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 |
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BASIC 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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$400
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Family Limit
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$700
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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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$5,000
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Family Limit
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Not Applicable
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Primary Care Physician (PCP)
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$25 copay/visit
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Specialist Physician
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$40 copay/visit
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Behavioral Health Provider
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$15 copay/visit
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Preventative Care
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$25 copay/visit
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Maternity Care (one/pregnancy)
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$25 copay/visit
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Hospital Care
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Hospital Inpatient Care including professional services (Precertification Required)
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$350 copay/1st Admission each year: 30% of the network charge after deductible
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Hospital Outpatient Surgery/Testing
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30% of the network charge after deductible
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Emergeny Room (true emergency only/waived if admitted)
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$50 copay/visit
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Urgent Care Center
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$25 copay/visit
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Ambulance
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30% of the network charge after deductible
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Skilled Nursing (up to 100 days per calendar year)
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30% 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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30% 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 when a generic equivalent is available |
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Retail Copay- up to 30-day supply (Generic)
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$5
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$5
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Retail Copay- up to 30-day supply (Preferred Brand)
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$10
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$10
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Retail Copay- up to 30-day supply (Non-Preferred Brand)
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$25
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$25
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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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$5
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Not Covered
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Mail Order Copay- up to 90-day supply (Preferred Brand)
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$15
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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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$50
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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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