2024 State of Illinois 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.

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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.

Our statewide network of doctors, hospitals and clinics connects you to world-class care with names you already know and trust. Wherever you’re at in Illinois, we connect you with the care you deserve.

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 or call Customer Service to find in-network doctors, hospitals and pharmacies.

For a full list, visit: HealthAlliance.org/StateOfIllinois

Out-of-Network Care

With your health maintenance organization (HMO) plan, you can go out of network for emergency situations. If you have an urgent or emergency situation, we’ll still cover your claims at the in-network level anywhere you go.

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 prior authorization from us.

Prior Authorization

For specific drugs or services, your doctor must request prior authorization to make sure you meet certain requirements before we’ll cover them. This process helps control member costsharing by reducing things that do not meet medical necessity. To find out if a drug or service requires prior authorization, please refer to your policy document.

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.

Nurse Advice Line

Get 24/7 answers to your health questions, like whether you need to set up an appointment or see a doctor right away.

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.

Disease Management

For long-term help, support and resources for managing your diseases. We’re here to help you take control of your long-term disease or condition. While it’s important to take your medicine and work with your primary care provider to keep it in check, it’s always good to have more support.

When you get disease management help from us, we’ll send you a welcome letter and newsletters and help connect you to the right resources, support and reminders to be your best.

We can help you manage your:

• Asthma.

•  Diabetes.

•  High blood pressure.

And even for other conditions, like migraines, we are always here to connect you to up-to-date resources to help you and your doctor find what works best for you.

Emergency Care

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 increase 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.

Always go to the emergency 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.

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.

Understanding Drug Tiers

Think of tiers like steps: the lower the step (tier), the less you pay for your medication. Before filling a prescription, it’s a good idea to check our drug formulary for your medication’s tier. The plan you’re on will affect your copayments or coinsurance. You’ll always pay the lowest amount for a Tier 1 drug.

If you or your doctor requests a brand-name drug when the generic is available on a lower tier, you’ll usually pay the copayment or coinsurance for the brand-name, plus the difference in cost between the brand-name drug you requested and the generic drug.

Specialty Tier Drugs

These drugs are usually for complex and ongoing conditions. To work correctly, they often have special directions or need to be administered by a healthcare professional. Check your plan documents for your tier and copayment information.*

Specialty medications are available through Optum Specialty Pharmacy nationwide and through Carle Specialty Pharmacy in select states.

*Certain specialty medications for the treatment of obesity also require participation in a lifestyle management program administered by Health Alliance™ .

See the list of drugs we cover in our formulary at HealthAlliance.org/Pharmacy.

Prescriptions

Where you get your drugs filled matters. Log in at hally.com or call Customer Service to find an in-network pharmacy near you.

Before you go, check the drug formulary for your drug’s tier at hally.com. Every drug listed in our formularies is put into a cost group, or tier. You typically pay the lowest price for a Tier 1 drug. As you step up to the next tier, the amount you pay increases.

Your provider can call our Pharmacy department at (800) 851-3379 (Option 4) to ask about lower-cost options for your drugs.

Drug Formulary

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 Pharmacy and Therapeutics committee. It consists of a group of clinical pharmacists, medical directors and doctors in various specialties.

Mail-Order Discount

You can order a 90-day supply of certain prescription drugs through the mail for a discounted rate. Learn more about the program by calling Optum Rx ®, your pharmacy benefit manager, at (800) 763-0044.

90-Day Supply Options

With our mail-order benefit, you can get a 90day supply of your drugs delivered directly to you for 2.5 copays. If you prefer to get your drugs at a retail pharmacy, you can visit any in-network pharmacy and get a 90-day supply for the same 2.5 copays.

When can I get a refill?

For your convenience, you can refill your prescription slightly early, before all of your last month’s medications run out. Call us if you have any questions.

Your Care 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.

Send a secure message to our care coordination team through your Hally account on the MyChart app or call the number on the back of your ID card.

For more information, visit hally.com/care.

Find helpful resources.

Care for yourself to help prevent illness and hospital stays.

Set and reach health and wellness goals.

Understand and manage health issues, like diabetes and asthma.

Coordinate your care when you have complicated health conditions.

Use your health benefits to save money.

Your Health at Your Fingertips

We know with everything going on in life, staying healthy is easier said than done.

We value giving you the member experience you deserve with a variety of options to fit your busy lifestyle –and as a member of our health plan, you get access to our comprehensive suite of health and wellness resources, programs, perks and offerings. We call this Hally health. Hally health is your ally in your wellness journey. Whenever you see the word “Hally,” it’s us at your health plan connecting you with a resource or support that’ll help you live your healthiest life.

