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Personal Alliance Personal Alliance

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				What you need to apply

All Plans - optional benefits

3. optional benefits

Our plans offer coverage choices to meet your unique needs and budget. With prescription, dental and vision options, HAP Personal Alliance offers the coverage you need in one convenient location.

When you complete your application or get a quote remember to select the optional benefits that you are interested in. The cost of the optional benefits that you choose will be included in the quote that you receive.

	SHORT-TERM	HSA	PPO
Prescription Coverage	Included	Included	Optional
Dental Coverage	Not Included	Optional	Optional
Vision Coverage	Not Included	Optional	Optional

Prescription Drug Plan Options
Three Prescription Drug plan options are offered with HAP Personal Alliance PPO plans:

$15 Generic/$30 Preferred/$50 Non-Preferred
$15 Generic/$30 Preferred/$50 Non-Preferred (after $500 deductible per person for all tiers)*
$10 Generic/$60 Preferred/$60 Non-Preferred

Members can drop or add drug coverage only upon renewal.

^{*The $500 prescription deductible is in addition to the medical deductible selected and applies to each member on the contract}

Dental Plan Options
Three PPO dental plan options from Delta Dental are offered with HAP Personal Alliance PPO or HSA plans:

Vision Plan Options
A Vision rider is offered with any of our HAP Personal Alliance PPO or HSA plans. Riders are not available with HAP Personal Alliance Short-Term plans.

Vision Hardware option:

$80 limit
One pair every 24 months, or 12 months with prescription change. The coverage is limited to STANDARD (basic) lenses and the amount is limited to $40 for frames. Contact lenses in place of eyeglasses are covered with a limitation of $80. Contact lens fitting is not covered. Enrollee responsible for the difference in cost between STANDARD frame cost and the frame selected.

Members can drop or add vision coverage only upon renewal.

Still looking for guidance, check out our Health Insurance Made Simple Videos.

HMO, PPO, EPO, HSA and HRA:
The Health Insurance Alphabet Decoded

Health Plan Terminology:
The Words You Need to Know

Additional Resources

View Personal Alliance Brochure

FAQ's

Application Status

Award Winning Customer Service

Call us at (855) 948-4427, 8:30 a.m. to 5 p.m. EST, Monday through Friday

E-mail us anytime at personalalliance@hap.org

HAP Personal Alliance is offered by Alliance Health and Life Insurance Company, Inc., a wholly owned subsidiary of Health Alliance Plan.

Checklist for Customers Before You Apply

Before you apply, please be sure to gather the following information which you will need for the application process. Be sure you read each question carefully and make sure all the information you provide is 100% accurate to expedite the application process:

Names and addresses of your doctors/physicians

Dates of service when you last saw your doctor/physician for any condition/check–up–need details on reason for visit, treatment, dr. recommendation, and if there was a resolution.

Latest blood pressure and cholesterol readings – last three readings along with the dates

Name and dosage of any medications taken in the last 5 years with the dates listed for each medication

Credit / debit card information or checking account routing / account number

Agent information

Use the additional information section on the application for any information you want to share with Underwriting.

Be sure to gather the information for each applicant, not just the primary applicant.




	What is an HSA? An HSA is a savings account similar to a traditional Individual Retirement Account (IRA), but designated for medical expenses. With an HSA, you can pay for current covered health expenses and save for future qualified medical health care expenses. Plus, you contributions may be tax deductible. To be eligible to set up an HSA and make annual contributions, you must be covered by a qualified High-Deductible Health Plan (HDHP) like HAP's Personal Alliance HSA 2500 or 5000 plans. A HDHP is a health insurance plan with minimum annual deductions, out-of-pocket maximums and contribution levels set by the IRS and adjusted annually for inflation.




	How does it work? You can use your HSA to pay for your health care costs, from doctor and hospital visits to copayments, eyeglasses and prescriptions. Covered health care costs paid from your HSA are applied toward meeting your annual health plan deductible.




	What are the benefits? It's tax-advantaged • Contributions are made with pre-tax dollars; they're not subject to federal or state income taxes in Michigan, so you pay less income tax at the end of the year. It's Flexible • The money grows and remains with you, even when you change medical plans, or retire - and even if you're no longer eligible to make contributions. After age 65, or in cases of disability, the funds in the account can be used for non-qualified expenses.




