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HMO Plans
When you enroll in one of our three HMO plans, you will be asked to select a Primary Care Physician for yourself and one for each covered family member from our list of participating Primary Care Physicians. Your Primary Care Physician is your personal health care advocate-providing or coordinating your care. If your Primary Care Physician believes you require specialty care, he or she will refer you to a participating Health Alliance specialist. Visits to a specialist not authorized by your Primary Care Physician will not be covered. With our HMO plans, you don't have any deductibles to meet before your coverage begins. You simply pay small copayments or coinsurance when you receive services. Our Custom Choice HMO plans are summarized in the chart below.

HMO 50 offers the lowest premium amount, while with HMO 90, you will pay the lowest out-of-pocket costs when you receive services. HMO70 and HMO 80 offer a middle ground between these options. The choice is yours.

Click on the plan name for complete details.

	HMO 50	HMO 70	HMO 80	HMO 90
Office Visit Copayment	$20	$20	$20	$15
Percent of Other Covered Services Paid by Health Alliance	50%	70%	80%	90%
Emergency Room Visit Copayment	$150	$150	$150	$150
Out-of-pocket maximums	Family: $6,000 Single: $3,000	Family: $6,000 Single: $3,000	Family: $6,000 Single: $3,000	Family: $6,000 Single: $3,000

Another Custom Choice-Rx Coverage
You can add pharmacy benefits, including oral contraceptives, to Custom Choice HMO (summarized below). This coverage is available for an additional premium amount.

Click here to see the Health Alliance standard drug list.

Rx Option 1:
$100 deductible.
Tier 1: $7 copayment for generic drugs
Tier 2: 30% coinsurance for brand-name, preferred drugs
Tier 3: 50% coinsurance for brand-name, non-preferred drugs

Rx Option 2:
No deductible.
Tier 1: $15 copayment for generic drugs
Tier 2: $30 copayment for brand-name, preferred drugs
Tier 3: $50 copayment for brand-name, non-preferred drugs
(For Rx Plans, Out-of-Pocket Maximum is $1,500. After Out-of-Pocket Maximum is reached, copayments are waived for Tiers 1 and 2, but only waived for Tier 3 drugs if there is a medical reason the member must have the Tier 3 drug.)

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