MILA : WHAT IS COVERED

	Benefits Summary


	What Is Covered

Explanation of Terms

Covered Medical Services

Routine Preventitive Care (In-Network Only)

Care for an Ongoing Medical Condition or Specific Symptom

Disease Management Program for Chronic Conditions

Case Management for Catastrophic Conditions

Maternity Care

Family Planning

Care from a Specialist

Outpatient Surgery

Second Opinions

Emergency and Urgent Care

Urgent Care

Hospital Care

Room and Board

Other Hospital Expenses

Emergency Room Expenses

Pre-AdmissionExpenses

Physician Vists

Surgical Costs

Ambulance Service

Other Medical Services

Non-Routine Care and Services

What is Covered Under the Behavioral Health Program

The Prescription Drug Program

Medical Expensese Not Covered Under the Plan

Charges Not Covered in the Behavioral Health Program

Charges Not Covered in the Prescription Drug Program

Coordination of Benefits

Third Party Reimbursement and Subrogation


	Participation Under the Plan


	Claims and Appeals


	Your Rights Under ERISA


	Administrative Information


	Glossary

WHAT IS COVERED

Care from a Specialist

A specialist is a provider whose practice is limited to a specific disease (for example, an oncologist), specific parts of the body (podiatrist), a specific age group (pediatrician) or a specific procedure (oral surgeon). Some specialists may also provide the general medical services of a PCP. You do not need a referral to visit a specialist. However, the specialist may decide you need a procedure or treatment that requires advance approval.

See here for a list of procedures and treatments that require prior approval. Types of specialty care that are covered under the Plan include:

Care provided by any medical specialist including a cardiologist, a pulmonologist, a gastroenterologist, a neurologist, a rheumatologist and so forth;
Podiatry, for the treatment of corns, calluses, weak or flat feet, fallen arches, chronic foot strain or instability of the feet, toenails (including removal of nail matrix or root), treatment of any metabolic or peripheral vascular disease or neurological condition. Covered podiatry expenses are limited to $1,000 per calendar year. (This limit does not apply to the diagnosis and treatment of toenail disease or the treatment of a metabolic or peripheral vascular disease or a neurological condition);
Rehabilitation therapy, which includes physical and occupational therapy, speech therapy, cardiac and pulmonary rehabilitation therapy and cognitive therapy for up to 60 outpatient visits per calendar year;
Acupuncture or acupressure (from an In-Network provider only);
Nurse midwife services (from an In-Network provider only);
Hyperalimentation or total parenteral nutrition (TPN) treatment for an individual who is recovering from or preparing for surgery with benefit payments limited to three months (unless a longer period is approved by a care coordinator); and
Treatment for conditions affecting the joints between the jawbone and the skull, known as temporomandibular joint and craniomandibular joint disorders. Covered expenses are limited to $1,000 per calendar year.