Alliance Medicare PPO
PPO
hap.org/medicare
Prospective members:
If you have questions, or for full information about our benefits, enrollment periods or plan network, call a licensed HAP Medicare Sales Representative toll-free at:
(800) 868-3153 or TTY/TDD (800) 649-3777
Current members:
If you have any questions, please contact Client Services toll-free at:
(800) 801-1770 or TTY/TDD (800) 649-3777
For your convenience, our office hours are:
October 1 through February 14
8 a.m. to 8 p.m., seven days a week
February 15 through September 30 8 a.m. to 8 p.m., Monday through Friday
8 a.m. to noon, Saturday
Outside of those business hours, you may access our Interactive Voice Recording
system at the same number and leave your name and phone number. A HAP Medicare
Customer Service Representative will return your phone call the next business day.
If you prefer, you can mail your questions to:
HAP Client Services, Attn: Medicare 2850 W. Grand Boulevard
Detroit, MI 48202
hap.org/medicare
Ask. Learn. Understand your Medicare. With a little help from HAP.
© 2013 Health Alliance Plan of Michigan. A Nonprofit Company.
Y0076_PPO 2014012 PPO FF BRO CMS ACCEPTED 09/09/2013
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We can all use a little reassurance.
A focus on living a full and healthy life: Yours.
To achieve and maintain good health, be sure to choose a good partner. One that looks
out for your overall well-being and supports your efforts to achieve a healthy lifestyle.
HAP’s focus on healthy living starts with ensuring you have access to a full range of
qualified doctors, hospitals and other health care providers. It doesn’t stop there.
Alliance Medicare PPO offers a choice of plans that combine value with built-in flexibility,
giving you control over which doctors and specialists you see.
We are committed to working with you, providing information and programs that can
better help you achieve the best health possible so you can enjoy doing everything you
love to do.
A plan that’s your health partner.
That’s Alliance Medicare PPO.
Alliance Medicare PPO is a Medicare-approved plan from Alliance Health and Life
Insurance Company (Alliance). Alliance is a wholly owned subsidiary of Health
Alliance Plan (HAP), a nonprofit, Michigan-based company that has been serving the
community for more than 50 years and Medicare beneficiaries for 25 years.
You can tell how much your friends truly care by the little things they do for you.
Shouldn’t you expect as much from your health plan? We think so. That’s why Health
Alliance Plan (HAP) offers this booklet and many other resources to help you make
sense out of an important decision that affects you and your family. In this booklet we
will share the main points, as well as the extras, you can expect when you decide on a
HAP Medicare Solution.
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Looking out for your well-being.
A dedicated team.
When you are a member of Alliance Medicare
PPO, you can select from any Medicareparticipating doctor or hospital. For greater
savings, you can elect to receive care within
our approved network of thousands of
doctors and specialists, every hospital in the
nine counties of southeast Michigan, and
dozens of other health care facilities.
Working closely with this extensive network of providers, HAP’s goal is to continuously
improve the quality of care, help you better control chronic conditions and uncover
medical conditions before they lead to more serious health issues. As a team, we work
together to improve your well-being.
Inspired customer service.
Customer service is deeply rooted in the HAP culture. It is what each HAP employee
strives for each day with every phone call, every email, every member touchpoint. We
make it easy so you can focus your attention on doing what’s best for you and your family.
One of the ways we provide this high level of service is by making sure as a new HAP
member, you have your very own Personal Service Coordinator – someone fully trained
in our Medicare plans, who understands the decisions you face and has the answers to
your questions.
Your Personal Service Coordinator is here for you, ready to provide assistance, explain
plan details and introduce you to special programs designed to help you improve and
maintain your health.
After the first two years as a HAP member, whenever you want extra assistance or
information, you can call any of our Medicare Customer Service Representatives. These
are dedicated men and women who specialize in Medicare, work here in southeast
Michigan, and can access your plan records immediately.
Taking care of you wherever you go.
