BENEFITS SUMMARY

Networks

The Claim Administrators for medical and behavioral health will be Medicare instead of CIGNA or ComPsych when Medicare covers the expense. The Claims Administrator for the Prescription Drug Program, Caremark®, supplies the network of retail and mail service pharmacies. It is important to keep in mind that the MILA Prescription Drug Program provides coverage on both an In-Network and Out-of-Network basis at the benefit levels noted on the MILA Medicare Wrap-Around Plan chart.

Because the CIGNA and ComPsych networks generally are not available in this Plan, the Trustees have decided that the benefits should be “Out-of-Area” benefits. The only time when In-Network benefits will be available to you is when you access the Member Assistance Plan (MAP) or when a service is not covered by Medicare but it is covered by the Plan. This will happen very infrequently. See the explanation of the Out-of-Area benefits here.

Most hospitals and other institutions are contracted in the Medicare “network” and MILA will pay the balance of these costs which you incur and Medicare covers as indicated in the Medicare Wrap-Around Chart.

Medicare covers physician’s services and the MILA Medicare Wrap-Around Plan will supplement those payments as indicated in the Chart. There are three categories of physicians in the Medicare “network” and the majority of physicians participate in one of these three categories. Medicare controls the prices which these physicians may charge and the type of physician you use controls your cost and MILA’s cost.

For example, assume you have satisfied Medicare’s deductible. Then, you visit a physician who accepts assignment and he bills $200. Medicare determines that $100 is the covered charge and it pays $80. The physician who accepts assignment will accept this as payment in full. Your Medicare Explanation of Benefits (EOB) will tell you this.

Prescription drugs are subject to the copay which is applicable to the type of drug indicated in the MILA Medicare Wrap-Around Plan Chart. If you have a prescription for a brand drug for which there is a generic equivalent drug, the generic drug will be issued unless the prescribing physician has indicated that substitution may not occur. In that case, the cost of the prescription will first be subject to the $500 deductible per family each calendar year. Click here for more information on prescription brand deductibles and generic drug substitution.

The Caremark® network of pharmacies includes all the retail pharmacies with which Caremark® has a contract. If the Caremark® logo is displayed, the retail pharmacy is available to MILA Members. If you use another pharmacy, you will have to have to follow the claim submission procedures detailed here for obtaining reimbursement from the Plan. MILA has been assigned to one Caremark® mail service pharmacy and, at this time, that pharmacy location is the exclusive provider of mail service to MILA Members.

The In-Network providers have been selected based upon that provider’s credentials and the quality of service which that provider has delivered in the past. In contrast, there are no “credentialing requirements” for participation in the Medicare network. The provider must give Medicare a fixed discount on the cost of service. However, quality service is the most important contributor to lower Plan cost. If the service is appropriate to the Member’s medical needs, the Member will recover faster and require less medical service. Not only will this result in lower total Plan cost, but it will create a more satisfactory experience for the Member.