2024 Northwest Member Handbook

Healthcare Coverage Made for You

2024 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.

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

Because 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.

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.

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

V irtual PCP

Get care when and where you need it with virtual health coverage. Talk with a primary care provider virtually for routine wellness visits, preventive care and chronic care. Members can receive a certain number of free visits each year. Check your plan benefits for more information. For questions and enrollment, call (800) 400-6354.

V irtual Visits

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.

P rimary 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.

D isease Management

Get help with programs and support if you have asthma, diabetes or high blood pressure.

Always go to the emergency department or call 911 if you experience:

• Stroke symptoms.

• Chest pains.

• Head or spinal injuries.

• Severely broken bones.

Customer Service

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 the answers, guidance and resources you need.

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.

E mergency 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.

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.

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. 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 lowercost 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 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

Limit your trips to the pharmacy with two convenient options. With our mail-order benefit,you can get a 90-day supply of your drugs delivered directly to your door – and with some plans you may even save money using mail order. Check your plan’s coverage documents for more details. And if you prefer to get your drugs at a retail pharmacy, you can visit any in-network pharmacy and get a 90-day supply in one trip.

When can I get a refill?

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

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.

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.

Find helpful

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 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 Health at Your Fingertips

When it comes to your health and wellness, we’ve got you covered.

Your Health at Your Fingertips

Hally ® health is all about helping you live your healthiest life. It’s one of the best parts of your health plan – giving you plenty of ways to stay on top of your health. Here you’ll find fitness courses, recipes, wellness rewards, health coaching, care coordination and more. Staying healthy isn’t easy, but with the help of your health plan, you’ve got this!

When it comes to your health and wellness, we’ve got you covered.

E xclusive perks for health plan members: when you sign in to your member portal through hally.com, you can:

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

Hally ® health is all about helping you live your healthiest life. It’s one of the best parts of your health plan – giving you plenty of ways to stay on top of your health. Here you’ll find fitness courses, recipes, wellness rewards, health coaching, care coordination and more. Staying healthy isn’t easy, but with the help of your health plan, you’ve got this!

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

Exclusive perks for health plan members – when you sign in to your member portal through hally.com, you can:

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

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

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

• Track spending on healthcare expenses.

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

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

• Ask a customer service or care coordination question.

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

• Track spending on healthcare expenses.

•  Sign up for text alerts.

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

• Ask a customer service or care coordination question.

• Sign up for text alerts.

Find helpful tools at hally.com.

Find helpful tools at hally.com.

Get access to plenty of resources to help you stay healthy with no login required at hally.com. You’ll find:

Get access to plenty of resources to help you stay healthy with no login required at hally.com. You’ll find:

•  Classes on exercise, cooking and caring for your conditions.

•  Hally blog.

• Classes on exercise, cooking and caring for your conditions.

• Hally blog.

• The Hally Healthcast , a monthly podcast focused on health and wellness.

• The Hally Healthcast , a monthly podcast focused on health and wellness.

Your Perks and Programs

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

Active&Fit Direct™

Join one of 10,000+ fitness centers nationwide for just $28 a month (plus a one-time $28 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.

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.

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 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).

*An of fi ce visit copayment and/or coinsurance may apply.

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 the number on the back of your ID card.

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

Coinsurance

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

Contribution

The monthly premium you pay for coverage.

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.

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 non covered 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.

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.

Primary Care Provider (PCP)

A personal doctor 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.

Telehealth

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

Notes

Notes

Notes