	What is a PPO? Members do not have a primary care physician (PCP). Members can self-refer, and receive a higher level of benefits when they receive care from participating providers, and a lower level of benefits when they receive care from non-participating providers.




	What is Short-Term? Sometimes people find themselves needing a short-term health plan solution. Maybe they are between jobs or just in transition. But just because it's a temporary fix, doesn't mean it can't deliver quality care and coverage. Our three short-term solutions are long-term minded in the quality of partnership we want to achieve with all our HAP members. Each plan is available for six months or less (up to 185 days)

Personal Alliance - PPO 500

Plan Type

PPO

Copay

Coinsurance

20% In-Network

50% Out-of-Network

Preventive Office Visit	$0 copay / NSD
Office Visits*	$25 copay / NSD
Allergy testing	$25 copay / NSD
Injections / Lab Test & X-Rays*	$25 copay / NSD
Back Care / Chiro	$25 copay / NSD
Outpatient Surgery	SD CI
Radiation / Chemo	SD CI
Eye Exam (for medical resons)	SD CI
Audiology Exam	SD CI
Emergency Room Service	$250 copay
Urgent Care Services	$50 copay
Emergency Ambulance Services	$100 copay

Deductible
(individual / family)

$500 / $1,000
In-Network

$1,000 / $2,000
Out-of-Network

Out-of-Pocket Max
(individual / family)

$1,500 / $3,000
In-Network

$3,000 / $6,000
Out-of-Network

Optional Benefits (Riders)
See below for descriptions

Prescription Coverage

Dental

Vision Hardware

Summary of Benefits

Click here to view the PDF of summary of benefits chart

SD = Subject to Deduct.	CI = Subject to Coinsurance
CAD = Covered After Deduct. NSD = Not Subject to Deduct.

*One copay is applied to an office visit that includes injections, lab tests and/or x-rays performed on the same day.

Prescription Coverage

Dental

Vision Hardware

Three Prescription Drug plan options are offered with HAP Personal Alliance PPO plans:

$15 Generic/$30 Preferred/$50 Non-Preferred
Generic/ Preferred/ Non-Preferred (after 0 deductible per person for all tiers)*
$10 Generic/$60 Preferred/$60 Non-Preferred

^{*The $500 prescription deductible is in addition to the medical deductible selected and applies to each member on the contract}

Dental plan options
Three PPO dental plan options are offered through Delta Dental and cover a wide range of services - from routine services like oral exams, cleanings, and X-rays to more complex (and expensive) services like bridges, crowns, and dentures.

High
Medium
Low

Great networks
Delta Dental has the largest network of dentists in the United States. Nationwide, more than 72,000 dentists participate in Delta Dental PPO, and more than 132,000 dentists participate in Delta Dental Premier®.3 Find a dentist

Call Delta Dental toll-free for more information
Learn more about Delta Dental's benefits by talking with a Delta Dental representative at
(800) 971-4108. You also may access Delta Dental's interactive voice recording system at the same number.

For more oral health information, please visit the Health and Wellness section of Delta Dental of Michigan's Web site at www.deltadentalmi.com.
1, 2 Oral Health in America: A Report of the Surgeon General, 2000.
3 Statistics: Delta Dental Plans Association, September 2009.
Delta Dental is a registered trademark of the Delta Dental Plans Association.

A Vision benefit is offered with any of our HAP Personal Alliance PPO or HSA plans.

Vision Hardware option:

$80 limit

One pair every 24 months, or 12 months with prescription change. The coverage is limited to STANDARD (basic) lenses and the amount is limited to $40 for frames. Contact lens in place of eyeglasses are covered with a limitation of $80. Contact lens fitting is not covered. Enrollee responsible for the difference in cost between STANDARD frame cost and the frame selected.

*One copay is applied to an office visit that includes injections, lab tests and/or x-rays performed on the same day.

