Page 19 - EPO_Member_Kit

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Some Alliance-Specific Information
Non-Covered Services
In general, we do not provide benefits for the following:
• Any service that is not medically necessary, such as custodial care (cooking, bathing and
other activities of daily living), long-term care, private duty nursing and private rooms
• Cosmetic surgery such as breast augmentation
or liposuction, experimental or investigative
• Maternity coverage for dependents
For a listing of covered services, please check your
Subscriber Contract and Riders and your Benefit
Summary. You may also check online at
see if a service is covered and what your cost-sharing
amounts might be. Once you log in, select
and use the procedure code provided by
your doctor.
What is our Service Area?
We are approved by the state of Michigan to provide
medical services in southeast Michigan, Flint, west
Michigan, mid Michigan, northern Michigan and the
Upper Peninsula. Many hospitals in these areas are
affiliated with us. For a complete list of affiliated
hospitals reference your Provider Directory or access
our Provider Directory on our Web site,
What are Cost-Sharing Amounts?
When you see an Alliance provider for covered services, you are responsible for the cost-sharing
amounts (like copays, coinsurance and deductibles) that may be a part of your benefit package.
Cost-sharing amounts are the amounts paid by you (and other family members on your policy) for
specific services such as office visits, prescription medications or emergency services. If you’re
unsure about your cost-sharing amounts, you can visit
and register with Online Services.
You may then view the information screen where you can verify these amounts. For more
information on cost-sharing responsibilities (including coinsurance and deductibles), please see
“The Facts About Your Plan” step sheet.