Now there's affordable, secure health care coverage available that rewards you for taking good care of yourself.

Waiting Periods
All members must serve a 365-day waiting period for pre-existing conditions. (A pre-existing condition is any sympton or condition that has been treated or diagnosed within two years prior to the effective date.)

All members must serve a 365-day waiting period from your effective date for maternity benefits, the removal of tonsil and/or adenoids, hysterectomy, myringotomy(ear tubes), insertion of a penile prosthesis, surgical treatment of any congenital anomaly (abnormality), or total joint replacements (unless the joint replacement is required due to trauma occuring to a healthy joint after the member's coverage beginning date). This also includes related surgical procedures of such surgeries (e.g. salpingo-oophorectomy performed in conjunction with hysterectomy). There are no maternity benefits on an individual policy. Maternity benefits are only available for the insured or spouse of the insured on a family plan.

Cost Of The Plan
The cost of the Alfa Plan is based on both your age and the location of your primary residence. The age rate categories are:

Inpatient Facility Services

• No dollar limit for hospital benefits
• $200 deductible per person per admission
• The following inpatient hospital services are covered in full: semi-private room and board; intensive care and other special care units; general nursing care and all other usual hospital ancillary services
• 365 days of care
• 30 days of care each 12 consecutive months for mental and nervous conditions
• Pre-admission Certification required

Outpatient Facility Services - Physicians Bill Separately
Expanded benefits are provided for many services when you visit a Preferred Outpatient Facility or Preferred Ambulatory Surgical Center. The following outpatient facility services are available:

• Chemotherapy and radiation therapy - 100 percent allowed amount
• Hemodialysis - 100 percent allowed amount
• IV therapy - 100 percent allowed amount
• Diagnostic lab, x-ray and pathology - $300 copay - 100 percent allowed amount
• Medical emergencies (treatment of sudden and severe symptoms which require immediate medical attention) - $300 copay - 100 percent allowed amount
• Outpatient surgery - $300 copay - 100 percent allowed amount
• Emergency room/accidental injury - $300 copay - 100 percent allowed amount

Preferred Care Services
When you use a Preferred Medical Doctor (PMD) or other Preferred providers, you will receive these benefits at 80% after meeting your annual $500 Major Medical deductible. The 20% Preferred co-pay applies to the Major Medical out-of-pocket and once the out-of-pocket maximum is met, these benefits are increased to 100%:

• Surgery (inpatient, outpatient and doctor's office)
• Anesthesia services
• Maternity care
• Physician's visits (inpatient, outpatient and office visits)
• Inpatient visits by a PMD physician for routine newborn care and routine immunizations by a PMD physician to prevent invasive pneumoccocal disease in children during the first two years of life.
• In-hospital consultation (one for surgery, medical care and maternity care per confinement)
• Diagnostic x-rays, laboratory and pathology
• Routine immunizations for diphtheria, tetanus, chicken pox, pertussis, poliomyelitis, measles, rubella, mumps, hepatitis B and Hib (meningitis, epiglottis, joint infections)
• Home Health and Hospice
• Physical Therapy

In addition, these physician services are covered at 100% subject to a $25 co-payment after meeting your annual $500 Major Medical deductible:

• Routine well-child care (office visits, only four visits during the first year of the baby's life, plus one visit per year ages one through five.)
• Office visits and outpatient consultations
• Emergency room physician care

The plan provides Physician Preventive Benefits only when the physician is a PMD. If you receive physician preventive services from a non-PMD, the services will not be covered under this or any other portion of the plan.

Major Medical
Coverage and deductibles:

• $1,000,000 lifetime maximum per person
• $500 deductible per person each calendar year
• Maximum $1,500 deductible per family each calendar year
• Pays 80 percent of the allowed amount for Major Medical covered expenses per person each calendar year; annual out-of-pocket maximum per person (excluding mental/nervous) is $1,500 plus the Major Medical deductible; then 100 percent of the allowed amount for the remainder of the year.

Major Medical covered services include:

• Prescription drugs (When purchased from a participating pharmacy, generic drugs are covered at 100 percent and brand name drugs are covered at 80 percent.)
• Ambulance service
• Oxygen, casts, splints, braces and other prosthetic appliances
• Durable medical equipment
• Pays 50 percent UCR of outpatient mental and nervous conditions
  

Additional Benefits
A. Health Management Benefits