As a member, you also get secure, instant access to your health insurance coverage by logging in to your Hally account through the MyChart app or on hally.com. Review your plan coverage, discover resources and support for your health conditions, and find the care you need anytime, anywhere.

Get access to a wealth of resources to help you stay healthy – with no login required. At hally.com, you’ll find:

• Health tools, tips and resources.

• Access to our quarterly “Simply Well” newsletter.

• Hally Healthcast , a monthly podcast led by medical experts who discuss common health and wellness topics.

• Free online fitness and cooking classes.

• Hally health blog, featuring informational articles and healthy tips for the entire family.

• Tasty recipes that’ll help you eat healthier.

Download the MyChart mobile app to access your Hally account information on the go. Visit the App Store ® or Google Play ®, or simply scan one of these QR codes.

Once downloaded, start typing “Hally” in the “Select an Organization” search bar and choose Hally. If you already have the MyChart app, swipe left, click “Add organization” and type “Hally” in the search bar.

With your Hally account on the MyChart app, you’re able to:

• Go paperless by opting in for secure e-Delivery of your plan materials.

• View past and current claims, authorizations and Explanations of Benefits (EOBs).

• Find doctors, facilities and pharmacies covered by your plan.

• Track spending on healthcare expenses.

• Know where to go for care depending on your symptoms.

• Sign up for text alerts.

• You also stay seamlessly connected to all the Hally health resources, programs, perks and offerings from your health plan. You get the tools, tips and resources you need to help you live your healthiest life.

*Benefits and coverage may vary from plan to plan. Please review your plan documents or call the number on the back of your member ID card for specifics.

Here’s a little more info on what Hally health can do for you:

“Go Paperless”

Save paper (and hassle!) with these e-Delivery options:

•  Opt in for your plan materials to be electronically delivered.

•  Receive your Explanations of Benefits (EOBs) electronically via the member portal.

•  Get your premium bill statements electronically.

•  Receive helpful health and wellness updates.

Why go paperless?

•  Faster access to materials and information.

• 24/7 on-demand access to your documents.

•  Use less paper. Some member materials can be 30 to 100 pages in length!

•  Be eco-friendly. It takes a lot of energy to make paper and ink, print, and package paper materials - e-Delivery is a more eco-friendly approach to get the same information.

Virtual Health Coverage

Get care when and where you need it through virtual health coverage. With the telehealth benefit, you can connect with your primary care provider or specialist over the phone or online without the inconvenience of going to the doctor’s office or sitting in a waiting room. And with the virtual visit benefit, you can connect 24/7 with a board certified doctor or counselor by phone, secure video or our member app.

Telehealth Benefit

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.

Virtual Visits

Get 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 hally.com at any time of the day, any day of the year.

Get seen for 50+ conditions – physical and behavioral:

• Addictions.

• Allergies.

• Cold/flu.

• Depression.

Virtual PCP

• Ear problems.

• Fever.

• Grief and loss.

• Panic disorders.

• Skin conditions.

• Trauma.

All virtual visits through Hally health are available with only a $10 copay, whether your virtual visit is for primary care, acute care or specialty services. These virtual visits are conducted with expert providers from MDLIVE®, our trusted partner in virtual care.

Go to hally.com to log in and get started, or call Member Services at the number on the back of your member ID card for more information.

Quit For Life ®

When you’re ready to quit tobacco, this program offers:

•  One-on-one coaching.

• A quit plan made just for you.

• An online learning and support community.

Go to HealthAlliance.org/Quit-For-Life for more information.

Your Perks and Programs

Your plan is made with plenty of perks and programs to help you with your health goals.

Active&Fit Direct™

Find a fitness center or stay active at home.

With the Active&Fit Direct program, you’ll have access to:

• 1,500+ digital workout videos so you can work out at home or on the go.

• 11,000+ fitness centers, with the ability to change anytime.

•  Unlimited lifestyle coaching in areas such as fitness, nutrition, stress and sleep.

• Activity tracking with 250+ wearable trackers and apps.

•  No long-term contract.

All for just $28 a month.

NEW: two ways to try fitness for free.

•  Join us for a variety of workout classes available anytime on YouTube and Facebook, designed for all levels.

• 200 free digital workout videos available to all eligible members, even before you enroll.

Disclaimer: 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.

