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BENEFITS SUMMARY

MILA Premier Plan

Benefits Summary

Shown below is the MILA Premier Plan Benefits Summary for eligible active Members, and for those Pensioners age 62 or older who are not eligible 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 covered charges.

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.