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SUMMARY OF THE MILA NATIONAL HEALTH PLAN: PREMIER BENEFITS

SUMMARY OF THE MILA NATIONAL HEALTH PLAN: PREMIER BENEFITS
PREMIER PLAN
FEATURES IN-NETWORK OUT-OF-NETWORK
Calendar Year Deductible- This deductible applies to both medial and behavioral benefits.
Individual None $300
Family Limit None $600
Annual Out-of-Pocket Maximum: Deductible & Coinsurance: Deductible & Coinsurance: This maximum includes your deductible and coinsurance payment for medical and behavioral health benefits.
Individual None $6,500
Family Limit None $13,000
No Liftime Maximum Benefit
Physician Services Copay/Visit
Primary Care Physician (PCP) $15 copay/visit 40% of R&C* after deductible plus excess over R&C
Specialist Physician $30 copay/visit 40% of R&C after deductible plus excess over R&C
Short-Term Rehabilitation (STR) $10 copay/visit 40% of R&C after deductible plus excess over R&C
Behavioral Health Provider $15 copay/visit 40% of R&C after deductible plus excess over R&C
Preventative Care $15 copay/visit In-Network Only
Maternity Care (one/pregnancy) $15 copay/pregnancy 40% of R&C after deductible plus excess over R&C
Hospital Care
Hospital Inpatient Care including professional services (Precertification Required) $0 (Paid in full by Plan) 40% of R&C after deductible plus excess over R&C
Hospital Outpatient Surgery/Testing $0 (Paid in full by Plan) 40% of R&C after deductible plus excess over R&C
Emergeny Room (true emergency only/waived if admitted) $25 copay/visit Treated as In-Network
Urgent Care Center $25 copay/visit 40% of R&C after deductible plus excess over R&C
Ambulance $0 (Paid in full by Plan) 40% of R&C after deductible plus excess over R&C
Skilled Nursing (up to 100 days per calendar year) $0 40% of R&C after deductible plus excess over R&C
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 $0 40% of R&C after deductible plus excess over R&C
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 Plus excess over contract cost
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

*R&C means the reasonable and customary charges as defined in the Glossary at the back of this SPD.