Personal Alliance - PPO 1000

Plan Type

PPO

Copay

Coinsurance

20% In-Network

50% Out-of-Network

Preventive Office Visit	$0 copay / NSD
Office Visits*	$25 copay / NSD
Allergy testing	$25 copay / NSD
Injections / Lab Test & X-Rays*	$25 copay / NSD
Back Care / Chiro	$25 copay / NSD
Outpatient Surgery	SD CI
Radiation / Chemo	SD CI
Eye Exam (for medical resons)	SD CI
Audiology Exam	SD CI
Emergency Room Service	$250 copay
Urgent Care Services	$50 copay
Emergency Ambulance Services	$100 copay

Deductible
(individual / family)

$1,000 / $2,000
In-Network

$2,000 / $4,000
Out-of-Network

Out-of-Pocket Max
(individual / family)

$3,500 / $7,000
In-Network

$7,000 / $14,000
Out-of-Network

Optional Benefits (Riders)
See below for descriptions

Prescription Coverage

Dental

Vision Hardware

Summary of Benefits

Click here to view the PDF of summary of benefits chart

SD = Subject to Deduct.	CI = Subject to Coinsurance
CAD = Covered After Deduct. NSD = Not Subject to Deduct.

Prescription Coverage

Dental

Vision Hardware

Three Prescription Drug plan options are offered with HAP Personal Alliance PPO plans:

$15 Generic/$30 Preferred/$50 Non-Preferred
Generic/ Preferred/ Non-Preferred (after 0 deductible per person for all tiers)*
$10 Generic/$60 Preferred/$60 Non-Preferred

^{*The $500 prescription deductible is in addition to the medical deductible selected and applies to each member on the contract}

High
Medium
Low

A Vision benefit is offered with any of our HAP Personal Alliance PPO or HSA plans.

Vision Hardware option:

$80 limit

*One copay is applied to an office visit that includes injections, lab tests and/or x-rays performed on the same day.

Personal Alliance - PPO 2000

Plan Type

PPO

Copay

Coinsurance

20% In-Network

50% Out-of-Network

Preventive Office Visit	$0 copay / NSD
Office Visits*	$25 copay / NSD
Allergy testing	$25 copay / NSD
Injections / Lab Test & X-Rays*	$25 copay / NSD
Back Care / Chiro	$25 copay / NSD
Outpatient Surgery	SD CI
Radiation / Chemo	SD CI
Eye Exam (for medical resons)	SD CI
Audiology Exam	SD CI
Emergency Room Service	$250 copay
Urgent Care Services	$50 copay
Emergency Ambulance Services	$100 copay

Deductible
(individual / family)

$2,000 / $4,000
In-Network

$4,000 / $8,000
Out-of-Network

Out-of-Pocket Max
(individual / family)

$4,500 / $9,000
In-Network

$9,000 / $18,000
Out-of-Network

Optional Benefits (Riders)
See below for descriptions

Prescription Coverage

Dental

Vision Hardware

Summary of Benefits

Click here to view the PDF of summary of benefits chart

SD = Subject to Deduct.	CI = Subject to Coinsurance
CAD = Covered After Deduct. NSD = Not Subject to Deduct.

Prescription Coverage

Dental

Vision Hardware

Three Prescription Drug plan options are offered with HAP Personal Alliance PPO plans:

$15 Generic/$30 Preferred/$50 Non-Preferred
Generic/ Preferred/ Non-Preferred (after 0 deductible per person for all tiers)*
$10 Generic/$60 Preferred/$60 Non-Preferred

^{*The $500 prescription deductible is in addition to the medical deductible selected and applies to each member on the contract}

High
Medium
Low

A Vision benefit is offered with any of our HAP Personal Alliance PPO or HSA plans.

Vision Hardware option:

$80 limit

*One copay is applied to an office visit that includes injections, lab tests and/or x-rays performed on the same day.

Personal Alliance - PPO 3000

Plan Type

PPO

Copay

Coinsurance

0% In-Network

50% Out-of-Network

Preventive Office Visit	$0 copay / NSD
Office Visits (Limit 4/Year)*	$25 copay / NSD
Allergy testing	$25 copay / NSD
Injections / Lab Test & X-Rays*	$25 copay / NSD
Back Care / Chiro	$25 copay / NSD
Outpatient Surgery	CAD
Radiation / Chemo	CAD
Eye Exam (for medical resons)	CAD
Audiology Exam	CAD
Emergency Room Service	$250 copay
Urgent Care Services	$50 copay
Emergency Ambulance Services	$100 copay

Deductible
(individual / family)

$3,000 / $6,000
In-Network

$6,000 / $12,000
Out-of-Network

Out-of-Pocket Max
(individual / family)

$3,000 / $6,000
In-Network

$10,000 / $20,000
Out-of-Network

Optional Benefits (Riders)
See below for descriptions

Prescription Coverage

Dental

Vision Hardware

Summary of Benefits

Click here to view the PDF of summary of benefits chart

SD = Subject to Deduct.	CI = Subject to Coinsurance
CAD = Covered After Deduct. NSD = Not Subject to Deduct.