You are covered for emergencies and urgent care at home as well as when you travel
anywhere in the world. Your copay is the same no matter where you are. You also have
access to prescriptions from our network pharmacies across the United States.
As a member of Alliance Medicare PPO, you can also use any Medicare-participating
doctor or hospital in the United States. Out-of-network benefits may apply.
We also provide our members Assist America®*, a valuable program for our members
who travel. Anytime you travel at least 100 miles from home or outside the U.S. for up
to 90 days, a single phone call is all it takes to put Assist America in motion on your
behalf 24/7. Some of its fully paid services include emergency medical evacuation,
medical repatriation, and assistance with lost luggage and lost documents.
The Flexible Health Options Benefit.
Have fun.Get fit. Stay fit.
As a member of Alliance Medicare PPO, you automatically receive a Flexible Health
Options benefit of up to $40 monthly ($480 annually)**. You can use your Flexible
Health Options benefit for any qualified program or activity you choose – anywhere.
You select the programs that fit you best.
• Membership at a gym, health club or fitness
facility of your choice where you can choose
the type of exercise you like best – fitness
classes, swimming, yoga, aerobics, Tai Chi,
weight training and more.*** If you travel,
choose a membership with a nationwide –
or worldwide – network of facilities
• Fitness membership and classes that focus on
weight management, such as Weight Watchers®
*Assist America does not replace your HAP coverage. You are covered for urgent and emergency care based on your HAP member contract. **Amount varies by plan. See chart on pages 8 and 9. Unused amounts cannot be carried over month to month. The Flexible Health Options benefit may be available in some of our group-purchased plans.
***Facilities must meet Medicare guidelines and provide each member with an orientation to
the facility and equipment.
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Your choice of doctors.
We’re always here to help you.
As an Alliance Medicare PPO member,
you can choose:
To help you stay healthy and active,
we provide you the latest health-related
information. You also have access to
HAP health and wellness programs that
can help you:
• Any Medicare-participating
doctor or hospital in the U.S.,
or
• Doctors and hospitals who
participate in our approved
network within the nine
counties in Michigan.
Alliance Medicare PPO. The benefits you need.
Original Medicare covers many hospital and medical expenses. But there are expenses
you may be paying if you only have Medicare. For example, Medicare Part A has a
deductible of $1,184* for hospitalization that you pay before your Medicare coverage
begins. If your hospital stay is more than 60 days, you begin paying a copay of $296*
per day and, after 90 days, your copay doubles. These out-of-pocket expenses can pose
serious financial consequences.
Alliance Medicare PPO can reduce these expenses significantly. Plus, Alliance Medicare
PPO out-of-pocket costs – including premiums – may cost less than Original Medicare,
a Medicare Supplement (Medigap) plan and a Medicare Prescription Drug Plan combined,
while giving you more health care coverage and additional benefits like our wellness
programs, our disease management program and emergency care worldwide.
Serving Medicare beneficiaries in nine counties.
Alliance Medicare PPO serves people with Medicare who live in Wayne, Oakland, Macomb, Genesee, Lapeer, Livingston, Monroe, St. Clair or Washtenaw county.
*These are 2013 amounts. 2014 amounts may be higher.
Alliance Medicare PPO covers your care,
whether it is in- or out-of-network, with
no referrals. Your costs may be higher
when using out-of-network providers.
In addition, you have coverage anywhere
in the world for urgent and emergency
care at the same copay you pay at home.
• Learn the fundamentals
of good health
• Eat healthier
• Quit smoking
• Prevent disease
In addition, special programs and
services such as CareTrack® are
available to help people with chronic
disease stick with their prescribed
treatment plan in order to improve
their quality of life.
A significant value.
When you choose Alliance Medicare
PPO, you are choosing coverage that
focuses on your overall health and
well-being and gives you control over
which doctors and specialists you see.
You have access to the health care
you need whenever and wherever you
need it – including preventive care and
wellness programs. You even have
help paying for memberships at fitness
centers or in weight management
programs.
