Alliance Health Benefit Plan 2002
http:// www.
ahbp. com
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
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
Inspector General Advisory
.......................................................................................................................................................................
4
Section 1. Facts about this fee-for-service plan
......................................................................................................................................
5
Section 2. How we change for 2002
.......................................................................................................................................................
6
Section 3. How you get care
....................................................................................................................................................................
7
Identification cards
..................................................................................................................................................................
7
Where you get covered care
...................................................................................................................................................
7
Covered providers
.........................................................................................................................................................
7
Covered Facilities
..........................................................................................................................................................
7
What you must do to get covered care
..................................................................................................................................
8
How to get approval for
..........................................................................................................................................................
8
Your hospital stay (precertification)
..........................................................................................................................
8-9
Other services
................................................................................................................................................................
9
Section 4. Your costs for covered services
............................................................................................................................................
10
Copayments
.................................................................................................................................................................
10
Deductible
....................................................................................................................................................................
10
Coinsurance
............................................................................................................................................................
10-11
Differences between our allowance and the bill
........................................................................................................
11
Your out-of-pocket
maximum...............................................................................................................................................
12
When government facilities bill us
.......................................................................................................................................
12
If we overpay you
.................................................................................................................................................................
12
When you are age 65 or over and you do not have
Medicare
...........................................................................................
13
When you have Medicare.
....................................................................................................................................................
14
Section 5. Benefits
..................................................................................................................................................................................
15
Overview
...............................................................................................................................................................................
15
(a) Medical services and supplies provided by
physicians and other health care professionals
...................................... 16
(b) Surgical
and anesthesia services provided by physicians and other health care
professionals .................................. 24
(c) Services provided by a hospital or other facility, and
ambulance services
................................................................. 29
(d) Emergency services/ accidents
.......................................................................................................................................
32
(e) Mental health and substance abuse benefits
.................................................................................................................
34
(f) Prescription drug benefits.
.............................................................................................................................................
36
Table of Contents
2002 Alliance Health Benefit Plan 2 Table of Contents 2
2 Page 3 4
(g) Special features
..............................................................................................................................................................
38
Flexible benefits option
24 hour nurse line
Services for
deaf and hearing impaired
High risk pregnancies
Centers of
excellence for transplant/ heart surgery/ etc.
Travel benefits for organ
transplant
(h) Dental benefits
...............................................................................................................................................................
39
(i) Non-FEHB benefits available to Plan members
...........................................................................................................
40
Section 6. General exclusions things we don't
cover
......................................................................................................................
41
Section 7. Filing a claim for covered services
......................................................................................................................................
42
Section 8. The disputed claims process
.................................................................................................................................................
44
Section 9. Coordinating benefits with other
coverage
..........................................................................................................................
46
When you have other health coverage
.................................................................................................................................
46
Original Medicare
.................................................................................................................................................................
46
Medicare managed care plan
................................................................................................................................................
49
TRICARE/ Workers Compensation/ Medicaid
.......................................................................................................................
49
When other Government agencies are responsible for
your care
.......................................................................................
50
When others are responsible for injuries
.............................................................................................................................
50
Section 10. Definitions of terms we use in this
brochure
.......................................................................................................................
51
Section 11. FEHB facts
...........................................................................................................................................................................
55
Coverage
information............................................................................................................................................................
55
No pre-existing condition limitation
...........................................................................................................................
55
Where you get information about enrolling in the FEHB Program
.......................................................................... 55
Types of coverage available for you and your family
...............................................................................................
55
When benefits and premiums start
.............................................................................................................................
55
Your medical and claims records are confidential
.....................................................................................................
56
When you retire
...........................................................................................................................................................
56
When you lose benefits
.....................................................................................................................................................
56
When FEHB coverage ends
........................................................................................................................................
56
Spouse equity coverage
...............................................................................................................................................
56
Temporary Continuation of Coverage (TCC)
............................................................................................................
56
Converting to individual coverage
..............................................................................................................................
57
Getting a Certificate of Group Health Plan Coverage
...............................................................................................
57
Long term care insurance is coming later in 2002
.................................................................................................................................
58
Department of Defense/ FEHB Program Demonstration
Project
............................................................................................................
59
Index
.........................................................................................................................................................................................................
61
Summary of benefits
...........................................................................................................................................................................