Student Extended Network Program

You and your family get access to top-notch doctors and hospitals. That doesn’t have to change when your student seeks education outside our service area.

Through our Student Extended Network, dependent children on your plan who leave our service area to attend an academic institution, including (but not limited to) a college/university, technical school or vocational school, can get access to the national First Health Network while in school.

Your dependent student will receive a special ID card and can search the First Health Network by logging in to your Hally account.

All other family members on the plan will keep their current ID cards and use the standard provider network.

When your child gets care in the extended network, it’s their responsibility to make sure prior authorization is received when necessary. They can call Customer Service to check whether prior authorization is needed, and if so, they should ask their doctor to request it. Scan the QR code below for more information.

Your Perks and Programs

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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.

Preventive Care

We cover preventive services and tests to keep you healthy. Here is a partial list of the services included in your comprehensive preventive service bene fi t.*

•  One preventive service exam per member (no age limitations) per plan year.

•  One preventive service visit to a Women’s Principal Health Care Provider per plan year.

•  Well-child care.

•  The screenings, procedures and immunizations listed below, within the applicable preventive service bene fi t:

Blood sugar screening.

Cervical cancer screening (Pap smear).

Cervical cancer vaccine.

Childhood immunizations.

Chlamydia screening.

Cholesterol screening.

Colorectal cancer screening (flexible sigmoidoscopy, screening colonoscopy, fecal occult blood test, including FIT).

*Of fice visit copayment and/or coinsurance may apply.

OTC4Me

Get a 10% discount code for a wide variety of competitively priced over-the-counter (OTC) products with OTC4Me. You can order online or by phone, and all orders are shipped directly to you. Shipping is free on orders over $25.

Knowing Your Costs

Log into your member portal at hally.com to use these resources, track your spending and more.

Treatment Cost Calculator

This tool lets you explore a wide range of healthcare treatment options, helping you potentially save money by seeing different costs.

You can:

•  Compare costs on procedures, facilities and doctors.

•  See in- and out-of-network cost estimates.

•  Find doctors, hospitals and clinics in your area that offer the service you need.

Explanation of Benefits

After you visit your doctor or receive medical services, you’ll 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.

Claims Status

Our member portal provides secure access to your plan materials, letters and messages, and it’s where you can view past and current claims. You can check if a claim was submitted to us and whether it has been paid. We can also help you with next steps. Send a secure message to our Customer Service team through your Hally account on the MyChart app or call the number on the back of your ID card.

“Go Paperless”

Go green with paperless member materials and simplify your life.

•  Opt in today to have materials readily available on the go.

•  Get access to your plan materials and important information about your account anytime, anywhere.

•  Reduce wasted paper with online access to your plan.

•  Our portal provides secure access to your plan materials, letters and messages.

•  Know your personal health information is safe from being intercepted or stolen in the mail.

For more information, visit HealthAlliance.org/Go-Paperless .

Helpful Terms

Benefit Period

The stretch of time your plan covers you (for example, July 1 to June 30). See your plan materials for your benefits’ start and end dates.

Benefits

The healthcare services your health plan covers: doctor visits, routine physicals, diagnostic tests, etc.

Coinsurance

The percentage you pay for services at a doctor’s office, pharmacy or hospital.

Contribution

The monthly premium you pay for coverage.

Copay

The set fee you pay each time you use a medical service covered by your plan.

Deductible

The amount you pay before your benefits kick in. Some plans have separate medical and pharmacy deductibles.

Dependents

Children or a spouse covered on your plan.

Formulary

A list of drugs covered by your plan, including generic and brand-name drugs. Log in at hally.com to find your plan’s list of drugs.

Generic Drugs

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.

Member

A person covered under a health plan, either the enrollee or eligible dependent.

Out-of-Pocket Maximum (OOPM)

Once you’ve paid this amount, we pay 100% of covered expenses for the rest of the benefit period. You’ll no longer pay copayments or coinsurance, just your monthly premium, as long as your copayment or coinsurance applies to the OOPM. In-network services (also referred to as Tier 1 and Tier 2) both apply to the in-network OOPM. Note that if you receive services that are not covered or use out-of-network providers (referred to as Tier 3), you may be required to cover costs above the OOPM. For some plans, there is no cap on the amount that you may have to pay for noncovered services or using out-of-network providers.

Primary Care Provider

A personal doctor (or advanced practice provider) you choose to oversee your care.

Prior Authorization

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. See Page 4 for more information.

Telehealth

Remote healthcare you get from a primary care provider or specialist over the phone or online.

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