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Original Medicare
Which option is right for you?
This chart summarizes some of the key
benefits for each Alliance Medicare PPO
plan option. On the pages that follow,
you will find additional information
about prescription drug benefits, optional
dental plans and preventive services.
Monthly Plan Premium*
Maximum Out-Of-Pocket cost**
Hospital and Part B deductibles
(must be paid before coverage begins)
Primary doctor’s/specialist’s office visits
Hospital coverage
Please review the Summary of Benefits
to learn more about each plan option
before making a decision about your
coverage.
Option 1
In-network
Option 2
In-network
Option 1/Option2
Out-of-network
$124
$203
No additional
premium
No limit
$1,184† per hospital stay, $147†
annually for medical services
Option 1: $250 deductible in- or out-of-network
Option 2: No deductible in- or out-of-network
20% of Medicare-approved
amount
$20/$40 per visit
$15/$30 per visit
25%/20%
$1,184 † Deductible
Days 61-90: $296† per day
Days 91-150:
$592† per day
$125 per day
first 5 days
$100 per day
first 5 days
$300/$250 per day
first 5 days
Days 1-20: $0† per day
Days 21-100: $148† per day
Unlimited days
Doctor’s services included
Days 1-20: $0† per day
Days 21-100: $148 † per day
Minimum 3-day prior
hospital stay
Home health care
Standard X-rays and lab tests
Preventive services
Hospital outpatient/ambulatory surgery center
Eyeglasses or contacts
(Beyond Medicare-covered benefit )†††
Worldwide emergency/urgent care
Ambulance
Flexible Health Options
Prescription coverage
(Copays shown for 30-day supply)
$10,000 in- and
out-of-network
$3,401
150-day limit
Doctor’s services not included
Skilled nursing facility
*You must continue to pay your Medicare
Part B premium. Your Alliance monthly
premium may be reduced if you qualify for
extra financial assistance.
**Limit on the total of deductibles, copays or
coinsurance you might pay for Part A and
Part B services during the calendar year.
After you have reached the Maximum OutOf-Pocket cost for covered services, you will
have no more copays or coinsurance for
the rest of the year for those services. Your
monthly plan premiums, prescription drug
costs and non-Medicare-covered services
such as dental or eyewear do not count
toward your Maximum Out-Of-Pocket cost.
See page 17 for more information.
***Original Medicare coverage is available
only within the United States, except
under limited circumstances for medical
emergencies.
†These are 2013 amounts. 2014 amounts
may be higher.
††Unused amounts cannot be carried over from month to month.
‡ Except for approved lab services.
†††All members are covered for eyeglasses after cataract surgery.
Medicare Part B Premium
Alliance Medicare PPO
Days 1-20:
$100 per day/
Days 21-100:
$145 per day
No prior hospital stay required
$0†
$0
25%/20%
20%‡
$0
25%/20%
Limitations on coverage
$0/office visit copay
(See page 16 for details)
25%/20%
20% coinsurance
Not covered
20% coinsurance
Coverage only within U.S.***
$100 facility fee
$25 copay per visit for radiation/chemo/ESRD
Not covered
25%/20%
Option 1: One pair every 2 years in- or out-of-network
Option 2: Not covered
$65/$35 copay, worldwide coverage
Copay is waived if you are admitted to the hospital
$75
20% coinsurance
Not covered
$75 facility fee
Benefit up to $25/
month†† ($300/year)
Benefit up to $40/month††
($480/year)
No deductible
$2/$15/$45/33%/33%
$150 deductible (Brand only)
$4/$10/$40/29%/29%
Coverage in Gap
See page 10 for details
25%/20%
No network applies
Nationwide
pharmacy network
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Convenient pharmacies.
Alliance Medicare PPO covers both
Brand-name and Generic prescription
drugs at thousands of pharmacies in
our network including retail, mailorder, medical center, long-term-care
facility and Indian Health, Tribal and
Urban pharmacies.
