Healthcare Coverage Made for You 2021 Member Handbook
When it comes to coverage, it’s all about you. Welcome to a health plan made with you in mind – access to doctors you trust, perks you deserve and customer service reps always ready to help. We’re happy you’re here and are excited to help you use your plan and all its perks made to fit your needs. Thanks for being a member.
2 | 2021 Member Handbook
Your Steps to Getting Started Member Name Member ID Job ID
ROBERT R FLAVIN 941048321 1045
1. W e mail you an ID card shortly after you enroll to keep in your wallet. (Plus, you can access a digital ID card by logging in to hally.com about 10 days before your plan starts.)
Member Name: Member Number: Subscriber Name: In-Network Copay/Coinsurance: Office Visit: Specialty Visit:
Processed Date 10/ Expected Mail Date Actual Mail Date
Group #: Rx BIN: 005947 Rx PCN: CLAIMCR Rx GRP: HA0017 Emergency:
Date Card Printed:
2. Make sure your doctor’s office and pharmacy have your new ID card on file. 3. K now where to find your secure member information using hally.com and the HallyŽ app. Visit the App Store or Google Play to download.
4. If you have questions, call Customer Service at (877) 749-3302 (TTY 711). App Store is a service mark of Apple Inc., registered in the U.S. and other countries. Google Play and the Google Play logo are trademarks of Google LLC.
2021 Member Handbook | 3
Your Care and How It Works Your plan is made to give you access to the care you need from a large network of providers you trust.
In-Network Care You have access to a group of doctors, hospitals, pharmacies and other providers who agree to give you care at a discounted rate. Log in at hally.com, use the Hally app or call Customer Service to find in-network doctors, hospitals and pharmacies.
Out-of-Network Care If you have a point of service (POS) or preferred provider organization (PPO) plan, you have access to out-of-network coverage. You generally pay more when you use a provider that isn’t in your network because those providers don’t have an agreement with the health plan. If you have a health maintenance organization (HMO) plan, you can go out of network in emergency situations.
4 | 2021 Member Handbook
In-Network Specialty Care We don’t require you to get a referral to see an in-network specialist, but your doctor might. Check with your doctor before you see a specialist or other provider to make sure you’ve taken the proper steps. If there’s no in-network specialist to treat your specific condition, we’ll help you find one. And you’ll still pay the in-network cost if you get it preauthorized by us.
Your Care Options When you get sick or injured, it’s sometimes hard to know where to go for care. Your plan is made with plenty of options for different situations based on how severe your condition is, where you are and other factors.
Anytime Nurse Line
Emergency Care
Call (855) 802-4612. Get 24/7 answers to your health questions, like whether you need to set up an appointment or see a doctor right away.
Some injuries or illnesses require emergency care, but if your injury or illness doesn’t require immediate medical attention, calling your doctor or going to an urgent care clinic (sometimes called convenient care or a walk-in clinic) can save you time and money. Going to the emergency department for non-emergencies can drive up costs for you and healthcare overall, and the emergency department doesn’t know your full medical history like your doctor does. Plus, it usually has long wait times.
Virtual Health Coverage You can connect with a healthcare provider when and where you need care by phone or online with virtual health coverage. Learn more on page 9.
Primary Care Provider (PCP) Try setting up an appointment with your PCP if your injury or illness isn’t an emergency. Your PCP knows your health history and helps oversee your care.
Urgent Care (Convenient Care or Walk-In Clinic) If you can’t get an appointment with your PCP or you’re traveling, go to urgent care if your injury or illness isn’t an emergency. This can help you save time and money compared to the emergency department. You may need to pay upfront at some urgent care facilities but will be reimbursed. Pay attention to your bills to make sure you’re billed for urgent care. If your service is billed as a traditional office visit and is out of network, coverage may be denied on HMO plans.
lways go to the emergency A department or call 911 if you experience: • Stroke symptoms. • Chest pains. • Head or spinal injuries. • Severely broken bones. These are examples, not a complete list. If you think your condition is a life-threatening emergency, call 911 or go to the nearest emergency department. Then, after you’ve received treatment, contact your PCP and us. This will help us coordinate your care after your visit. Your plan covers emergency and urgent care out of network, so even if you’re traveling, you can still get the care you need without having to worry about finding an in-network facility. 2021 Member Handbook | 5
Your Pharmacy Coverage Plans with pharmacy coverage built right in help you keep all your coverage in one place and help you save with special programs and discounts made for you.
Prescriptions
Drug Formulary
Where you get your drugs filled matters. Log in at hally.com, use the Hally app or call Customer Service to find an in-network pharmacy near you.
