Alliance Value Plan - Plan Details

Inpatient Hospital Services*	In Network	Out of Network
Hospital Coverage	Covered in full	EmblemHealth pays 80% of the allowed charge, not to exceed the Hospital charge
Skilled Nursing	Not covered	Not covered
Maternity and Routine Nursery Care	Covered in full	EmblemHealth pays 80% of the allowed charge, not to exceed the Hospital charge
Hospice Care	Covered in full 210 days per lifetime (includes 5 bereavement counseling sessions for family members)	EmblemHealth pays 80% of the allowed charge, not to exceed the Hospital charge
Outpatient Hospital Services*	In Network	Out of Network
Ambulatory Surgery	Covered in full	EmblemHealth pays 80% of the allowed charge, not to exceed the Hospital charge
Home Health Care	Covered in full - 40 visits per year	EmblemHealth pays 80% of the allowed charge, not to exceed the Hospital charge
Diagnostic Lab Tests	$25 copay	EmblemHealth pays 80% of the allowed charge, not to exceed the Hospital charge
Diagnostic X-Rays, MRI, Cat Scan & Sonogram	$25 copay	EmblemHealth pays 80% of the allowed charge, not to exceed the Hospital charge
Medical Services	In Network	Out of Network
Home and Office Visits	Not covered, except for the purpose of preventive care	Not covered
Annual Physical Check-up	Covered in Full	Not covered
OB/GYN preventive 2 visits	Covered in Full	Not covered
Allergy Care	Not covered	Not covered
Chiropractic Care	Not covered	Not covered
Physical Therapy, Osteopathic Manipulation, Occupational Therapy	Not covered	Not covered
Routine Podiatric Care	Not covered	Not covered
Speech Therapy	Not covered	Not covered
Well-baby and Well-child Care	Covered in Full	After deductible is met, $250 Individual / $500 Family deductible, EmblemHealth pays 100% of allowed charge
Diagnostic Lab Tests	Not covered	Not covered
Diagnostic X-Rays, MRI, Cat Scan & Sonogram	$20 copay	After deductible is met, $250 Individual / $500 Family deductible, EmblemHealth pays 100% of allowed charge
Emergency Services	In Network	Out of Network
ER Professional Charge	Not covered	Not covered
Emergency Facility Charge (Waived if Admitted)	$50 copay	$50 copay
Mental Health and Chemical Dependency Services*	In Network	Out of Network
Inpatient Mental Health	Covered in Full - 30 days per calendar year	EmblemHealth pays 80% of the allowed charge, not to exceed the Hospital charge
Inpatient Chemical Dependency Treatment (Detoxification)	Not covered	Not covered
Chemical Dependency Treatment (Rehabilitation)	Not covered	Not covered
Outpatient Chemical Dependency Treatment	Covered in full - 60 visits per year	EmblemHealth pays 80% of the allowed charge, not to exceed the Hospital charge
Outpatient Mental Health	Not covered	Not covered
Pharmacy	Retail Rx	Mail Order Rx
Pharmacy Deductible	$50 Deductible	$0 Deductible
Rx Copay Generic Drugs	$10 Copay for 30-Day supply	$8 Copay for 90-Day supply
Rx Copay Preferred Drugs with generic equivalents	$10 Copay plus difference in price between brand and generic for 30-Day supply	$15 Copay for 90-Day supply
Rx Copay Preferred Drugs without generic equivalents	$10 Copay for 30-Day supply	$15 Copay for 90-Day supply

*Services may be subject to Precertification or Pre-authorization.

The benefits described here are only brief highlights of the coverage available. Some benefits may have calendar year limits and/or maximums. The terms, limitations, conditions, and exclusions of the insurance contract and certificate will govern.