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Producers

Individuals & Families

Alliant Plus

Offered by Group Health Options, Inc.

Summary of Benefits  
(Effective July 1, 2010 - June 30, 2011)
PLAN ANNUAL DEDUCTIBLE MEMBER COINSURANCE OFFICE VISITS
 PREVENTIVE CARE OFFICE VISITS
 MATERNITY CARE - OUTPATIENT PRESCRIPTION DRUG COVERAGE
 BENEFIT SUMMARY
Balance 1250
In-network		 $1,250 ind.
$3,750 family		 20% $30 visit, no deductible or coinsurance $30 visit, deductible does not apply $30 visit, no deductible $10 generic/
30% brand name.
50% non-formulary. Deductible does not apply. $3000 annual maximum shared in-and-out-of-network		 PDF
Balance 1250
Out-of-network		 Shared with
in-network		 20% $30 visit after deductible, coinsurance does not apply $30 visit, $300 ind./$600 family annual benefit max. Deductible does not apply $30 visit after deductible $15 generic/
30% brand name.
50% non-formulary. Deductible does not apply. $3000 annual maximum shared in-and-out-of-network
Balance 1750
In-network		 $1,750 ind.
$5,250 family		 30% $30 visit, no deductible or coinsurance $30 visit, deductible does not apply $30 visit, no deductible
 $10 generic/
30% brand name.
50% non-formulary. Deductible does not apply. $3000 annual maximum shared in-and-out-of-network		 PDF
Balance 1750
Out-of-network		 Shared with
in-network		 30% $30 visit after deductible, coinsurance does not apply $30 visit, $300 ind./$600 family annual benefit max. Deductible does not apply $30 visit after deductible
 $15 generic/
30% brand name.
50% non-formulary. Deductible does not apply. $3000 annual maximum shared in-and-out-of-network
Balance 2500
In-network		 $2,500 ind.
$7,500 family		 40% $30 visit, no deductible or coinsurance $30 visit, deductible does not apply Not covered Not covered PDF
Balance 2500
Out-of-network		 Shared with
in-network		 40% $30 visit after deductible, coinsurance does not apply $30 visit. $300 ind./$600 family annual benefit max. Not covered Not covered
Balance 5000
In-network		 $5,000 ind.
$15,000 family		 50% $30 visit, no deductible or coinsurance $30 visit, deductible does not apply Not covered Not covered PDF
Balance 5000
Out-of-network		 Shared with
in-network		 50% $30 visit, no deductible, coinsurance does not apply $30 visit
$300 ind./$600 family annual benefit max. Deductible does not apply		 Not covered Not covered
HealthPays HSA
In-network		 $2,750 ind.
$5,500 family		 10% 10% after deductible 10%, deductible does not apply Not covered Not covered PDF
HealthPays HSA
Out-of-network		 Shared with
in-network		 20% 20% after deductible 20%
$300 ind./$600 family annual benefit max. Deductible does not apply		 Not covered Not covered

Lifetime maximum for all plans is $2 million. This is a summary of benefits and limitations, not a contract.
Coverage provided by Group Health Options, Inc.

Also see:
Complete summary of benefits 2010 (PDF)
Complete summary of benefits 2009 (PDF)
Summary of dental benefits (PDF)
Plan terms and conditions (PDF)
Copyright Group Health Cooperative