Prescription coverage
for today and tomorrow.
Deductible
Tier and Category
Initial Coverage Limit: $2,850** 1 Preferred Generic
2 Non-Preferred Generic
The combined drug costs
3 Preferred Brand
paid by you and the plan.
4 Non-Preferred Brand
5 Specialty Tier
Coverage Gap*** (Donut Hole)
Catastrophic Coverage:
After you pay $4,550 in annual
out-of-pocket costs**
Tier 1
Tier 2
Alliance Medicare PPO
Prescription Drug Benefits
Option 1
Option 2
$0
$0 Generic
$150 Brand†
$30-day supply*:
$2
$15
$45
33%
33%
$4
$10
$40
29%
29%
72%
72%
30-day supply*:
$4
$10
Tiers 3, 4, and 5
47.5% (plus applicable dispensing fee)
Tiers 1 and 2
$2.55 or 5% whichever is greater
Tiers 3, 4, and 5
$6.35 or 5% whichever is greater
If you travel, you can get your
prescription drugs at any network
pharmacy with nationwide locations
(like CVS or Kmart).
Time- and money-saving 90-day supplies
are available at many of our network
pharmacies and through mail order on
medications you take on a regular basis.
If you would like more information
about receiving prescriptions by mail,
call us at the number on this page.
Your licensed HAP Medicare Sales
Representative can answer questions
about your options, our formulary,
our pharmacy network and mail- order
prescriptions.
Questions? Call us toll-free
at (800) 868-3153 or
TTY/TDD (800) 649-3777.
For your convenience from October 1
through February 14, our office hours
are 8 a.m. to 8 p.m., seven days a week.
During the rest of the year, our regular
office hours are Monday through Friday,
8 a.m. to 8 p.m. and Saturday, 8 a.m.
to noon. Outside of those business
hours, you may access our Interactive
Voice Recording system at the same
number where you can leave your name
and phone number. A HAP Medicare
Customer Service Representative
will return your phone call the next
business day. Or you can write to us at:
HAP Client Services
Attn: Medicare
2850 W. Grand Boulevard
Detroit, MI 48202
All drug prices are based on the Alliance-negotiated price. You pay the lower of your copay or the actual
cost of a covered drug.
†Brand deductible only applies to Tiers 3, 4, and 5.
*A 90-day supply is available on most prescriptions filled through mail-order or select pharmacies at 2½ times the applicable 30-day copay.
**Excludes monthly premiums and costs of non-covered drugs, including costs of drugs purchased outside the U.S.
***See page 16 for more details about the Coverage Gap.
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What will your total premium payments be?
A. Which Alliance Medicare PPO option fits your needs?
Alliance Medicare PPO
Good dental health is important to your
overall well-being.
To make it easier to manage the costs of dental care, Alliance Medicare PPO offers you
an optional benefit – dental coverage through Delta Dental PPO network.
The chart below summarizes the plan benefits you can receive when you pay the
additional dental premium.
Delta Dental PPO
Dental Benefit Summary
Monthly premium
Plan 1
Plan 2
Member Pays* Member Pays*
$23.40/month
$44.90/month
Deductible
none
none
Diagnostic and preventive services
50%
0%
Emergency pain treatment
50%
0%
X-rays
50%
30%
Oral surgery services
50%
30%
Fillings and other restorative services
50%
30%
Crowns and other major restorative services
50%
50%
Plan 1
Pays
Plan 2
Pays
$800
$1,500
Yearly maximum for all covered services
Premium
Option 1
$124
Option 2
$203
B. Do you need optional dental coverage? Which plan is right for you?
Delta Dental PPO
Premium
Plan 1
$23.40
Plan 2
$44.90
Add up your monthly premium payment for the plans you want:
A. Health plan option
B. Optional dental plan
$
$
Your total monthly premium
$
When you become a member of Alliance Medicare PPO, you will receive one billing
statement from Alliance each month. If you choose to add the optional dental
coverage, the dental premium will be included on that monthly billing statement.
