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SUMMARY OF THE MILA NATIONAL HEALTH PLAN: CORE BENEFITS

SUMMARY OF THE MILA NATIONAL HEALTH PLAN: CORE BENEFITS
CORE PLAN
FEATURES IN-NETWORK
Calendar Year Deductible- This deductible applies to both medial and behavioral benefits.
Individual $750
Family Limit $1,500
Annual Out-of-Pocket Maximum: Deductible & Coinsurance: Deductible & Coinsurance: This maximum includes your deductible and coinsurance payment for medical and behavioral health benefits.
Individual $7,500
Family Limit $15,000
No Lifetime Maximum Benefit
Physician Services Copay/Visit
Primary Care Physician (PCP) $35 copay/visit
Specialist Physician $50 copay/visit
Behavioral Health Provider $35 copay/visit
Preventative Care $35 copay/visit
Maternity Care (one/pregnancy) $35 copay/visit
Hospital Care
Hospital Inpatient Care including professional services (Precertification Required) $500 copay/40% of the network charge after deductible
Hospital Outpatient Surgery/Testing 40% of the network charge after deductible
Emergeny Room (true emergency only/waived if admitted) $75 copay/visit
Urgent Care Center $50 copay/visit
Ambulance 40% of the network charge after deductible
Skilled Nursing (up to 100 days per calendar year) 40% 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 40% 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
Retail
Retail Copay- up to 30-day supply (Generic) $10 $10
Retail Copay- up to 30-day supply (Preferred Brand) $20 $20
Retail Copay- up to 30-day supply (Non-Preferred Brand) $50 $50
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) $20 Not Covered
Mail Order Copay- up to 90-day supply (Preferred Brand) $50 Not Covered
Mail Order Copay- up to 90-day supply (Non-Preferred Brand) $125 Not Covered
For Mail Order & Maintenance Choice: Up to 90-day supply- First fill plus one refill per prescription