62-63
Rates
..........................................................................................................................................................................................
Back Cover
2002 Alliance Health Benefit Plan 3 Table of Contents 3
3 Page 4 5
2002 Alliance Health Benefit Plan 4 Introduction/ Plain Language/
Advisory
Introduction
The Alliance Health Benefit Plan 1628
11 th Street NW
Washington, DC 20001
This brochure describes the
benefits of the 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, 2002, unless those benefits are also shown in this brochure.
OPM
negotiates benefits and rates with each plan annually.
Benefit changes are effective January 1, 2002, and changes are summarized on
page 6. Rates are shown at the end of this brochure.
Plain Language
Teams of Government and Health plans' staff worked
on all FEHB brochures to make them responsive, accessible, and under-standable
to the public. For instance,
Except for necessary technical terms, we use common words. For instance
"you" means the enrollee or family member; "we" means the Alliance Health
Benefit Plan.
We limit acronyms to ones you know. FEHB is the Federal
Employees Health Benefits Program. OPM is the Office of Personnel Management. If
we use others, we tell you what they mean first.
Our brochure and other
FEHB plans' brochures have the same format and similar descriptions to help you
compare plans.
If you have comments or
suggestions about how to improve the structure of this brochure, let OPM
know. Visit OPM's "Rate Us" feedback area at www. opm. gov/ insure or e-mail
OPM at fehbwebcomments@ opm. gov. You may also write to OPM at the Office
of
Personnel Management, Office of Insurance Planning and Evaluation Division,
1900 E Street, NW Washington, DC 20415-3650.
Inspector General Advisory
Stop health care fraud! Fraud increases
the cost of health care for everyone. If you suspect that a physician, pharmacy,
or hospital has charged you for services you did not receive, billed you twice
for the same service, or
misrepresented any information, do the following:
Call the provider and ask for an explanation. There may be an error.
If the provider does not resolve the matter, call us at 1/ 800-321-0347 and
explain the situation.
If we do not resolve the issue, call or write
THE HEALTH CARE FRAUD HOTLINE 202/ 418-3300
The United States
Office of Personnel Management Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400 Washington, DC 20415.
Penalties for Fraud Anyone who falsifies a claim to obtain FEHB
Program benefits can be prosecuted for fraud. Also, the Inspector General may
investigate anyone who uses an ID card if the person tries to
obtain
services for someone who is not an eligible family member, or is no longer
enrolled in the Plan and tries to obtain benefits. Your agency may also take
administrative action against
you. 4
4 Page 5 6
2002 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.
The non-PPO benefits are the standard benefits of this Plan. 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 Health to use The First Health Network, a Preferred Provider
Organization (PPO). This is a group of doctors, hospitals and other providers
who have contracted with First Health 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 8 and 9 for all inpatient
hospitalizations. It is your responsibility to complete this prior
notifica-tion;
however, your PPO doctor may initiate precertification
and will file your claims for you. Note: PPO benefits are not payable when the
Alliance Health Benefit Plan is not the primary payer.
Your Rights
OPM requires that all FEHB Plans provide certain information to their FEHB members. 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 specialty, professional skill and proper credentials Years in
existence
Profit status
If you want more information about us, call 1/
800-321-0347 or for calls in the Washington, DC metropolitan area (202)
939-6325, or write to Alliance Health Benefit Plan, 1628
11th 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
2002 Alliance Health Benefit Plan 6
Section 2
Section 2. How we change for 2002
Do not rely on
these change descriptions; this page is not an official statement of benefits.
For that, go to Section 5 Benefits. Also, we edited and clarified language
throughout the brochure; any language change not shown here is a clarification
that does not
change benefits.
Program-wide changes
We changed the address for sending disputed
claims to OPM. (Section 8)
Four states are added to the list of medically
underserved areas: Georgia, Montana, North Dakota, and Texas. Louisiana is no
longer medically underserved. (Section 3)
Changes to this Plan
Your share of the non-postal premium will
increase by 10.4% for Self Only or 8.0% for Self and Family.
We clarified
the brochure to better explain that the non-PPO benefits are the standard
benefits of this Plan, that PPO benefits apply only when you use a PPO provider,
and that when no PPO provider is available, non-PPO benefits apply.
We clarified that blood lead level screening for children is covered.
