2023 Alliance (HMO) Plan

PLEASE NOTE: You cannot have a Medicare Part D Prescription Drug plan if you enroll in the Alliance plan.

• Worldwide urgent and emergency care
• Large network of doctors across Maine and New Hampshire (see if your doctor is in-network)
• Over-the-counter (OTC): Up to $100 quarterly ($400 each year in total) for members to purchase select CVS-brand, over-the-counter products
• Wellness Wallet: Up to $450 reimbursed each year in total for fitness/wellness gear and services, face masks, naturopathic services, acupuncture, nutritional/dietary education, and weight management program (see what's covered)
• Eyewear: Up to $300 reimbursed each year for prescription lenses, frames, and contact lenses
• Hearing Aids: $295/$495/$895/$1,295/$1,895 copay per ear, depending on tier selected (no copays for fittings or evaluations)
• Flu shots: Get your annual flu shot at no cost, either at your primary care provider’s office (who may charge an office visit copay) or get your pharmacy flu shot reimbursed.¹

• No waiting periods for coverage
• $0 office visit copay
• $2,500 benefit maximum
• See a dentist in the Delta Dental network.
• Diagnostic and preventive services are fully covered with no coinsurance or deductible (includes cleaning, exams, and X-rays).
• Basic restorative services are covered with 20% coinsurance and no deductible (includes amalgam (silver) fillings, oral surgery, root canals, and periodontal maintenance).
• Major restorative services are covered with 50% coinsurance and no deductible (includes dentures, bridges, crowns, onlays, and implants).

*NOTE: This is not a comprehensive list of plan benefits, please refer to the Evidence of Coverage (EOC) for a full list of plan benefits.