• Single Coverage - you only
• Double Coverage - you and one dependent (spouse, domestic partner or child)
• Family Coverage - you and two or more dependents.

• Your legally married spouse or domestic partner (must submit notarized Declaration of Domestic Partnership)
• Your or your legally married spouse’s unmarried children defined as:
  • Biological child(ren)
  • Legally adopted child(ren) or child(ren) placed with you for adoption
  • Child(ren) for whom you or your legally married spouse have documentation of legal guardianship
  • Your handicapped children of any age if they become unable to earn a living before they reach age 19 or before age 25 if they are full-time students (documentation will be required)
  • Your non-custodial child(ren), as required by any qualified medical child support order [(“QMSCO”, as defined by ERISA Section 690(a).]

Unmarried dependent children can be covered until:

• The end of the year in which they attain age 19; or
• The end of the month in which they attain age 25 if they are enrolled as full-time students; or
• The end of the month in which they are no longer enrolled as full-time students. (Note: you may be required to annually submit proof of student status on your children age 19 or older.)

Documentation may be required to establish your relationship with any dependent you wish to cover on your benefits and to establish full-time student status.

Alliance Select Plan
Alliance Select (referred to in this Medical Plan section of the booklet as the “Plan”) is a managed care point-of-service plan that provides coverage through network providers, but also includes some out-of-network coverage. The out-of-network feature allows you to receive some services at reduced levels of payment if you use a provider who is not part of the Alliance Select network. Please note that it is your responsibility to determine whether a provider is in the Plan’s network or not before using that provider’s services.

In order to administer the network feature of the Plan, you are required to choose a network doctor (family practitioner, general internist, or for minors, a general pediatrician) to serve as your primary care physician (PCP). You are not required to use your network PCP or, for that matter, any network provider. However, you must choose a network PCP even if you elect to utilize out-of-network services on a regular basis. Your PCP is responsible for providing general care as well as to act as an advisor when you are in need of emergency care, urgent care, or care from a specialist.

Referrals from your PCP are not required to obtain care from a network specialist, but you are strongly encouraged to consult with your PCP before obtaining any specialized care.

Pre-authorizations (a mandatory process for acquiring approval by the Plan) for most medically necessary surgical and diagnostic testing procedures are not required; however, pre-authorizations are required for some services, equipment and drugs. Network providers are aware of services and treatments requiring pre-authorization and in most cases they will handle this for you. Discussing your treatment plan in advance with a network physician will help to avoid non-covered and out-of-pocket expenses for you. If you choose to use out-of-network providers, you are responsible for all pre-authorization requirements. Pre-authorization is not a guarantee of benefit payment since all terms and conditions of your Plan apply in determining your coverage for the procedure, service, supply or charge.

There is no preexisting condition limitation under the Alliance Select Plan. For both network care and out-of-network care, there is a $2,000,000 Lifetime Maximum Benefit.

Coverage
Refer to the “Summary Table of Benefits” section of this booklet for detailed information concerning the level of coverage, copayments, co-insurance, deductibles, and other charges and costs. In addition, the “Summary Table of Benefits” provides important information on benefit amount limits and/or day limits that apply to specific services.

In-Network Care
When you use network providers, you don't have to meet an annual deductible before the Plan begins to pay for covered care. Also, you are not responsible for billed charges that exceed the reimbursement amount determined by the Health Alliance for payment of covered services, referred to as the “network rate.” However, there are some out-of-pocket expenses that you will pay for services that are not covered at 100% by the Plan.

• All covered services rendered in a hospital, emergency room, urgent care center or other outpatient setting are paid by the Plan at 90%. For emergency services that are provided in an emergency room, you pay an additional $75 copayment that is waived if you are immediately admitted to the hospital. The Plan does not pay a benefit when treatment is given in an emergency room for non-emergent care. When urgent care is provided at a network urgent care facility, you pay an additional $30 copayment.
• You pay a $25 copayment on most office visits; then the Plan pays 100% on covered evaluation and management services, well care, preventative care, cancer screening and laboratory services. All other covered office testing and treatment for an illness, disease or injury are paid by the Plan at 90%. This includes all other diagnostic, therapeutic and surgical procedures.
• You pay a 25% co-insurance on covered prescription drugs that are included on the Plan’s list of preferred drugs, otherwise known as the “formulary.” There is a minimum charge of $10 for generic drugs and $20 for brand name drugs with a $40 maximum charge per drug. There is no coverage for non-formulary drugs purchased without prior approval by the Plan.

The Plan limits your annual out-of-pocket expenses on some covered services to $2,000 per member, limited to $6,000 per family (3 or more members). The annual out-of-pocket maximum applies to most inpatient, outpatient and office visit co-insurance amounts. However, it does not apply to all copayments, co-insurance on prescription drugs, durable medical equipment, medical/surgical supplies for home use and mental health/substance abuse services. You are responsible for all excluded out-of-pocket amounts as well as expenses applied to the annual out-of-pocket maximum.

Out-of Network Care
When you go out-of-network by using the services of providers who do not participate in the Alliance Select Plan, you are required to pay an annual deductible amount before the Plan begins to pay a benefit. Each year you pay the first $300 per member, limited to $900 per family (3 or more members) of covered services. You are responsible for billed charges that exceed the reimbursement amount determined by the Health Alliance for payment of covered services, referred to as the “network rate,” as well as any out-of-pocket expenses that are not covered at 100% by the Plan.

• All covered services rendered in a hospital, urgent care center or other outpatient setting are paid by the Plan at 60% of the network rate. When urgent care is provided at an out-of-network urgent care facility, you pay an additional $30 copayment. For emergency services that are provided in an emergency room, you pay an additional $75 copayment that is waived if you are immediately admitted to the hospital. The Plan does not pay a benefit when treatment is given in an emergency room for non-emergent care. If you are admitted to the hospital as an emergency admission, benefits will be paid as in-network as long as medical treatment in the out-of-network hospital is determined by the Plan to be medically necessary.
• The Plan pays 60% of the network rate on most office visit expenses that are necessary for the evaluation, testing, management, and treatment of a medical condition. This includes diagnostic, therapeutic and surgical procedures. Among other services that are not covered by out-of-network providers, the Plan does not cover most well care, preventative care and cancer screenings. Please refer to the "Summary Table of Benefits” for more details on services that are excluded from out-of-network coverage.
• If you purchase prescription drugs that are included on the Plan’s formulary from an out-of-network pharmacy, you may submit charges to the Plan for reimbursement. The Plan reimburses the amount that it would have paid if you purchased the drug from a network pharmacy. This holds you responsible for 25% co-insurance (minimum charge of $10 for generic drugs and $20 for brand name drugs with a $40 maximum charge per drug) plus any cost exceeding the network rate. There is no coverage for non-formulary drugs purchased without prior approval by the Plan.

The Plan limits your annual out-of-pocket expenses on some covered service to $4,300 per member, limited to $10,900 per family (3 or more members). The annual out-of-pocket amount includes the applicable annual deductible of $300 per member, limited to $900 per family (3 or more members) and applies to most inpatient, outpatient and office visit co-insurance amounts. However, it does not apply to all copayments, co-insurance on prescription drugs, durable medical equipment, medical/surgical supplies for home use, mental health/substance abuse services and provider charges that exceed the network rate. You are responsible for all excluded out-of-pocket amounts as well as expenses applied to the annual out-of-pocket maximum.