Under the retail prescription drug benefit, you pay 10% coinsurance for the
initial prescription and 50% for all refills.
Occupational and physical
therapy services are limited to 45 visits per calendar year
Speech therapy
services are limited to 45 visits per calendar year
We changed speech
therapy benefits by removing the requirement that services must be required to
restore functional speech. (Section 5( a))
We no longer limit total blood cholesterol tests to certain age groups.
(Section 5( a))
We now cover certain intestinal transplants. (Section 5(
b)) 6
6 Page 7 8
2002 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 and you pay 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: 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 2002, the states
are: Alabama, Georgia, Idaho, Kentucky, Mississippi, Missouri, Montana, New
Mexico, North Dakota, South
Carolina, South Dakota, Texas, 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.
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 also includes Christian Science Nursing
facilities that
are approved by the Commission for the Accreditation of
Christian Science Nursing Organizations/ Facilities, Inc. 7
7 Page 8 9
2002 Alliance Health Benefit Plan 8 Section 3
What you must do to get It depends on the kind of care you want
to receive. You can go to any provider you covered care 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 PPO
specialist because we drop out of the Federal Employees Health Benefits (FEHB)
Program and you enroll in another FEHB Plan, or
lose access to your PPO specialist because we terminate our contract with
your specialist for other than cause,
you may be able to continue seeing
your PPO specialist and receiving any PPO benefits 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 PPO specialist based on the above
circumstances, you can continue to see your
specialist and any PPO benefits continue 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.
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 92nd 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 prior to your inpatient hospital
admission 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; 8
8 Page
9 10
2002 Alliance Health Benefit Plan
9 Section 3
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.
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 including for maternity
care needs to be extended, you, needs to be extended: your
representative, 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 in the hospital beyond the do not follow the
number of days we approved and did not get the additional days precertified,
then:
precertification rule 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.
Mental
Health and Substance Abuse services and admissions
Growth Hormone Therapy
9
9 Page 10 11
2002 Alliance Health Benefit Plan 10 Section
4
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, facility,
pharmacy, etc., when you receive services.
Example: When you see your PPO physician you pay a copayment of $15 per visit
and when you go in a PPO hospital, you pay $150 per admission.
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 30% of our allowance for non-PPO physician
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;
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 hospital
charges for treatment of mental conditions;
30% for non-PPO inpatient
hospital charges for treatment of mental conditions;
10% for PPO doctors'
visits for (inpatient) mental conditions;
30% for non-PPO doctors' visits
(inpatient and outpatient) for mental conditions;
10% for PPO inpatient
hospital charges for treatment of substance abuse; 10
10 Page 11 12
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
2002 Alliance Health Benefit Plan 11 Section 4
30% for non-PPO inpatient hospital charges for treatment of substance
abuse;
50% for non-PPO inpatient and outpatient professional charges for
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 payment for covered
our allowance and services. Fee-for-service plans arrive at their
allowances in different ways, so their
the bill 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.
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 or copayment. Here is an example about coinsurance: 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
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 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. 11
11 Page 12 13
2002 Alliance Health Benefit Plan 12 Section 4
Your
catastrophic protection For those services with coinsurance, the Plan pays
100% of the plan allowance for the out-of-pocket maximum for remainder of
the calendar year after the calendar year deductible is met when
out-of-deductibles,
coinsurance, pocket expenses for coinsurance in
that calendar year exceed $2,000 under the PPO and copayments 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 8 and 9);
PPO office visit copayments;
Expenses for prescription drugs
purchased through retail or mail order program; and
Expenses for skilled nursing facility confinements.
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 of Defense, and the bill us 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. 12
12 Page 13 14
2002 Alliance
Health Benefit Plan 13 Section 4
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 you
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 the "equivalent Medicare amount" 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 (EOB) form that we send you; 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 on...
an amount set by Medicare and called the
"Medicare approved amount," or
the actual charge if it is lower than the
Medicare approved amount.
It is generally to your financial advantage to use a physician who
participates with Medicare. Such physicians are permitted to collect only 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.
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 your deductibles, coinsurance,
copayments and in 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 13
13 Page
14 15
2002 Alliance Health Benefit
Plan 14 Section 4
When you have the Original Medicare Plan
We limit our payment to an amount that supplements the benefits that
(Part A, Part B, or both) Medicare would pay under Medicare Part A
(Hospital insurance) and
Medicare 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 that 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.