*The dental plan premium is paid in addition to your Alliance Medicare PPO plan premium. Dental
benefits paid based on Delta Dental PPO negotiated in-network fee schedule.You pay the difference
if any. The dental plan premium and services do not count toward your annual Maximum
Out-Of-Pocket cost. Delta Dental is a registered trademark of the Delta Dental Plans Association.
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Am I covered when I travel?
Yes. You have worldwide emergency and
urgent care coverage for the same copay
you pay at home.
You also have access to your other benefits
at the out-of-network level when you travel
within the U.S. To fill prescriptions, you can
go to any pharmacy within our nationwide
network.
In addition, you are covered with Assist America any time you travel at least 100
miles from home or outside the U.S. One phone call will help you take care of medical
monitoring, emergency medical assistance, medical repatriation and much more.
(See disclaimer page 5.)
Can I see a specialist without a referral?
What people ask us about
Alliance Medicare PPO.
Yes, you can see any doctor or specialist within our network and receive the
maximum benefit. You can also use any Medicare-participating provider for care
outside of our network, but you may have higher out-of-pocket costs.
You still have the choice of selecting a Personal Care Physician if you want the
advantages that come from having one physician coordinating all of your care.
Am I eligible?
Do I lose my Medicare benefits when I enroll in Alliance Medicare PPO?
You can join Alliance Medicare PPO if you are enrolled in Medicare Part A and Part B and
reside in Wayne, Oakland, Macomb, Genesee, Lapeer, Livingston, Monroe, St. Clair or
Washtenaw county.
No. As a member of Alliance Medicare PPO, you are still in the Medicare program.
You still have all the benefits to which you are entitled under Medicare, including
the Medicare list of preventive services covered at no cost to you and provided from
network doctors. You also receive additional benefits, such as Flexible Health Options
and special health and wellness programs. You can use your Alliance Medicare PPO
card for all your covered health care services.
You must continue to pay your Part B premium after you enroll. If you decide to have your
monthly plan premiums paid as a withholding from your Social Security check or move
from that method to direct billing from Alliance Medicare PPO, it can take up to three
months for the request to take effect. You will remain responsible for those premiums.
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Is a mail-order prescription
service available with this plan?
How does the Health Reform law improve my benefits in the
Coverage Gap (Donut Hole)?
The Health Reform law created drug savings programs for Medicare beneficiaries who
reach the Coverage Gap (Donut Hole). Alliance Medicare PPO members are eligible for
these savings.
In 2013, for Generic drugs purchased in the Coverage Gap:
Yes. Mail order is available for 90-day
supplies, saving you both time and
money on medications you take on a
regular basis. If you prefer, you can
obtain 90-day supplies with the same
savings at select retail pharmacies.
What advantage does the
Maximum Out-Of-Pocket cost
provide?
• With Option 1 — you pay 72% of our negotiated price
• With Option 2 — you pay whichever is lower: the fixed copay or 72% of our
negotiated price
For all Brand-name drugs purchased in the Coverage Gap:
• You pay 47.5% of our negotiated price plus the applicable pharmacy dispensing
fee. Even though you pay only part of the costs, the full cost of Brand-name
drugs counts toward your annual total out-of-pocket cost for prescription
drugs. This means you may exit the Coverage Gap and enter the Catastrophic
Coverage period with its enhanced benefits more quickly
Members who get Extra Help from the Social Security Administration for their
prescription drugs do not have a Coverage Gap.
Does the Health Reform law provide any other benefits?
Under the Health Reform law, Original Medicare covers some preventive services
at no cost to you. HAP also covers those services at no cost to you when you receive
them from our network providers. Please refer to the Summary of Benefits for the list
of preventive services available at no cost to you. For covered services not included in
Medicare’s subset of preventive services, you pay the applicable office visit copay or
coinsurance.