You can find a list of drugs covered by your plan, including the payment tier for each drug, using the formulary. Drug coverage is voted on by the P&T (Pharmacy and Therapeutics) committee. It consists of a group of clinical pharmacists, medical directors and doctors in various specialties.
Before you go, check the drug formulary for your drug’s tier at hally.com or on the Hally app. You typically pay the lowest price for a Tier 1 drug. Your provider can call our Pharmacy department at (800) 851-3379 (option 4) to ask about lowercost options for your drugs.
See the list of drugs we cover in our formulary at HealthAlliance.org/Pharmacy.
6 | 2021 Member Handbook
Mail-Order Discount You can order a 90-day supply of prescription drugs through the mail for a discounted rate. Learn more about the program by calling OptumRx, your pharmacy benefits manager, at (800) 763-0044.
Your Team Your plan is made for more than when you’re sick. It’s made to help you stay healthy in the first place, so you have a team of health coaches, care coordinators and more to help you with both.
Care Coordinators Whether you’d like to speak to a dietitian, want to quit smoking or need help understanding a recent diagnosis, we have teams to help you achieve your goals or get you back on track. Connect to a team of providers, like nurse practitioners, social workers, health coaches, dietitians, pharmacists and more, who work with your doctor to make sure you have the resources you need to stay healthy or work through your medical issues. The care coordination team reaches out to offer these free services, but you can also request them if you’d like this personalized help.
Set and reach health and wellness goals.
Find helpful resources.
Understand and manage health issues, like diabetes and asthma.
Care for yourself to help prevent illness and hospital stays.
Coordinate your care when you have complicated health conditions.
Use your health benefits to save money.
Your Community We like to get out and meet members of the entire community. We’ll be at health fairs, senior expos and other events ready to educate and talk with you and others throughout the area. Led by our team of liaisons, we’re excited to get to know you. 2021 Member Handbook | 7
Your Health at Your Fingertips We know with everything going on in life, staying healthy is easier said than done. That’s why Hally® health is all about helping you live your healthiest life. You can find plenty of resources and support – with no login or extra steps needed – at hally.com.
Get access to: • Exercise
classes, health courses and cooking demos. • The Hally blog. • Hally Healthcast, a monthly podcast led by medical experts. • Health tips, coaching and information on care coordination. • Tools and resources for asthma, diabetes and high blood pressure. • And lots more. You can also download the Hally app or sign in to hally.com to stay in the know. Once you log in, you get instant, secure access to your coverage anytime, anywhere.
You can: • See
all your account activities in one place. your virtual ID card. • Search for doctors and other resources. • Quickly connect with a doctor over virtual visits. • Get cost estimates. • Access
Visit hally.com for more information, and find the Hally app on the App Store or Google Play.
8 | 2021 Member Handbook
Here’s a little more info on what Hally health can do for you: Anytime Nurse Line, (855) 802-4612
Treatment Cost Calculator
Get 24/7 answers to your health questions, like whether you need to set up an appointment or see a doctor right away.
Estimate what your out-of-pocket costs will be for thousands of treatments and tests.
Fitness Allowance Program Get up to $20 per month toward the cost of a fitness class or membership at a participating fitness center. Members and their dependents (18 years or older) are eligible for the program. The monthly allowance for fitness classes or membership doesn’t carry over month to month. Your card will be reloaded each month.
Call Customer Service for more information and to request your card.
Managing Chronic Conditions Get help staying on track if you have asthma, diabetes or high blood pressure. We connect you to resources, support and reminders.
Virtual Health Coverage Get care when and where you need it with virtual health coverage. If you need to interact with your primary care provider (PCP) or specialist over the phone or online, you’re covered through the telehealth benefit. You don’t even need to leave the comfort of your home. Learn more about telehealth on page 13. You can also get on-demand care for common conditions like allergies, cold, flu and pink eye from anywhere you have phone or internet connection in the U.S.* Whether at home or traveling, you can talk to a board certified doctor or counselor by phone or secure video through the Hally app or hally.com at any time of the day, any day of the year.
Go to hally.com/care to log in and get access to this immediate care. * Not available to members on transitional plans.
2021 Member Handbook | 9
Your Perks and Programs Your plan is made with plenty of perks and programs to help you with your health goals.
Active&Fit Direct™
Assist America®
Join one of 10,000+ fitness centers nationwide for just $25 a month (plus a one-time $25 enrollment fee and applicable taxes). For more info, go to HealthAlliance.org/Active-Fit-Direct.
Get expert medical help when you’re 100 miles or more from home. Go to HealthAlliance.org/ Assist-America to learn more. Other conditions and exclusions may apply.