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 the physician to reduce the
charges. If the physician does not, report
the physician 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 you Private Contract with a physician can be
billed directly for services Medicare ordinarily covers. 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. 14
14 Page 15 16
2002 Alliance Health Benefit Plan 15 Section 5
Section
5. Benefits OVERVIEW
(See page 6 for how
our benefits changed this year and pages 62-63 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 provided by physicians and other health
care professionals .................................................... 16-23
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 Chiropractic
Allergy care Alternative treatments
Treatment therapies Education
classes and programs Physical and occupational therapy
Speech therapy
(b) Surgical and anesthesia services provided by physicians and other health
care professionals ................................................. 24-28
Surgical procedures Organ/ tissue transplants Reconstructive surgery
Anesthesia
Oral and maxillofacial surgery
(c) Services provided by a hospital or
other facility, and ambulance services
...............................................................................
29-31
Inpatient hospital Hospice care Outpatient hospital or
ambulatory surgical center Ambulance
Extended care benefits/ Skilled nursing care facility benefits
(d)
Emergency services/ Accidents
.....................................................................................................................................................
32-33
Medical emergency Ambulance Accidental emergency
Ambulance
(e) Mental health and substance abuse benefits
...............................................................................................................................
34-35
(f) Prescription drug benefits
............................................................................................................................................................
36-37
(g) Special features
.................................................................................................................................................................................
38
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
..................................................................................................................................................................................
39
(i) Non-FEHB benefits available to Plan members
..............................................................................................................................
40
SUMMARY OF
BENEFITS.................................................................................................................................................................
62-63 15
15 Page
16 17
I M
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Benefit Description You pay After the calendar year deductible
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 PPO: $15 copayment (No
deductible)
In physician's office
Second surgical opinion
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
At home
2002 Alliance Health Benefit Plan 16 Section 5 (a)
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.
Section 5 (a). Medical services and supplies provided by physicians and
other
health care professionals
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 16
16 Page 17 18
2002 Alliance Health Benefit Plan 17 Section
5 (a)
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:
Blood Cholesterol Screening
Chlamydial Infection Screening
Colorectal Cancer Screening, including
Fecal occult blood test annually
for members age 40 and older
Sigmoidoscopy, screening one every five
years starting at age 50
Prostate Specific Antigen (PSA test) one annually for men age 40 and older
PPO: Nothing after office visit copayment
Non-PPO: 30% of the Plan allowance and any difference between our allowance
and
the billed amount
Routine pap test one annually for women age 18
and older PPO: Nothing after office visit copayment
Non-PPO: 30% of the Plan allowance and any difference between our allowance
and
the billed amount
Routine mammogram 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
Routine physical one annually every two years
Note: The maximum PPO
benefit is $150
Routine immunizations, limited to:
Tetanus-diphtheria (Td) booster
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
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: $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 17
17 Page 18 19
2002 Alliance Health Benefit Plan 18 Section 5 (a)
Preventive care, children You pay
Childhood immunizations
recommended by the American Academy PPO: Nothing (No deductible) of Pediatrics
for children under age 22
Non-PPO: 30% of the Plan allowance and any difference between our allowance
and the billed amount
For well-child care charges for routine
examinations, immunizations PPO: $15 copayment (No deductible) and care (to age
6) limited to 12 well care visits.
Non-PPO: 30% of the Plan allowance and Sickle Cell Screening for newborns
for sickle cell anemia any difference between our allowance and
the billed
amount Blood lead level screening
Examinations, limited to: PPO: $15 copayment (No deductible)
Examinations for amblyopia and strabismus limited to one screening (ages 2
through 6)
Examinations done on the day of the immunizations (ages 3 through age 22)
Maternity care
Compete maternity (obstetrical) care, such as: PPO:
10% of the Plan allowance
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 9 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, you representative, your doctor, or your hospital
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, size
or sex All charges
Family planning
A broad range of voluntary family planning
services, limited to:
Voluntary sterilization
Surgically implanted
contraceptives (such as Norplant)
Injectable contraceptive drugs (such as
Depo provera)
Intrauterine devices (IUDs)
Diaphragms
Note: We
cover contraceptive drugs in Section 5( f).