Alliance Medicare PPO members who
need extensive health services have the
added protection of having a limit on
spent out-of-pocket costs in a calendar
year. For covered services received
from Alliance Medicare PPO network
providers that limit is $3,401.
If you receive services from Medicareparticipating providers that are not in
our network, your combined in- and
out-of-network Maximum Out-Of-Pocket
cost for the calendar year is $10,000.
After you have paid the Maximum
Out-Of-Pocket cost for Part A and
Part B covered services, you will have
no more copays or coinsurance for the
rest of the calendar year for those
covered services. Your monthly plan
premiums, prescription drug costs and
non-Medicare-covered services
(like dental services or eyewear) do
not count toward your Maximum
Out-Of-Pocket cost.
Many people are eligible
for additional savings
and don’t even know it.
Is Extra Help available for
prescription drug coverage?
People with limited incomes may
qualify for Extra Help to pay for their
prescription drug costs. If you qualify,
Medicare could pay for up to 75% or
more of your drug costs, including
monthly prescription drug premiums,
annual deductibles and coinsurance.
Additionally, those who qualify will not
be subject to the Coverage Gap or a late
enrollment penalty.
To see if you qualify for Extra
Help, call:
1-800 MEDICARE (1-800-633-4227).
TTY users should call 1-877-486-2048,
24 hours a day, 7 days a week;
The Social Security Administration at
(800) 772-1213 between 7 a.m. and
7 p.m., Monday through Friday. TTY
users should call (800) 325-0778; or
your state Medicaid office.
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Important plan information.
Alliance Medicare PPO is a health plan with a Medicare contract. Enrollment in the plan
depends on contract renewal. Alliance Medicare PPO is a product of Alliance Health and
Life Insurance Company, a wholly owned subsidiary of Health Alliance Plan (HAP).
You may be eligible to enroll if you are entitled to Medicare benefits under Part A
and enrolled in Part B and reside within Wayne, Oakland, Macomb, Genesee, Lapeer,
Livingston, Monroe, St. Clair or Washtenaw county. Medicare beneficiaries may enroll in
a Medicare Advantage plan only during specific times of the year. For more information
about enrollment rules, contact a licensed HAP Medicare Sales Representative.
Call today.
To enroll in our Medicare plan, you can use one of the following
five options:
1. Call a licensed HAP Medicare Sales Representative toll-free at:
(800) 868-3153 or TTY/TDD (800) 649-3777
Monday through Friday, 8 a.m. to 5 p.m.
2. Mail a completed enrollment form to:
HAP Medicare Division
2850 W. Grand Boulevard
Detroit, MI 48202
Generally, Alliance Medicare PPO prescription drug benefits are only available at
HAP-contracted pharmacies, except in emergency or urgent care situations. Quantity
limitations and restrictions may apply. You are covered throughout the U.S. at any of
our network pharmacies with nationwide locations.
Medicare Advantage plan members must receive prescription drug coverage through
their plan. If you enroll in a stand-alone Prescription Drug Plan, you will automatically
lose your Alliance Medicare PPO benefits.
You can call Medicare at 1-800-MEDICARE (1-800-633-4227), TTY 1-877-486-2048.
You can call this number 24 hours a day, 7 days a week.
The benefit information provided is a brief summary, not a complete description of
benefits. For more information, contact HAP. Benefits, formulary, pharmacy network,
premiums and/or copayments/coinsurance may change on January 1 of each year.
Limitations, copayments and restrictions may apply.
3. Enroll online at the HAP website at hap.org/medicare
4. Enroll online through the Centers for Medicare & Medicaid Services
Online Enrollment Center, located at www.medicare.gov
5. Come to a HAP Medicare workshop where you can talk with other Medicare
beneficiaries. A licensed HAP Medicare Salesperson will be present with
information and applications. Call us toll-free for dates and locations near you,
or for accommodation of persons with special needs at sales meetings:
(800) 449-1515 or TTY/TDD (800) 649-3777, Monday through Friday, 8 a.m. to 6 p.m.
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