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Alliance Bronze Care on Demand 8500 Exchange Legacy LHP

Plan Overview

Combined Medical and Drug Deductible
  • Individual: $8,500
  • Family: $17,000
  • Per Person: $8,500
Combined Medical and Drug Out of Pocket Maximum
  • Individual: $8,700
  • Family: $17,400
  • Per Person: $8,700

Office Visit

Primary Doctor
  • CoPay: Not Applicable
  • CoInsurance: 20.00% Coinsurance after deductible
  • Covered: Covered
Specialist
  • CoPay: Not Applicable
  • CoInsurance: 20.00% Coinsurance after deductible
  • Covered: Covered

Prescription Drug Information

Preferred Brand Drugs
  • CoPay: Not Applicable
  • CoInsurance: 30.00% Coinsurance after deductible
  • Covered: Covered
  • Limit Quantity: 30
  • Limit Unit : Days per Month
  • Benefit Explanation: Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill.
Non Preferred Brand Drugs
  • CoPay: Not Applicable
  • CoInsurance: 50.00% Coinsurance after deductible
  • Covered: Covered
  • Limit Quantity: 30
  • Limit Unit : Days per Month
  • Benefit Explanation: Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill.
Generic Drugs
  • CoPay: $15.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Limit Quantity: 30
  • Limit Unit : Days per Month
  • Benefit Explanation: Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill. 71281WA1360005 both WAF017, WAF022 apply; 71281WA1360006 both WAF020, WAF023 apply; 71281WA1360007 both WAF021, WAF024 apply; 71281WA1360001 both WAF004, WAF014 apply; 71281WA1360004 both WAF008, WAF013 apply. Alliance Silver 3200 Exchange Legacy LHP & Alliance Bronze Care on Demand 8500 Exchange Legacy LHP plans Generic Drug cost share represents Preferred Generic Drugs in Tier 1. Non-preferred Generic Drugs that fall into Tier 2 are covered at a higher cost share.
Specialty Drugs
  • CoPay: Not Applicable
  • CoInsurance: 40.00% Coinsurance after deductible
  • Covered: Covered
  • Limit Quantity: 30
  • Limit Unit : Days per Month
  • Benefit Explanation: First fill allowed at a retail pharmacy. Additional fills must be provided at a specialty pharmacy. Coverage is limited to a 30-day supply for specialty and self-administrable cancer chemotherapy medications from a specialty pharmacy per fill or refill. Alliance Silver 3200 Exchange Legacy LHP & Alliance Bronze Care on Demand 8500 Exchange Legacy LHP plans - Specialty medications that fall into Tier 6 Specialty are non-preferred medications and covered at 50% coinsurance after deductible.

Inpatient Coverage

Hospital Services
  • CoPay: Not Applicable
  • CoInsurance: 20.00% Coinsurance after deductible
  • Covered: Covered
Inpatient Services
  • CoPay: Not Applicable
  • CoInsurance: 20.00% Coinsurance after deductible
  • Covered: Covered

Emergency and Urgent Care

Emergency Room
  • CoPay: Not Applicable
  • CoInsurance: 20.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: Out of service area coverage is available.
Urgent Care Facility
  • CoPay: Not Applicable
  • CoInsurance: 20.00% Coinsurance after deductible
  • Covered: Covered

Maternity

Labor and Delivery Hospital Stay
  • CoPay: Not Applicable
  • CoInsurance: 20.00% Coinsurance after deductible
  • Covered: Covered
Pre and Postnatal Office Visit
  • CoPay: Not Applicable
  • CoInsurance: 20.00% Coinsurance after deductible
  • Covered: Covered

Vision

Routine Eye Exams For Children
  • CoPay: No Charge
  • CoInsurance: No Charge
  • Covered: Covered
  • Limit Quantity: 1
  • Limit Unit : Exam(s) per Year

Major Dental Care

Routine Dental Checkups for Children
  • Covered: Not Covered
Basic Dental Care - Child
  • Covered: Not Covered
Major Dental Care - Child
  • Covered: Not Covered
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