Not covered: Reversal of voluntary surgical sterilization, genetic
counseling. All charges
Non-PPO: 30% of the Plan allowance and any difference between our allowance
and
the billed amount
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 18
18 Page 19 20
2002 Alliance Health Benefit Plan 19 Section 5 (a)
PPO: 10%
of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference
between our allowance and
the billed amount
Infertility services You pay
Diagnosis and treatment of
infertility, except as shown in Not covered. PPO: 10% of the Plan
allowance
(Including fertility drugs) Non-PPO: 30% of the Plan allowance and any
difference between our allowance and
the billed amount
Not covered:
All charges
Infertility services after voluntary sterilization
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.
Cost of donor sperm
Cost of
donor egg
Allergy care
Testing and treatment, including materials (such as
allergy serum) PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our allowance
and
the billed amount
Allergy injections 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 desensitization All charges
Treatment therapies
Chemotherapy and radiation therapy
Note:
High dose chemotherapy in association with autologous bone
marrow transplants is limited to those transplants listed on page 26.
Dialysis Hemodialysis and peritoneal dialysis
Intravenous (IV)
Infusion Therapy Home IV and antibiotic therapy
Growth hormone therapy
(GHT)
Note: Growth hormone is covered under the prescription drug benefit.
Note: We only cover GHT when we preauthorize the treatment. Call 1/
800-225-4423 for preauthorization. We will ask you to submit information
that establishes that the GHT is medically necessary. Ask us to authorize GHT
before you began treatment; otherwise, we will only cover GHT
services from
the date you submit the information. If you do not ask or if we determine GHT is
not medically necessary, we will not cover the GHT or
related services and
supplies. See Services requiring our prior approval in Section 3.
Respiratory and inhalation therapies 19
19
Page 20 21
2002
Alliance Health Benefit Plan 20 Section 5 (a)
Physical and
occupational therapies You pay
Physical and Occupational therapy;
Up to 45 visits per calendar year for the services provided by a:
qualified physical therapist; and
occupational therapist
Note: We only cover therapy to restore bodily function when there has been a
total or partial loss of bodily function 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
Chelation therapy,
except for acute arsenic, gold, lead, or mercury poisoning.
Massage therapy
Speech therapy
Speech therapy:
Up to 45 visits per calendar year for the services provided by a:
Speech
therapist
Hearing services (testing, treatment, and supplies)
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 impairment PPO: 10% of the Plan
allowance 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
Not covered: All charges
Eyeglasses or contact
lenses and examinations for them
Eye exercise and orthoptics
Radial keratotomy and other refractive surgery
PPO: 10% of the Plan allowance and all cost after 45 visits.
Non-PPO: 30%
of the Plan allowance and any difference between our allowance and
the
billed amount and all cost after 45 visits.
PPO: 10% of the Plan allowance and all cost after 45 visits.
Non-PPO: 30%
of the Plan allowance and any difference between our allowance and
the
billed amount and all cost after 45 visits. 20
20
Page 21 22
2002
Alliance Health Benefit Plan 21 Section 5 (a)
Foot care You
pay
Routine foot care when you are under active treatment for a
metabolic or PPO: $15 copayment and/ or 10% of the Plan peripheral vascular
disease, such as diabetes. allowance
See orthopedic and prosthetic devices for information on podiatric shoe
Non-PPO: 30% of the Plan allowance and inserts. 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
Externally worn breast prostheses and surgical bras, including
necessary replacements following a mastectomy
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
Durable medical equipment (DME)
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.
Durable medical equipment (DME) 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
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and
the billed amount 21
21 Page 22 23
2002 Alliance Health Benefit Plan 22 Section
5 (a)
Durable medical equipment (DME) (continued) You
pay
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
Home health services
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 consists 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;
Home health services 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
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 visit
Non-PPO: (No
deductible) all charges after we pay $40 per visit 22
22 Page 23 24
2002 Alliance Health Benefit Plan 23 Section 5 (a)
Home
health services (continued) You pay
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 53; 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
Home care primarily for personal assistance that does not include a
medical component and is not diagnostic, therapeutic, or rehabilitative.
Chiropractic
Chiropractor The Plan pays a maximum of $225 per
person annually for outpatient services for:
Manipulation of the spine and extremities
Adjunctive procedures such
as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack
application
Note: No other services of a chiropractor are covered under any other
provision of this Plan.
