2023 Northwest Member Handbook

to coverage,

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.

When it comes

it’s all about you.

Your Care and How It Works

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.

Out-of-Network Care

If you have a point of service (POS) 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.

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.

Nationwide Extended Network

You have access to a nationwide extended network of doctors, hospitals and clinics through First Health®. Take a look at your ID card. If the First Health logo is on the front, First Health is your primary network and replaces our standard network. If the logo’s on the back, we’re your primary network but you also have access to providers in the First Health network. For more information, including how to find doctors in each network, call the Customer Service number on the back of your ID card.

When you get care in the First Health network, it’s your responsibility to make sure prior authorization is received when necessary.

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 cost-sharing 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.

Providers can submit a prior authorization one of the following 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.

Your plan is made to give you access to the care you need from a large network of providers you trust.

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

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.

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.

You can also 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.

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.

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 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.

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

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.

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

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 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.

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.

Your Care Team

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.

Care for yourself to help prevent illness and hospital stays.

Use your health benefits to save money.

Understand and manage health issues, like diabetes and asthma.

Coordinate your care when you have complicated health conditions.

Your Community

We like to get out and meet members of the entire community. We’ll be at health fairs, community events 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.

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.

How to Access Care

Member Services

We’re here to help. Call us at the number on the back of your member ID card or contact us online at HealthAlliance.org with your questions. We’ll help you find the plan and doctors that make the most sense for your needs.

Primary Care Provider (PCP)

Find your PCP online using our Find Care tool at HealthAlliance.org/Find-Care. You can also call our care coordination team for assistance at (877) 933-8475 (TTY 711).

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.

Virtual Health Coverage

Get care when and where you need it through virtual health coverage.

Telehealth Benefit

Connect with your primary care provider or specialist over the phone or online with the telehealth benefit. You can securely speak with your personal healthcare providers without having to leave the comfort of your home. Copayment may apply.

Access varies by provider. Speak with your provider to determine availability.

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. You can connect with a board certified doctor or counselor by phone or secure video through hally.com, 24 hours a day, 365 days a year – whether you’re at home, in the office or on the go.

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.

Urgent Care

Your plan covers both in-network and out-of-network urgent care centers at the same copay. So if you experience an injury or illness anywhere in the world, your plan has you covered.

Emergency Services

If you’re having a medical emergency, you shouldn’t have to worry about your coverage. That’s why all Health Alliance Northwest™ plans include coverage for emergency services anywhere in the world.

How to Access Care

Hally.com

While you’re logged in to hally.com, you can:

• Sign up for text alerts.

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

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

• Pay your monthly premium using Premium Bill Pay and set up recurring payments.

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

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

• Check your spending.

Your Perks and Programs

Active&Fit Direct™

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.

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

• Treatment must be for headache, neck pain or lower back pain diagnoses.

• You don’t need prior authorization.

• 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.

Assist America®

Get expert medical help when you’re 100 miles or more from home. Go to HealthAlliance.org/AssistAmerica to learn more.

Other conditions and exclusions may apply.

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.

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.

Quit For Life

®

Get help ending your tobacco use with:

• One-on-one coaching from a quit coach.

• Quit plan made just for you.

• Helpful tools, like Text2Quit ®

• Web Coach®, an online learning and support community.

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

Get paid back for a variety of fitness activities. You choose how you want to work out, and we pay you back up to $360 a year. Activities include the following and more:

• Fitness class fees.

• Gym memberships.

• Online fitness subscriptions.

• Weight loss subscriptions.

• Ski memberships.

• Rowing.

• Golf.

• Bowling.

• Tennis.

• Pickleball.

• Recreational league fees.

• Pool exercise classes.

• 5K/10K race fees.

If your fees are more than $360 a year, you pay the difference. If they’re less, we pay you back the amount you paid. Be Fit doesn’t cover fitness trackers or personal equipment.

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

Your Perks and Programs (continued)

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 benefit.*

• 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 preventiveservice 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 fi ce visit copayment and/or coinsurance may apply.

Wellness Rewards

Take simple steps to improve your health, and be entered to win exciting prizes, like this and more:

• Wearable fitness devices.

• Exercise equipment.

• Meditation kits.

• Cooking appliances.

• Latest in wellness tech.

Complete these three steps, and we’ll enter you into our raffle:

1. Fill out a Health Risk Assessment at HealthAlliance.org/HealthSurvey

2. Complete a wellness exam with your primary care provider (PCP).

3. Consult with a wellness coach by calling (800) 851-3379, ext. 28947, and choose option 1.

Each winner receives a voucher to an online wellness gift shop. Call the number on the back of your ID card for more information.

Knowing Your Costs

Your plan has processes in place to help make sure you’re getting the proper treatment.

Treatment Cost Calculator

Explore a wide range of healthcare options and potentially save money with this helpful tool that gives you more power when seeking care.

It helps you:

• Save money with more-informed shopping.

• Review a helpful estimate of costs for specific treatments (based on your plan’s coverage).

• Compare costs for in-network and out-ofnetwork providers.

• Search by medical treatment, service or condition.

• Find doctors, hospitals and clinics in your area.

Explanation of Benefits

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.

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.

Go Paperless

Go green with paperless member materials and simplify your life.

• Always available

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

• Less clutter and waste.

• Avoid mountains of mail, storing paperwork and wasted paper with online access to your plan.

• Secure access.

• 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, January 1 to December 31). See your plan materials for your benefits’ start and end dates.

Contribution

The monthly premium you pay for coverage.

Coinsurance

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

Copayment

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

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

Health Maintenance Organization (HMO)

With an HMO plan, you choose a PCP to oversee your care and refer you to specialists. You must stay in network, unless it’s an emergency or for urgent care.

Point of Service (POS)

With a POS plan, you choose an in-network PCP to oversee your care and refer you to specialists. You have the flexibility to see out-of-network providers, but you may save money staying in network.

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.

Out-of-Pocket Maximum (OOPM)

Once you have paid this amount, we pay 100% of covered expenses for the rest of the benefit period. You 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 noncovered or use outof-network providers (referred to as Tier 3), you may be required to cover costs above the OOPM. There is no cap on the amount that you may have to pay for noncovered services or using out-ofnetwork providers.

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.

Primary Care Provider (PCP)

411 N. Chelan Ave., Suite A Wenatchee, WA 98801

HealthAlliance.org