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BENEFITS SUMMARY

MILA Basic Plan – Provides Only In-Network Benefits

Benefits Summary

Shown below is the MILA Basic Plan Summary Benefits Chart for active Members and for those Pensioners, ages 58 through 61, who are not eligible for Premier Plan benefits or to enroll for Medicare. This chart allows you to see at-a-glance the key Plan features. The copay, deductible and coinsurance amounts below reflect what you pay. MILA pays the balance of coverage charges.

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 Lifetime 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