1. No category

HMO 3500 Elite Silver Ind CSR
1/1/2017
Member Benefits
Plan Year Deductible
Embedded Deductible
Plan Year Out-of-Pocket Maximum
Combined medical and pharmacy expenses including deductible,
coinsurance amounts and copays.
Silver
Indian Health
Services
Single: $0
Family: $0
Single: $0
Family: $0
Ambulatory Patient Services
In-Network
Member Responsibility
Out-of-Network
Single: $3,500
Family: $7,000
Single: $7,150
Family: $14,300
Not Applicable
Not Applicable
Not Applicable
Not Applicable
Annual Vision Exam
Primary Care Physician Office Visits
Specialty Care Physician Office Visits
Spinal Manipulations
Urgent Care Visits
$0
$0
$0
$0
$0
$20
$30
$65
$65
$75
Emergency Department Visits
Emergency Ambulance Transportation
$0
$0
deductible, $400
deductible, 20%
deductible, $400
deductible, 20%
Outpatient Surgery/Procedures
Inpatient Facility*
$0
$0
deductible, 20%
deductible, 20%
Not Covered
Not Covered
$0
$0
$30
deductible, 20%
Not Covered
Not Covered
$0
$0
$0
$0
$0
$15
$50
$100
Not Covered
Not Covered
Not Covered
Not Covered
$0
$0
$0
$0
40%
40%
40%
$0
Not Covered
Not Covered
Not Covered
Not Covered
$0
$0
$0
deductible, 20%
deductible, 20%
deductible, 20%
Not Covered
Not Covered
Not Covered
MRI and CT Scans
Laboratory and X-rays
$0
$0
deductible, 20%
deductible, 20%
Not Covered
Not Covered
Routine Prenatal Care
Inpatient Maternity Facility*
Inpatient Newborn Facility*
$0
$0
$0
deductible, 20%
deductible, 20%
deductible, 20%
Not Covered
Not Covered
Not Covered
Pediatric Dental Exam
Pediatric Vision Exam
Pediatric Vision Materials
$0
$0
$0
$0
$0
$0
Not Covered
Not Covered
Not Covered
$0
$0
Not Covered
Emergency Services
Hospitalization
Mental Health/Substance Abuse
Outpatient Office Visits
Inpatient Facility*
Not Covered
Not Covered
Not Covered
Not Covered
$75
Prescription Drugs
Retail
Rxtra
Preferred Formulary/Generic - Tier 1
Preferred Formulary/Brand - Tier 2
Non-Preferred Formulary/Brand - Tier 3
Specialty
Preferred Formulary Specialty Pharmacy/Medical - Tier 4
Non-Preferred Specialty Pharmacy/Medical - Tier 5
Non-Formulary Specialty Pharmacy/Medical - Tier 6
Preventive Drugs - Tier 7
Rehabilitative and Habilitative Services
Physical Therapy
Occupational Therapy
Durable Medical Equipment
Diagnostic Services
Maternity
Inpatient newborn covered on
mother's policy up to 96 hours
Pediatric Services
Offered to children up to
age 19
Preventive & Wellness Services
Immunizations, adult and child annual physical exams, mammograms,
PAP smears, cancer screenings and more. Age/frequency schedules
apply.
Health Alliance complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex.
ATENCIÓN: Si habla español, servicios de asistencia lingüística, de forma gratuita, están disponibles para usted. Llame 1-800-851-3379 (TTY: 711). 注
意：如果你講中文，語言協助服務，免費的，都可以給你。呼叫 1-800-851-3379 (TTY: 711).
This plan includes an embedded deductible. An embedded deductible means two or more members have a separate
individual deductible within the family deductible. This gives each member a chance to start receiving their benefits before
the entire family meets the family deductible.
This is a brief summary of Health Alliance benefits and exclusions, which are subject to change. Please refer to
your Health Alliance Policy for detailed information regarding this plan.
*Facility coverage only; physician fees may apply.
mkt 1-2017 IL_IND_PUB SOB HMO 3500 Elite Silver Ind CSR 0616