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SUMMARY OF THE MILA NATIONAL HEALTH PLAN: BASIC BENEFITS

SUMMARY OF THE MILA NATIONAL HEALTH PLAN: BASIC BENEFITS
BASIC PLAN
FEATURES IN-NETWORK
Calendar Year Deductible- This deductible applies to both medial and behavioral benefits.
Individual $400
Family Limit $700
Annual Out-of-Pocket Maximum: Deductible & Coinsurance: Deductible & Coinsurance: This maximum includes your deductible and coinsurance payment for medical and behavioral health benefits.
Individual $5,000
Family Limit Not Applicable
No Liftime Maximum Benefit
Physician Services Copay/Visit
Primary Care Physician (PCP) $25 copay/visit
Specialist Physician $40 copay/visit
Behavioral Health Provider $15 copay/visit
Preventative Care $25 copay/visit
Maternity Care (one/pregnancy) $25 copay/visit
Hospital Care
Hospital Inpatient Care including professional services (Precertification Required) $350 copay/1st Admission each year: 30% of the network charge after deductible
Hospital Outpatient Surgery/Testing 30% of the network charge after deductible
Emergeny Room (true emergency only/waived if admitted) $50 copay/visit
Urgent Care Center $25 copay/visit
Ambulance 30% of the network charge after deductible
Skilled Nursing (up to 100 days per calendar year) 30% of the network charge after deductible
Home Health Care- (Includes up to 120 visits per calendar year.) Visits include part-time or intermittent nursing care or for care supervised by an RN, part-time or intermittent services of a home health aide and visits for physical, occupational or speech therapy 30% of the network charge after deductible
PRESCRIPTION DRUG IN-NETWORK OUT-OF-NETWORK
Prescription Brand Deductible per Family $500 Deductible applies to all Brand Name Drugs when a generic equivalent is available
Retail
Retail Copay- up to 30-day supply (Generic) $5 $5
Retail Copay- up to 30-day supply (Preferred Brand) $10 $10
Retail Copay- up to 30-day supply (Non-Preferred Brand) $25 $25
For Retail: Up to 30-day supply- First fill plus one refill per prescription
Maintenance Choice or Mail Order
Mail Order Copay- up to 90-day supply (Generic) $5 Not Covered
Mail Order Copay- up to 90-day supply (Preferred Brand) $15 Not Covered
Mail Order Copay- up to 90-day supply (Non-Preferred Brand) $50 Not Covered
For Mail Order & Maintenance Choice: Up to 90-day supply- First fill plus one refill per prescription