Download Health Alliance Plan of Michigan Health Care Services Coverage

Health Alliance Plan of Michigan
Health Maintenance Organization (HMO) Plan
Summary of Benefits for
UAW Retiree Medical Benefits Trust - GM Non MA
Health Care Services
Coverage
Limitations*
Benefit Period, Annual Deductible, and
Annual Co-insurance Maximum:
Benefit Period:
Annual Deductible
Co-insurance (amount member pays)
Annual Co-insurance Maximum
Calendar Year
None
None
NA
Preventive Services:
Preventive Office Visit / Physical Exam
Well Baby Office Visit
Routine Hearing Exam
Routine Eye Exam
Immunizations
Related Laboratory and Radiology Services
Pap Smears and Mammograms
$25 Copay
$25 Copay
$25 Copay
$25 Copay
Covered
Covered
Covered
Covered up to 24 months
Outpatient & Physician Services:
Personal Care Physician Office Visit
Specialty Physician Office Visit
Gynecology Office Visit
Audiology Office Visit
Eye Exam Office Visit
Allergy Treatment and Injections
Laboratory and Radiology Services
Dialysis
Chemotherapy
Radiation Therapy
Outpatient Surgery
Chiropractic Office Visit and Related Services
$25 Copay
$25 Copay
$25 Copay
$25 Copay
$25 Copay
Covered
Covered
Covered
Covered
Covered
Covered
Not Covered
Emergency/Urgent Care:
Emergency Room Services
Urgent Care Facility Services
Emergency Ambulance Services
$100 Copay
$50 Copay
Covered
Copay will be waived if admitted
Emergency transport only
Inpatient Hospital Services:
Hospital Inpatient Stay in Semi-Private Room, Specialty
Units as medically necessary, Physician Services,
Surgery, Therapy, Laboratory, Radiology, Hospital
Services and Supplies
Bariatric Surgery & Related Services
Covered
Covered
One procedure per lifetime
Maternity Services:
Initial Prenatal Office Visit
Subsequent Prenatal and Postnatal Office Visits
Labor, Delivery and Newborn Care
$25 Copay
$25 Copay
Covered
Mental Health:
Inpatient Services
Outpatient Services
Covered
Covered
Chemical Dependency:
Inpatient Services
Outpatient Services
Covered
Covered
Other Services:
Home Health Care
Hospice Care
Covered
Covered
Skilled Nursing Care
Covered
Durable Medical Equipment; Prosthetic & Orthotics
Hearing Aid Hardware
Covered
Covered
Vision Hardware
Covered
Physical, Occupational, and Speech Therapy
(PT/OT/ST)
Voluntary Sterilizations
Voluntary Termination of Pregnancy
Infertility Services
Assisted Reproductive Technologies
Covered
See PT/OT/ST Coverage
Up to 210 days per lifetime
Covered for authorized services - Up to 100 days per benefit period. This benefit is
renewable after 60 days of continuous non-confinement.
Coverage provided for approved equipment based on HAP's guidelines
Covered for authorized equipment
One pair every 24 months, or 12 months with prescription change; dollar limit applies.
Contact lenses in place of eyeglasses are covered, subject to a maximum retail allowance.
Contact lens fitting is not covered
Up to 60 combined visits per benefit period - May be rendered at home
Covered
Not Covered
Covered
Services for diagnosis, counseling, and treatment of anatomical disorders causing
infertility in accordance with HAP’s benefit, referral and practice policies
Not Covered
Pharmacy:
Generic / Preferred Brand / Non-Preferred Brand
$10 / $30 / $80 Copay
No coverage for Erectile Dysfunction (ED) medications except in prior authorized cases of
Pulmonary Arterial Hypertension. Also, No coverage for Proton Pump Inhibitor drug class
except in prior authorization cases of Barrett’s Esophagitis and Zoellinger-Ellision
syndrome.
Retail: 35 day supply for non-maintenance drugs at 1 Copay; 90 day supply for eligible
maintenance drugs at 2 Copays
Mail Order: 90 day supply for both eligible maintenance and non-maintenance drugs at 2
Copays
Rev 01/2012
Benefit Code / Riders: LE3 / 013,014,039,081,124,148,259,537,677, NEW SNF RIDER
* Hospital admissions require that HAP be notified within 48 hours of admission. Failure to notify HAP within 48 hours could result in a reduction of benefits, or nonpayment.
* Students away at school are covered for acute illness and injury related services according to HAP criteria. Students away at school are not covered for routine physicals,
non-emergency psychiatric care, elective surgeries, obstetrical care, sports medicine and vision care services while at school.
* In cases of conflict between this summary and your HMO Subscriber Contract, the terms and conditions of the HMO Subscriber Contract govern.
GM NON MA