The Active&Fit Direct program is provided by American Specialty Health Fitness, Inc., a subsidiary of American Specialty Health Incorporated (ASH). Active&Fit Direct and the Active&Fit Direct logos are trademarks of ASH and used with permission herein.
Acupuncture Benefit must be for headache, neck pain or lower back pain diagnoses. • You don’t need preauthorization. • You can choose any acupuncture provider. A per-visit copay may apply (varies by plan). • You or your provider should submit claims using the information on the back of your ID card.
If you have an HMO plan, all Assist America benefits do apply. Don’t forget, Health Alliance Northwest™ only covers your emergency care while traveling. Assist America will not pay you back for ambulance or other services you arrange on your own. In a life-threatening emergency, always call the ambulance right away.
• Treatment
10 | 2021 Member Handbook
LifeBalance Access thousands of discounts to start saving on healthy and fun activities through our LifeBalance program. Go to HealthAlliance.org/ Life-Balance and log in to start saving in areas like fitness, travel, movie tickets and more.
Your Perks and Programs (continued)
Quit For Life®
Preventive Care
Get help ending your tobacco use with:
Focus on preventing sickness and catching problems before they get worse with these covered services and more:
• One-on-one
coaching from a quit coach. plan made just for you. • Helpful tools, like Text2Quit®. • Web Coach®, an online learning and support community. • Quit
Go to HealthAlliance.org/Quit-For-Life for more information.
• Yearly
wellness visit. sugar screening. • Cervical cancer screening. • Childhood vaccines. • Colorectal cancer screening. • Flu shot. • Well-child care. • Blood
Hearing Services Get one routine hearing exam for a $75 copay when you see a TruHearing® provider and lowered rates on up to two TruHearing hearing aids per year. Learn more at TruHearing.com. Or you can get access to comprehensive hearing services at any in-network hearing provider (when medically necessary) up to a certain cost. See the Your Comprehensive Hearing Benefits flier for details or call Customer Service.
2021 Member Handbook | 11
Processes Made for Peace of Mind Your plan has processes in place to help make sure you’re getting the proper treatment.
Prior Authorization
Explanation of Benefits
For specific drugs or services, your doctor must request prior authorization to make sure you meet certain requirements before we’ll cover them. To find out if a drug or service requires prior authorization, please refer to your policy document.
After you visit your doctor or receive medical services, you get an Explanation of Benefits (EOB) showing the cost of the service, how much we paid on your behalf and the amount you may still owe.
Providers can submit a prior authorization one of the following two ways: • Submit
a prior authorization request through our provider website.
• Fax
a prior authorization form to (217) 902-9798.
Decisions are made within 24 to 72 hours of your provider’s request.
12 | 2021 Member Handbook
Claims Issues Always call us first (at the number on the back of your ID card) for claims questions. We can check if the claim was properly submitted to us and whether it has been paid. We also can help you with next steps.
Helpful Terms Benefit Period
Generic Drugs
The stretch of time your plan covers you (for example, January 1 to December 31). See your plan materials for your benefits’ start and end dates.
Drugs with the same active ingredients as the brand-name versions reviewed and approved by the Food and Drug Administration (FDA). They cost less because their makers don’t have to spend money on research, development and marketing.
Contribution The monthly premium you pay for coverage.
Coinsurance
Out-of-Pocket Maximum (OOPM)
The fixed dollar amount you pay for services at a doctor’s office, pharmacy or hospital.
Your plan pays 100% of covered expenses for the rest of the plan year after you reach this amount. You’ll no longer pay copayments or coinsurance, just your monthly premium. Tier 1 and Tier 2 services both apply to the in-network OOPM. If using Tier 3 out-of-network services, you may need to cover costs above the OOPM.
Deductible
Prior Authorization
The amount you pay before your benefits kick in. Some plans have separate medical and pharmacy deductibles.
A review process your doctor must request for a specific drug or service to make sure you meet certain requirements before the health plan agrees to cover it.
The percentage you pay for services at a doctor’s office, pharmacy or hospital.
Copayment
Dependents Children or a spouse covered on your plan.
Primary Care Provider
Formulary
A personal doctor you choose to oversee your care.
A list of drugs covered by your plan, including generic and brand-name drugs. Log in at hally.com or on the Hally app to find your plan’s list of drugs.
Telehealth Remote healthcare you get from a primary care provider or specialist over the phone or online.
Customer Service (877) 749-3302 (TTY 711) Weekdays 8 a.m. to 5 p.m. HealthAlliance.org
2021 Member Handbook | 13
GPMBHA21-NTWmbrhandbook-0920