Alternative treatments
Acupuncture by a doctor of medicine or
osteopathy for: PPO: 10% of the Plan allowance
anesthesia when used as an
anesthesic agent for covered surgery. Non-PPO: 30% of the Plan allowance and any
difference between our allowance and
the billed amount
Educational classes and programs
Coverage is limited to:
Cardiac rehabilitation program 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 Up to $100 for one smoking cessation program per member
per lifetime, including all related expenses such as drugs.
PPO: 10% of the Plan allowance and all cost after $225.
Non-PPO: 30% of
the Plan allowance and any difference between our allowance and
the billed
amount and all cost after the $225
PPO: 30% of the Plan allowance
Non-PPO: 50% of the Plan allowance and any
difference between our allowance and
the billed amount
PPO: all charges after benefits stop at $100
Non-PPO: all charges after
benefits stop at $100
PPO: (No deductible) all charges after we pay $40 per visit
Non-PPO: (No
deductible) all charges after we pay $40 per visit 23
23 Page 24 25
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.
I M
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Section 5 (b). Surgery and anesthesia services provided by physicians and
other
health care professionals
Benefit Description You pay After the calendar year deductible
NOTE:
The calendar year deductible applies to almost all benefits in this Section. We
say "( No deductible)" when it does not apply.
Surgical procedures
A
comprehensive range of services, such as:
Operative procedures
Treatment of fractures, including casting
Normal pre-and post-operative
care by a surgeon
Correction of amblyopia and strabismus
Endoscopy
procedures
Biopsy procedures
Electroconvulsive therapy
Removal
of tumors and cysts
Correction of congenital anomalies (See Reconstructive
surgery)
Surgical treatment of morbib obesity 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) Orthopedic and
prosthetic devices for device coverage information
Voluntary
sterilization, Norplant (a surgically implanted contraceptive), and intrauterine
devices (IUDs)
Treatment of burns
Assistant surgeons we cover up
to 20% of our allowance for the surgeon's charge
Surgical procedures continued on next page
2002 Alliance Health
Benefit Plan 24 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 24
24 Page 25 26
2002 Alliance Health Benefit Plan 25 Section
5 (b)
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
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and
the billed amount
Surgical procedures (continued) You pay
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
Reconstructive surgery
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
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.
25
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2002 Alliance Health Benefit Plan 26
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
Organ/ tissue transplants continued on next page
Oral and maxillofacial surgery You pay
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
Small
Intestine, including transplant with multiple organs (liver, stomach or
pancreas)
Lung: Single only for the following end-stage pulmonary diseases:
pulmonary fibrosis, primary pulmonary hypertension, or emphysema;
Double
only for patients with cystic fibrosis
Pancreas (when condition is not
treatable by use of insulin therapy)
Allogeneic bone marrow transplants
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 (autologous stem cell and autologous
peripheral stem cell support) for Acute lymphocytic or
non-lymphocytic
leukemia, Advanced 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.
The First Health 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. 26
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2002 Alliance Health Benefit Plan 27 Section
5 (b)
Organ/ tissue transplants continued on next page
Organ/ tissue transplants (continued) You pay
First Health 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 Health 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 Health 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.
PPO benefit not designated as National Transplant Program: If
you do not use a First Health 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
Health 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 Health 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 Health 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.
The First Health 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. 27
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2002 Alliance Health Benefit Plan 28 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
Note: If your PPO provider uses a non-PPO anesthesiologist, we will pay
non-PPO
benefits for the anesthesia charges.
Organ/ tissue transplants (continued) You pay
If
you do not follow the procedures required by the First Health (See above)
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 Health National
Transplant Program
facility. The charges above the maximum payment of $150,000 or $100,000 for
transplants provided outside the
First Health National Transplant Program
do not apply toward your out-of-pocket maximum.
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 Health 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 PPO; 10% of the Plan allowance
Hospital (inpatient)
Non-PPO: 30% of the Plan allowance and any difference between our allowance
and
the billed amount
Professional services provided in
Hospital
outpatient department
Skilled nursing facility
Ambulatory surgical
center
Office 28
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2002 Alliance Health Benefit
Plan 29 Section 5 (c)
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 5( a) and 5( b), in this Section 5( c) the
calendar year deductible applies to only a few benefits. In that case we added
"( calendar year deductible applies)". The PPO
calendar year deductible is: $100 per person ($ 300 per family) and the
non-PPO calendar year deductible is $300 per person ($ 900 per family).
