plan 48 Section 5 (f) 48
48 Page 49 50
Each new enrollee will receive a description of our
prescription drug program, a combined prescription drug/ Plan identification
card, a mail order form/ patient profile and a preaddressed reply envelope.
You may purchase the following medications and supplies prescribed by a
physician from either a pharmacy or by mail:
° Drugs and medicines
(including those administered during a non-covered admission or in a non-covered
facility) that by
Federal law of the United States require a physician's
prescription for their purchase, except as excluded below
° Insulin
° Diabetic diagnostic supplies used to test blood and
urine for glucose levels
° Needles and syringes for the administration of covered medications
° Contraceptive drugs and devices
Here are some things to keep in
mind about our prescription drug program:
° A generic equivalent will be dispensed if it is available, unless your
physician specifically requires a name brand. If
you receive a name brand
drug when a federally-approved generic drug is available, and your physician has
not
specified "dispense as written" for the name brand drug, you
have to pay the difference in cost between the name brand
drug and the
generic.
We have an open formulary. If your physician believes a name brand
product is necessary or there is no generic available, your
physician may
prescribe a name brand drug from a formulary list. This list of name brand drugs
is a preferred list of drugs
that we selected to meet patient needs at a
lower cost. To order a prescription drug brochure, call 1/ 800-225-4423
Benefit Description You pay After the annual prescription drug
deductibleÉ
Covered medications and supplies
° Network Retail: $10 generic or brand name for initial prescription and
first and second
refills. For third and subsequent refills 50% of Plan cost.
° Non-Network Retail: $10 generic or brand name for initial prescription
and first and
second refills. For third and subsequent refills 50% of Plan
cost and any difference
between our cost and the cost of the drug.
°
Network Mail Order: 20% of cost for generic or brand name
Prescription drug benefits Ñ Continued on next page.
2001
Alliance Health Benefit Plan 49 Section 5 (f) 49
49 Page 50 51
Covered medications and supplies Ñ Continued You pay
Not covered All charges
° Drugs and supplies for cosmetic purposes
° Vitamins,
nutrients and food supplements even if a
physician prescribes or administers
them
° Nonprescription medicines
° Medical supplies such as
dressings and antiseptics
° Medication that does not require a
prescription under Federal law even if your doctor prescribes it or a
prescription is required under your State law
° Drugs to aid in
smoking cessation except those limited to
the $100 lifetime maximum as part
of the smoking cessation
benefit, see page 30
° Drugs related to treatment of sexual dysfunction, sexual
inadequacy or sexual transformation
° Drugs that are investigational or experimental
° Drugs
prescribed for weight loss
2001 Alliance Health Benefit Plan 50 Section 5 (f) 50
50 Page 51 52
Section 5 (g). Special features
Special
features Description
Flexible benefits option Under the flexible benefits option, we
determine the most effective way to provide services.
° We may identify medically appropriate alternatives to traditional care
and coordinate other benefits as a less costly alternative benefit.
°
Alternative benefits are subject to our ongoing review.
° By approving
an alternative benefit, we cannot guarantee you will get it in the future.
° The decision to offer an alternative benefit is solely ours, and we may
withdraw it at any time and resume regular contract benefits.
° Our
decision to offer or withdraw alternative benefits is not subject to OPM review
under the disputed claims process.
24 hour nurse line For any of your health concerns, 24 hours a day, 7
days a week, you may call 1-800-225-4423 and talk with a nurse who will discuss
treatment options and answer your health questions.
Services for deaf and TDD services are available at 1/ 800-259-8179.
hearing impaired
High risk pregnancies For assistance you should call First
HealthÒ at 1-800-225-4423 during the first trimester of your
pregnancy. At this time, a Case Manager will
ask you questions about your
general health and medical history. This information will be discussed with your
physician or practitioner to help
determine the risk factor of your
pregnancy.
Centers of excellence for For assistance with the First
HealthÒ National Transplant Program transplant/ heart surgery/
etc. call us at 1/ 800-225-4423 for more information.
Travel benefit for organ First HealthÒ National Transplant
Program: transplants Travel and lodging must be approved in advance. They
include the cost
incurred for one companion to travel with the patient to
receive services in connection with any approved PPO transplant procedure.
Travel and
lodging expenses are covered up to a $10,000 maximum.
2001 Alliance Health Benefit Plan 51 Section 5 (g) 51
51 Page 52 53
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Here are some important things to keep in mind about these benefits:
° Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are
medically necessary.
° The calendar year
deductibles are: PPO $100 per person ($ 300 per family); Non-PPO $300 per person
($ 900 per family). Calendar year deductibles apply
to the accidental dental
injury benefit only. We added "( No deductible)" to show when a
calendar year deductible does not apply.
° Non-PPO dental benefit is subject to a $25 per person and $50 per
family calendar year deductible.
° Be sure to read Section 4, Your
cost for covered services, for valuable information about how cost sharing
works, with special sections for members
who are age 65 or over. Also read
Section 9 about coordinating benefits with other coverage, including with
Medicare.
° Note: We cover hospitalization for dental procedures only when a non-dental physical impairment exists which makes hospitalization n