Prescription Coverage

Dental

Vision Hardware

Three Prescription Drug plan options are offered with HAP Personal Alliance PPO plans:

$15 Generic/$30 Preferred/$50 Non-Preferred
Generic/ Preferred/ Non-Preferred (after 0 deductible per person for all tiers)*
$10 Generic/$60 Preferred/$60 Non-Preferred

^{*The $500 prescription deductible is in addition to the medical deductible selected and applies to each member on the contract}

High
Medium
Low

A Vision benefit is offered with any of our HAP Personal Alliance PPO or HSA plans.

Vision Hardware option:

$80 limit

*One copay is applied to an office visit that includes injections, lab tests and/or x-rays performed on the same day.

Personal Alliance - PPO 5000

Plan Type

PPO

Copay

Coinsurance

20% In-Network

50% Out-of-Network

Preventive Office Visit	$0 copay / NSD
Office Visits (Limit 4/Year)*	$25 copay / NSD
Allergy testing	$25 copay / NSD
Injections / Lab Test & X-Rays*	$25 copay / NSD
Back Care / Chiro	$25 copay / NSD
Outpatient Surgery	SD CI
Radiation / Chemo	SD CI
Eye Exam (for medical resons)	SD CI
Audiology Exam	SD CI
Emergency Room Service	$250 copay
Urgent Care Services	$50 copay
Emergency Ambulance Services	$100 copay

Deductible
(individual / family)

$5,000 / $10,000
In-Network

$10,000 / $20,000
Out-of-Network

Out-of-Pocket Max
(individual / family)

$10,000 / $20,000
In-Network

$20,000 / $40,000
Out-of-Network

Optional Benefits (Riders)
See below for descriptions

Prescription Coverage

Dental

Vision Hardware

Summary of Benefits

Click here to view the PDF of summary of benefits chart

SD = Subject to Deduct.	CI = Subject to Coinsurance
CAD = Covered After Deduct. NSD = Not Subject to Deduct.

Prescription Coverage

Dental

Vision Hardware

Three Prescription Drug plan options are offered with HAP Personal Alliance PPO plans:

$15 Generic/$30 Preferred/$50 Non-Preferred
Generic/ Preferred/ Non-Preferred (after 0 deductible per person for all tiers)*
$10 Generic/$60 Preferred/$60 Non-Preferred

^{*The $500 prescription deductible is in addition to the medical deductible selected and applies to each member on the contract}

High
Medium
Low

A Vision benefit is offered with any of our HAP Personal Alliance PPO or HSA plans.

Vision Hardware option:

$80 limit

*One copay is applied to an office visit that includes injections, lab tests and/or x-rays performed on the same day.

Personal Alliance - HSA 2500

Plan Type

HSA

Copay

Coinsurance

0% In-Network

50% Out-of-Network

Preventive Office Visit	$0 copay / NSD
Office Visits	SD
Allergy testing	SD
Injections / Lab Test & X-Rays	SD
Back Care / Chiro	SD
Outpatient Surgery	SD
Radiation / Chemo	SD
Eye Exam (for medical resons)	SD
Audiology Exam	SD
Emergency Room Service	SD
Urgent Care Services	SD
Emergency Ambulance Services	SD

Deductible
(individual / family)

$2,500 / $5,000
In-Network

$5,000 / $10,000
Out-of-Network

Out-of-Pocket Max
(individual / family)

$2,500 / $5,000
In-Network

$10,000 / $20,000
Out-of-Network

Optional Benefits (Riders)
See below for descriptions

Prescription Coverage

Dental

Vision Hardware

Summary of Benefits

Click here to view the PDF of summary of benefits chart

SD = Subject to Deduct.	CI = Subject to Coinsurance
CAD = Covered After Deduct. NSD = Not Subject to Deduct.

