BENEFITS SUMMARY

MILA Medicare Wrap-Around Plan

Summary Benefits Chart

Shown below is the MILA Medicare Wrap-Around Plan Summary Benefits Chart for Pensioners who are eligible to enroll for Medicare. This chart allows you to see at-a-glance the key Plan features. Medicare pays its benefits first. Then, with respect to the balance of eligible expenses indicated in your Medicare Explanation of Benefits (Medicare EOB), you pay the deductible and the coinsurance amounts shown in this Chart. MILA then pays the balance of covered charges on the basis of the MILA Medicare Wrap-Around Plan.

Benfit Plan
Medicare Wrap-Around Plan
Features
Calendar Year Deductible
  • Medical – Individual/Family
  • Behavioral Health – Individual/Family
$150/$300
$0/$0
Plus all benefits due and payable by Medicare, Part A & B
Annual Out-of-Pocket Maximum - Deductible & Coinsurance
  • Medical – Individual/Family
  • Behavioral Health – Individual/Family
$2,500
$5,000
Lifetime Maximum Benefits Payable By Plan
  • Medical
  • Chemical Dependency
  • All Behavioral Health – including Chemical Dependency
 $500,000 per person
$50,000 per person
$500,000 per person
PCP/Specialist & Short Term Rehabilitation (STR) Visits 20% of Eligible Charge after deductible
Preventive Medical Care 20% of Eligible Charge after deductible
Maternity Care (copay is once per pregnancy for all physician visits) Not Applicable
Family Planning Not Applicable
Counseling Services - Behavioral Health
  • Member Assistance Plan (MAP) – up to 3 visits
  • Psychological Counseling (maximum of 60 visits per calendar year)
$0 - for In-Network only;
20% of Eligible Charge
Hospital Inpatient Care $0
$0 for Behavioral Health
Hospital Outpatient Care $0
$0 for Behavioral Health
Hospital Emergency Room Care 20% of Eligible Charge after deductible or
20% of Eligible Charge for Behavioral Health
Urgent Care Center 20% of Eligible Charge after deductible or
20% of Eligible Charge for Behavioral Health
Ambulance $0
Outpatient Surgery 20% of Eligible Charge
Non-Hospital Services and Supplies (such as surgical dressings, x-rays, durable equipment and prostheses) 20% of Eligible Charge after deductible or 20% of Eligible Charge for Behavioral Health
Acupuncture 20% of Eligible Charge after deductible
Organ Transplants (such as autologous bone marrow and stem cell, heart, lung, heart/lung kidney, liver and pancreas) $0
Skilled Nursing (up to 100 days per calendar year) %20 of Eligible Charge 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. 		20% of Eligible Charge after deductible
Cancer therapy
Coverage includes chemotherapy, radiation and other cancer treatment therapies. 		20% of Eligible Charge 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”. 		$0
Prescription Brand Deductible per Family $500 Deductible applies to all Brand Name Drugs when a generic equivalent is available.
In-Network Out-of-Network
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 		Covered only through Caremark® Mail Service