BENEFITS SUMMARY

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.

Benfit Plan Core Plan
Hours to Qualify 700-999
Features In-Network Only
Calendar Year Deductible
  • Medical – Individual/Family
  • Behavioral Health – Individual/Family
$750/$1,500
$0/$0
Annual Out-of-Pocket Maximum - Deductible & Coinsurance
  • Medical – Individual/Family
  • Behavioral Health – Individual/Family
$7,500/$15,000
$7,500/$15,000
Lifetime Maximum Benefits Payable By Plan
  • Medical
  • Behavioral Health including Chemical Dependency
 No Maxmimum
No Maxmimum
Physician Visits
  • PCP/Specialist Visits
  • Retail Health Clinic Visits
$35/$50
$35
Preventive Medical Care $35
Maternity Care (copay is once per pregnancy for all physician visits) $35
Family Planning $35/$50
Counseling Services - Behavioral Health
  • Member Assistance Plan (MAP) – up to 3 visits
  • Psychological Counseling (maximum of 60 visits per calendar year)
$0
$35/$50
Hospital Inpatient Care 40% of contract rate after deductible plus a $500 per admission copay
40% of contract rate for Behavioral Health
Hospital Outpatient Care 40% of contract rate after deductible
40% of contract rate for Behavioral Health
Hospital Emergency Room Care (copay waived if admitted) $75
Urgent Care Center $50
Ambulance 40% of R&C after deductible
Outpatient Surgery 40% of R&C after deductible
Second and Third Opinions 40% of R&C after deductible
Non-Hospital Services and Supplies (such as surgical dressings, x-rays, durable equipment and prostheses) 40% of R&C after deductible
Acupuncture $50
Organ Transplants (such as autologous bone marrow and stem cell, heart, lung, heart/lung kidney, liver and pancreas) 40% of R&C after deductible
Skilled Nursing (up to 100 days per calendar year) 40% of R&C 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. 		40% of R&C after deductible
Cancer therapy
Coverage includes chemotherapy, radiation and other cancer treatment therapies. 		40% of R&C after deductible
Hospice Care
Terminally ill patients – having a life expectancy of 6 months or less – are covered for services such as bed and board in a semi-private room, services and supplies, pain relief treatment including medical supplies, individual and family counseling and services listed under “Hospice Care”. 		40% of R&C after deductible
Prescription Brand Deductible per Family $500 Deductible applies to all Brand Name Drugs
Prescription Drugs Retail (30-day supply)
  • Generic
  • Preferred Brand
  • Non-Preferred Brand
$10
$20
$50
Mail Order (90-day supply)
  • Generic
  • Preferred Brand
  • Non-Preferred Brand
$20
$50
$125