beneFiTs cHarT 2016 - Alignment Health Plan
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BENEFITS CHART 2017 Alignment Health Plan My Choice (HMO) 2017 BENEFIT 001 – Los Angeles, Orange, Riverside, San Bernardino 006 – San Joaquin and Stanislaus 007 – Santa Clara Premium $0 $19 $0 Doctor/Specialist PCP: $0 copay Specialist: $0 copay PCP: $0 copay Specialist: $5 copay PCP: $0 copay Specialist: $0 copay Inpatient Hospitalization $100 copay days 1-3 $0 copay days 4-90 (unlimited days) $0 copay days 1-4 $200 copay days 5-10 $0 copay days 11-90 (unlimited days) $100 copay days 1-5 $0 copay days 6-90 (unlimited days) Emergency Care $75 copay $75 copay $75 copay Urgent Care $0-$25 copay waived if admitted within 24 hours $0-$25 copay waived if admitted within 24 hours $0-$25 copay waived if admitted within 24 hours Worldwide Coverage $0 copay up to $7,500 $0 copay up to $7,500 $0 copay up to $7,500 24 Hour Nurse Hotline $0 copay $0 copay $0 copay Ambulance $125 waived if admitted $100 waived if admitted $175 waived if admitted Transportation $0 copay 22 one-way trips to plan approved locations (within a 20 mile radius) $0 copay 12 one-way trips to Alignment Healthcare Centers (within a 20 mile radius) Not covered Durable Medical Equipment 20% coinsurance for items $350.01 or more 0% coinsurance for items $350 or less 20% coinsurance for items $350.01 or more 0% coinsurance for items $350 or less 20% coinsurance for items $350.01 or more 0% coinsurance for items $350 or less Health Club/ Fitness Class Membership $0 copay $0 copay $0 copay 001 – Los Angeles, Orange, Riverside, San Bernardino 006 – San Joaquin and Stanislaus 007 – Santa Clara Vision Services $0 copay for routine eye exams (1 every year) $75 allowance for contacts/glasses every 2 years. $0 copay for routine eye exams (1 every year) $100 allowance for contacts/glasses every 2 years. $0 copay for routine eye exams (1 every year) $75 allowance for contacts/glasses every 2 years. Hearing Services $0 copay for Medicare covered benefits; $0 copay for exam/ fitting/evaluation 1 per year $0 copay for Medicare covered benefits; $0 copay for exam/ fitting/evaluation 1 per year $0 copay for Medicare covered benefits; $0 copay for exam/ fitting/evaluation 1 per year Dental Services Covered Refer to your Summary of Benefits for details Covered Refer to your Summary of Benefits for details. Covered Refer to your Summary of Benefits for details. 2017 BENEFIT Prescription Drug Benefits (30 day retail supply) Preferred Generic Drugs, T1 $3 copay $5 copay $0 copay Generic Drugs, T2 $5 copay $10 copay $5 copay Preferred Brand Drugs, T3 $30 copay $40 copay $40 copay Non-Preferred Brand Drugs, T4 $75 copay $93 copay $93 copay Specialty Drugs, T5 33% co-insurance 33% co-insurance 33% co-insurance Select Care Drugs, T6 $3 copay $5 copay $5 copay Alignment Health Plan is an HMO plan with a Medicare contract. Enrollment in Alignment Health Plan depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, formulary, premium and/or co-payments/co-insurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. This information is available for free in other languages. Please contact our Member Services number at 1-866-634-2247, TTY: 711, 8:00 a.m. to 8:00 p.m., 7 days a week (except Thanksgiving and Christmas) from October 1 through February 14, and Monday to Friday (except holidays) from February 15 through September 30. Esta información está disponible en otros idiomas sin costo alguno. Por favor comunicarse al Departamento de Membresía al 1-877-399- 2247, TTY: 711, 8:00 a.m. a 8:00 p.m., los 7 días de la semana (excepto el Día de Acción de Gracias y Navidad) desde el 1 de Octubre hasta el 14 de Febrero, y de lunes a viernes (excepto los feriados) desde el 15 de Febrero hasta el 30 de Septiembre. H3815_17028EN ACCEPTED
