BENEFITS SUMMARY

MILA Premier Plan

Summary Benefits Chart

Shown below is the MILA Premier Plan Summary Benefits Chart for 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.

Benefit Plan Premier Plan
Hours to Qualify 1,300 or more
Features In-Network Out-of-Network
Calendar Year Deductible
  • Medical – Individual/Family
  • Behavioral Health – Individual/Family
$0
$0
$300/$600
$0/$0
Annual Out-of-Pocket Maximum - Deductible & Coinsurance
  • Medical – Individual/Family
  • Behavioral Health – Individual/Family
$0
$0
$6,500/$13,000
$6,500/$13,000
Lifetime Maximum Benefits Payable By Plan
  • Medical
  • Chemical Dependency
  • All Behavioral Health including Chemical Dependency
No Maximum
No Maximum
No Maximum
$500,000 per person
$50,000 per person
$500,000 per person
Physician Visits
  • PCP/Specialist Visits
  • Retail Health Clinic Visits
  • Short-Term Rehabilitation (STR)
$15/$30
$15
$10
40% of R&C after deductible
40% of R&C after deductible
40% of R&C after deductible
Preventive Medical Care $15
These services are only covered In-Network
Maternity Care (copay is once per pregnancy for all physician visits)
$15
40% of R&C after deductible
Family Planning (PCP/Specialist) $15/$30
These services are only covered In-Network
Counseling Services - Behavioral Health
  • Member Assistance Plan (MAP) – up to 3 visits
  • Psychological Counseling (maximum of 60 visits per calendar year)
 $0
$15
Services are In-Network only; 50% of contract rate plus excess over contract rate
Hospital Inpatient Care $0
40% of R&C after deductible; 50% of contract rate for Behavioral Health
Hospital Outpatient Care $0
40% of R&C after deductible; 50% of contract rate for Behavioral Health
Hospital Emergency Room Care (copay waived if admitted) $25
Treated as In-Network
Urgent Care Center $25
40% of R&C after deductible; 50% of contract rate for Behavioral Health
Ambulance $0
40% of R&C after deductible; 50% of contract rate for Behavioral Health
Outpatient Surgery $0
40% of R&C after deductible
Second and Third Opinions $30
40% of R&C after deductible; 50% of contract rate for Behavioral Health
Non-Hospital Services and Supplies (such as surgical dressings, x-rays, durable equipment and prostheses)
Covered at 100% after $15/$30 copay per visit
40% of R&C after deductible
Acupuncture $30
40% of R&C after deductible
Organ Transplants (such as autologous bone marrow and stem cell, heart, lung, heart/lung kidney, liver and pancreas)
Covered at 100% if done at a CIGNA Life Source Center
40% of R&C after the deductible, subject to a maximum benefit limit
Skilled Nursing (up to 100 days per calendar year) $0
40% of R&C after deductible; 50% of contract rate for Behavioral Health
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; 50% of contract rate for Behavioral Health
Cancer Therapy
Coverage includes chemotherapy, radiation and other cancer treatment therapies. 		$0
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 semiprivate room, services and supplies, pain relief treatment including medical supplies, individual and family counseling and services listed under “Hospice Care”. 		$0
40% of R&C after deductible
Prescription Brand Deductible per Family $500 Deductible applies to all Brand Name Drugs when a generic equivalent is available.
Prescription Drugs Retail (30-day supply)
  • Generic
  • Preferred Brand
  • Non-Preferred Brand
 $5
$10
$25 		$5
$10
$25
Plus excess over contract rate
Mail Order (90-day supply)
  • Generic
  • Preferred Brand
  • Non-Preferred Brand
 $5
$10
$25 		Not Covered