MILA Core Plan – Provides Only In-Network Benefits
Summary Benefits Chart
Shown below is the MILA Core Plan Summary Benefits Chart for active Members. 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
covered charges.
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CORE PLAN |
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Calendar Year Deductible- This deductible applies to both medial and behavioral benefits.
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Individual
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$750
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Family Limit
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$1,500
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Annual Out-of-Pocket Maximum: Deductible & Coinsurance: Deductible & Coinsurance: This maximum includes your deductible and coinsurance payment for medical and behavioral health benefits.
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Individual
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$7,500
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Family Limit
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$15,000
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Physician Services Copay/Visit
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Primary Care Physician (PCP)
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$35 copay/visit
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Specialist Physician
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$50 copay/visit
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Behavioral Health Provider
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$35 copay/visit
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Preventative Care
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$35 copay/visit
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Maternity Care (one/pregnancy)
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$35 copay/visit
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Hospital Care
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Hospital Inpatient Care including professional services (Precertification Required)
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$500 copay/40% of the network charge after deductible
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Hospital Outpatient Surgery/Testing
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40% of the network charge after deductible
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Emergeny Room (true emergency only/waived if admitted)
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$75 copay/visit
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Urgent Care Center
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$50 copay/visit
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Ambulance
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40% of the network charge after deductible
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Skilled Nursing (up to 100 days per calendar year)
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40% of the network charge after deductible
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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
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40% of the network charge after deductible
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| PRESCRIPTION DRUG |
IN-NETWORK |
OUT-OF-NETWORK |
| $500 Deductible applies to all Brand Name Drugs |
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Retail Copay- up to 30-day supply (Generic)
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$10
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$10
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Retail Copay- up to 30-day supply (Preferred Brand)
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$20
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$20
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Retail Copay- up to 30-day supply (Non-Preferred Brand)
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$50
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$50
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For Retail: Up to 30-day supply- First fill plus one refill per prescription
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Mail Order Copay- up to 90-day supply (Generic)
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$20
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Not Covered
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Mail Order Copay- up to 90-day supply (Preferred Brand)
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$50
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Not Covered
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Mail Order Copay- up to 90-day supply (Non-Preferred Brand)
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$125
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Not Covered
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For Mail Order & Maintenance Choice: Up to 90-day supply- First fill plus one refill per prescription
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