Benefit Summary

This summary lists your share of Allowable Charges after the Plan pays benefits; be sure to review both the table below and its footnotes, which include important requirements and limitations on various benefits.

See "Highlights of the Plan" for additional information about out-of-pocket limits and other plan features. See "Eligible Expenses" for more details about eligible expenses mentioned below.

All benefits shown are determined based on Allowable Charges. (Non-Direct providers will bill you for any deductible/coinsurance/copay amounts that are your responsibility to pay. In addition, their bill might also include “balance bill” amounts above the Plan’s Allowable Charges. If you have questions or would like to discuss your options for addressing a balance bill with your provider, contact Member Services at (855) 979-5192.)

Footnotes

¹ Coverage for the following services is limited to the specified number of days, visits, or injections, combined for Alliance Direct and Non-Direct providers:

• Acupuncture: up to 25 visits per calendar year
• Home health care: up to 120 visits per calendar year
• Inpatient hospital and/or residential treatment center: up to 180 days per calendar year, combined
• Skilled-nursing facility: up to 90 days per calendar year
• Speech, occupational, or physical therapy: up to 25 visits per calendar year for each type of therapy

² To avoid a benefit penalty, preauthorization must be obtained as soon as possible before receiving scheduled, nonemergency services or products. For a detailed listing of services and products for which preauthorization must be obtained, see "Appendix C: Services and Products that Require Preauthorization." Failure to obtain preauthorization when required will result in a 25% benefit penalty (100% benefit penalty for transplants). As with all claims, any services determined not to be medically necessary will not be covered.

³ Coverage for chiropractic includes related office visits and eligible services billed and performed by the chiropractor, osteopath, or other medical professional who provides spinal manipulation services.

⁴ If you are admitted to the hospital, the copay still applies. Also, if you are admitted at a Non-Direct hospital, deductible and coinsurance apply to any inpatient hospital services, as noted in this Benefit Summary (except as otherwise required by law). If you use a Non-Direct ER for items or services that are not emergency services, you are responsible for any charges above Allowable Charges (balance-billing). Please note that some Alliance Direct ERs utilize Non-Direct providers for certain physician services and/or ancillary services (such as anesthesiologists); at a Direct ER, the Plan will cover those Non-Direct services at 100% of Allowable Charges, but you are responsible for any charges above Allowable Charges (balance-billing) unless applicable law prevents balance-billing. Please see “Surprise Billing Protections” for more information about certain balance-billing protections.

⁵ The Plan pays 100% of Allowable Charges for preauthorized infusion services when the services are provided at an Alliance Direct provider, an on-site clinic or an alternate site (including at-home administration) arranged through Care Coordination.

⁶ To be covered, preventive care services must not exceed certain frequencies. Coverage for preventive care includes related office visits and services (such as lab tests and X-rays) if not billed separately and if the primary purpose of the visit is the preventive care.

⁷ Coverage for TMJ is 100% of billed charges, up to a $3,500 lifetime maximum (combined for Alliance Direct and Non-Direct services). This maximum amount also applies to any complications from TMJ treatment. If the treatment plan for TMJ includes orthodontia appliances, the orthodontia expenses will be covered by the Medical Plan’s TMJ benefit until this $3,500 lifetime maximum is exhausted, and then the Dental Plan’s orthodontia coverage will apply.

Other services may be covered at benefit levels that are different from the levels listed above. For example, see “Eligible Expenses” for information about coverage for certain cosmetic treatments to restore normal physical function.