Benefit Summary

This summary lists your share of Allowable Charges after the Plan pays 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 Coal 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. If you use a Non-Direct ER, you are responsible for any charges above Allowable Charges (balance-billing). Please note that some Alliance Coal 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).

⁵ The Plan pays 100% of Allowable Charges for preauthorized infusion services when the services are provided at an Alliance Coal Direct provider, an on-site Health Center 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 private-duty nursing is limited to a $25,000 lifetime maximum benefit (combined for Alliance Coal Direct and Non-Direct services).

⁸ Coverage for TMJ is limited to a $3,500 lifetime maximum (combined for Alliance Coal Direct and Non-Direct services). This maximum amount also applies to any complications from TMJ treatment.

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.