Prescription Coverage

Dental

Vision Hardware

Subject to Deductible

High
Medium
Low

A Vision benefit is offered with any of our HAP Personal Alliance PPO or HSA plans.

Vision Hardware option:

$80 limit

Personal Alliance - HSA 5000

Plan Type

HSA

Copay

Coinsurance

0% In-Network

50% Out-of-Network

Preventive Office Visit	$0 copay / NSD
Office Visits	SD
Allergy testing	SD
Injections / Lab Test & X-Rays	SD
Back Care / Chiro	SD
Outpatient Surgery	SD
Radiation / Chemo	SD
Eye Exam (for medical resons)	SD
Audiology Exam	SD
Emergency Room Service	SD
Urgent Care Services	SD
Emergency Ambulance Services	SD

Deductible
(individual / family)

$5,000 / $10,000
In-Network

$10,000 / $20,000
Out-of-Network

Out-of-Pocket Max
(individual / family)

$5,000 / $10,000
In-Network

$20,000 / $40,000
Out-of-Network

Optional Benefits (Riders)
See below for descriptions

Prescription Coverage

Dental

Vision Hardware

Summary of Benefits

Click here to view the PDF of summary of benefits chart

SD = Subject to Deduct.	CI = Subject to Coinsurance
CAD = Covered After Deduct. NSD = Not Subject to Deduct.

Prescription Coverage

Dental

Vision Hardware

Subject to Deductible

High
Medium
Low

A Vision benefit is offered with any of our HAP Personal Alliance PPO or HSA plans.

Vision Hardware option:

$80 limit

Personal Alliance - Short-Term 500

Plan Type

Short-Term

Copay

Coinsurance

20% In-Network

50% Out-of-Network

Office Visits	SD CI
Allergy testing	SD CI
Injections / Lab Test & X-Rays	SD CI
Back Care / Chiro	SD CI
Outpatient Surgery	SD CI
Radiation / Chemo	SD CI
Eye Exam (for medical resons)	SD CI
Audiology Exam	SD CI
Emergency Room Service	$250 copay
Urgent Care Services	$50 copay
Emergency Ambulance Services	$100 copay

Deductible
(individual / family)

$500 / $1,000
In-Network

$1,000 / $2,000
Out-of-Network

Out-of-Pocket Max
(individual / family)

$1,000 / $2,000
In-Network

$2,000 / $4,000
Out-of-Network

Presciption Coverage

Subject to deductible and coinsurance

Summary of Benefits

Click here to view the PDF of summary of benefits chart

SD = Subject to Deduct.	CI = Subject to Coinsurance
CAD = Covered After Deduct. NSD = Not Subject to Deduct.

Personal Alliance - Short-Term 1000

Plan Type

Short-Term

Copay

Coinsurance

20% In-Network

50% Out-of-Network

Office Visits	SD CI
Allergy testing	SD CI
Injections / Lab Test & X-Rays	SD CI
Back Care / Chiro	SD CI
Outpatient Surgery	SD CI
Radiation / Chemo	SD CI
Eye Exam (for medical resons)	SD CI
Audiology Exam	SD CI
Emergency Room Service	$250 copay
Urgent Care Services	$50 copay
Emergency Ambulance Services	$100 copay

Deductible
(individual / family)

$1,000 / $2,000
In-Network

$2,000 / $4,000
Out-of-Network

Out-of-Pocket Max
(individual / family)

$2,000 / $4,000
In-Network

$4,000 / $8,000
Out-of-Network

Prescription Coverage

Subject to deductible and coinsurance

Summary of Benefits

Click here to view the PDF of summary of benefits chart

SD = Subject to Deduct.	CI = Subject to Coinsurance
CAD = Covered After Deduct. NSD = Not Subject to Deduct.

Personal Alliance - Short-Term 2000

Plan Type

Short-Term

Copay

Coinsurance

20% In-Network

50% Out-of-Network

Office Visits	SD CI
Allergy testing	SD CI
Injections / Lab Test & X-Rays	SD CI
Back Care / Chiro	SD CI
Outpatient Surgery	SD CI
Radiation / Chemo	SD CI
Eye Exam (for medical resons)	SD CI
Audiology Exam	SD CI
Emergency Room Service	$250 copay
Urgent Care Services	$50 copay
Emergency Ambulance Services	$100 copay