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 Sections 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
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
Inpatient hospital continued on next page
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. 29
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2002 Alliance Health Benefit
Plan 30 Section 5 (c)
Inpatient hospital (continued)
You pay
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,
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
NOTE: We cover hospital services and supplies related to 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
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) 30
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2002 Alliance Health Benefit Plan 31 Section
5 (c)
Extended care benefits/ Skilled nursing care facility benefits
You pay
Skilled nursing facility (SNF): We cover semiprivate room,
board, services, PPO: 20% of the Plan allowance supplies in a SNF for up to 60
days confinement when:
1) you are admitted within 14 days from a precertified hospital stay of at
Non-PPO: 20% of the Plan allowance 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.
Not covered: Custodial care All
charges
Hospice care
Hospice is a coordinated program of maintenance and
supportive care for PPO: Nothing until Plan allowance stops the terminally ill
provided by a medically supervised team under the at $4,500
direction of a Plan approved independent hospice administration. Non-PPO:
Nothing until Plan allowance
We pay $4,500 per lifetime for inpatient and
outpatient services. stops at $4,500
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 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) 31
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2002 Alliance Health Benefit Plan 32 Section
5 (d)
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.
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
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and
the billed amount
PPO: Nothing (No deductible)
Non-PPO: Only the difference between our
allowance and the billed amount
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 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.
Benefit Description You pay After the calendar year deductible
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. 32
32 Page 33 34
2002 Alliance Health Benefit Plan 33 Section
5 (d)
Medical emergency You pay
Outpatient medical or
surgical services and supplies in an emergency room. PPO: $25 copayment
Non-PPO: $25 copayment and the difference between our allowance and
the
billed amount
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 PPO: 10% of the Plan allowance
Note: If hospital treatment requiring special equipment is necessary but not
Non-PPO: 30% of the Plan allowance and locally available, the Plan covers
transportation within the United States any difference between our allowance and
and Canada by professional ambulance, railroad, or scheduled commercial the
billed amount airlines to the nearest hospital equipped to furnish the
treatment.
Note: See 5 (c) for non-emergency service.
Not covered: All charges
Routine transportation necessary to obtain the services of a doctor or
any other practitioner 33
33 Page 34 35
2002 Alliance Health Benefit Plan 34 Section 5 (e)
You may
choose to get care Out-of-Network or In-Network. 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 35.
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Section 5 (e). Mental health and substance abuse benefits
In-Network benefits continued on next page
Benefit
Description You pay After the calendar year deductible
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 Your cost
sharing responsibilities are no we approve. The treatment plan may include
services, drugs, and supplies greater than for other illnesses or conditions.
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.
Professional
services, including individual or group therapy by $15 per visit 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. 34
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2002 Alliance Health Benefit Plan 35 Section 5 (e)
In-Network benefits (continued)
Preauthorization
To be eligible to receive these enhanced mental health and substance abuse
benefits you must obtain a treatment plan and follow all of the following
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 8 for
details. For precertification call 1/ 800-225-4423
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. For
precertification call 1/ 800-225-4423
Network limitation If you do not obtain 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. 30% of our allowance and any difference between our allowance and
the billed
amount for up to 45 visits; all charges after 45 visits
Inpatient and outpatient professional services to treat substance abuse 50%
of our allowance and any difference conditions. between our allowance and the
billed
amount and all charges after the $4000 calendar year maximum
Inpatient care to treat mental conditions includes ward or semiprivate After
a $500 deductible per admission to a accommodations and other hospital charges
non-PPO hospital, 30% of charges for up
to 45 days per calendar year; all
charges after 45 days
Inpatient care to treat substance abuse includes room and board and 30% of
Plan allowance and any difference ancillary charges for confinement in a
treatment facility for rehabilitative between our allowance and the billed
treatment of alcoholism or substance abuse amount and all charges after the
$4000 calendar year maximum
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
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 full
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 4, Your costs for covered services, for
information about catastrophic protection for these benefits.
Section 7,
Filing a claim for covered services, for information about submitting
out-of-network claims. 35
35 Page 36 37
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 37.
