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Comparison of MILA Medical Plans
	Wrap Around Plan	Core Plan	Basic Plan	Premier Plan
Hours to Qualify	Medicare Wrap Around Plan	700-999	1,000 - 1,299	1,300 or more
Features		In-Network	Out-of-Network	Out-of-Network	Out-of-Network
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	$750/$1,500 $0/$0	$400/$700 $0/$0	$0 $0	$300/$600 $0/$0

Annual Out-of-Pocket Maximum - Deductible & Coinsurance Medical – Individual/Family Behavioral Health – Individual/Family	$2,500 $5,000	$7,500/$15,000 $7,500/$15,000	$5,000/N/A $5,000/N/A	$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	$500,000 per person $50,000 per person $500,000 per person	No Maxmimum No Maxmimum	No Maxmimum No Maxmimum	No Maximum No Maximum No Maximum	$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

Physician Visits PCP/Specialist Visits Retail Health Clinic Visits Short-Term Rehabilitation (STR)		$35/$50 $35	$25/$40 $25	$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	20% of Eligible Charge after deductible	$35	$25	$15	These services are only covered In-Network

Maternity Care (copay is once per pregnancy for all physician visits)	Not Applicable	$35	$25	$15	40% of R&C after deductible

Family Planning (PCP/Specialist)	Not Applicable	$35/$50	$25/$40	$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 - for In-Network only; 20% of Eligible Charge	$0 $35/$50	$0 $15	$0 $15	Services are In-Network only; 50% of contract rate plus excess over contract rate

Hospital Inpatient Care	$0 $0 for Behavioral Health	40% of contract rate after deductible plus a $500 per admission copay 40% of contract rate for Behavioral Health	30% of contract rate after deductible, plus a $350 copay once/year 30% of contract rate for Behavioral Health	$0	40% of R&C after deductible; 50% of contract rate for BehavioralHealth

Hospital Outpatient Care	$0 $0 for Behavioral Health	40% of contract rate after deductible 40% of contract rate for Behavioral Health	30% of contract rate after deductible 30% of contract rate for Behavioral Health	$0	40% of R&C after deductible; 50% of contract rate for BehavioralHealth

Hospital Emergency Room Care (copay waived if admitted)	20% of Eligible Charge after deductible or 20% of Eligible Charge for Behavioral Health	$75	$50	$25	Treated as In-Network

Urgent Care Center	20% of Eligible Charge after deductible or 20% of Eligible Charge for Behavioral Health	$50	$25	$25	40% of R&C after deductible; 50% of contract rate for Behavioral Health

Ambulance	$0	40% of R&C after deductible	30% of R&C after deductible	$0	40% of R&C after deductible; 50% of contract rate for Behavioral Health

Outpatient Surgery	20% of Eligible Charge	40% of R&C after deductible	30% of R&C after deductible	$0	40% of R&C after deductible

Second and Third Opinions		40% of R&C after deductible	$25/$40	$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)	20% of Eligible Charge after deductible or 20% of Eligible Charge for Behavioral Health	40% of R&C after deductible	30% of R&C after deductible	Covered at 100% after $15/$30 copay per visit	40% of R&C after deductible

Acupuncture	20% of Eligible Charge after deductible	$50	$40	$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)	$0	40% of R&C after deductible	30% of R&C after deductible	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)	20% of Eligible Charge after deductible	40% of R&C after deductible	30% of R&C after deductible	$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.	20% of Eligible Charge after deductible	40% of R&C after deductible	30% of R&C after deductible	$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.		40% of R&C after deductible	30% of R&C after deductible	$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” on page 39.	$0	40% of R&C after deductible	30% of R&C after deductible	$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.	$500 Deductible applies to all Brand Name Drugs	$500 Deductible applies to all Brand Name Drugs when a generic equivalent is available.	$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	In Network $5 $10 $25 Out of Network $5 $10 $25 (Plus excess over contract rate)	$10 $20 $50	$5 $10 $25	$5 $10 $25	$5 $10 $25 Plus excess over contract rate

Mail Order (90-day supply)	In Network $5 $10 $25 Out of Network Covered only through Caremark® Mail Service	$20 $50 $125	$5 $15 $50	$5 $10 $25	Not Covered