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 home delivery pharmacy 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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Section 5 (f). Prescription drug benefits
There are important features you should be aware of. These include:
Who can write your prescription. A licensed physician or licensed dentist
must write the prescription.
Prior authorization. Prior
authorization is required for some drugs. To get a list of these drugs please
call 1/ 800-225-4423.
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
rather than a non-network
pharmacy.
Network Pharmacy Benefit. After satisfying your
combined annual $200 per person prescription drug deductible, you pay 10%
coinsurance for the initial prescription for up to a 30 day supply of medication
(as prescribed by your doctor) and 50%
for each refill.
Merck-Medco Home Delivery Pharmacy Services.
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 Home Delivery Pharmacy 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 10% coinsurance per
prescription for the initial 30 day supply. All 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.
We use a formulary. 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. 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 home delivery the dispensing limit
is a 90 day supply with the initial home delivery 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.
Generic
Equivalent. 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 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.
Why use generic drugs? Generic drugs contain the same active
ingredients and are equivalent in strength and dosage to the original brand name
product. Generic drugs cost you and your plan less money than a name-brand drug.
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.
2002 Alliance Health Benefit Plan 36 Section 5 (f) 36
36 Page 37 38
2002 Alliance Health Benefit Plan 37 Section 5 (f)
Benefit Description You pay After the prescription drug deductible
NOTE: The prescription drug deductible applies to almost all benefits in
this Section. We say "( No deductible)" when it does not apply.
Covered
medications and supplies
Each new enrollee will receive a description of
our prescription drug program, a combined prescription drug/ Plan identification
card, a home
delivery 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 those
listed as Not covered.
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
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 23
Drugs related to treatment of sexual dysfunction, sexual inadequacy or
sexual transformation
Drugs that are investigational or experimental
Drugs prescribed
for weight loss
Network Retail: 10% generic or brand name for the initial prescription. For
all
refills 50% of Plan cost
Non-Network Retail: 10% generic or brand
name for initial prescription and
any difference between our Plan cost and
the cost of the drug. For all refills, 50%
of the Plan cost and any
difference between our cost and the cost of the drug.
Home Delivery: 20% of cost for generic or brand name. 37
37 Page 38 39
2002 Alliance Health Benefit Plan 38 Section
5 (g)
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 hearing TDD services are available
at 1/ 800-259-8179. impaired
High risk pregnancies For assistance you should call First Health 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 Health National Transplant
Program call us at transplant/ heart surgery/ etc. 1/ 800-225-4423 for
more information.
Travel benefit for organ First Health 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. 38
38 Page 39 40
2002 Alliance Health Benefit Plan 39 Section
5 (h)
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.
Non-PPO dental benefit is
subject to a $25 per person and $50 per family calendar year deductible.
We added "( No deductible)" to show when a dental deductible does not
apply.
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
necessary to safeguard the health of the
patient. We do not cover the dental procedure.
I M
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I M
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Section 5 (h). Dental benefits
Accidental injury benefit You pay
We cover restorative services
and supplies necessary to promptly repair PPO: 10% of the Plan allowance (but
not replace) sound natural teeth. The need for these services must result
from an accidental injury. Services must be received within 12 months from
Non-PPO: 30% of the Plan allowance and the date of the accident. any difference
between our allowance and
the billed amount
Dental benefits
Preventive services:
Cleanings
Exams
Flouride treatments
Sealants
Diagnostic
X-rays
Note: Cleanings, exams, flouride treatments and sealants are limited to two
visits per person annually.
Basic restorative care:
Fillings
Note: The annual benefit maximum per person (Combined In-Network and
Out-of-Network) is $500.
Not covered: All charges
Dental
extractions including the removal of impacted teeth
All dental services
and appliances not listed above
Periodontal prophylaxis
Emergency
exams
Charges in excess of the combined annual benefit maximum
PPO: Nothing "( No deductible)"
Non-PPO: 10% of the Plan allowance and
any difference between our allowance and
the billed amount
PPO: 20% of the Plan allowance "( No deductible)"
Non-PPO: 30% of the
Plan allowance and any difference between our allowance and
the billed
amount. 39
39 Page
40 41
2002 Alliance Health Benefit
Plan 40 Section 5 (i)
Section 5 (i). Non-FEHB benefits
available to Plan members
The benefits on this page are not part of the
FEHB contract premium, and you cannot file a