SUMMARY OF THE MILA NATIONAL HEALTH PLAN: BASIC BENEFITS

SUMMARY OF THE MILA NATIONAL HEALTH PLAN: BASIC BENEFITS
	BASIC PLAN
FEATURES	IN-NETWORK
Calendar Year Deductible- This deductible applies to both medial and behavioral benefits.
Individual	$400
Family Limit	$700

Annual Out-of-Pocket Maximum: Deductible & Coinsurance: Deductible & Coinsurance: This maximum includes your deductible and coinsurance payment for medical and behavioral health benefits.
Individual	$5,000
Family Limit	Not Applicable
No Liftime Maximum Benefit
Physician Services Copay/Visit
Primary Care Physician (PCP)	$25 copay/visit
Specialist Physician	$40 copay/visit
Behavioral Health Provider	$15 copay/visit
Preventative Care	$25 copay/visit
Maternity Care (one/pregnancy)	$25 copay/visit
Hospital Care
Hospital Inpatient Care including professional services (Precertification Required)	$350 copay/1st Admission each year: 30% of the network charge after deductible
Hospital Outpatient Surgery/Testing	30% of the network charge after deductible
Emergeny Room (true emergency only/waived if admitted)	$50 copay/visit
Urgent Care Center	$25 copay/visit
Ambulance	30% of the network charge after deductible
Skilled Nursing (up to 100 days per calendar year)	30% of the network 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	30% of the network charge after deductible
PRESCRIPTION DRUG	IN-NETWORK	OUT-OF-NETWORK
Prescription Brand Deductible per Family	$500 Deductible applies to all Brand Name Drugs when a generic equivalent is available
Retail
Retail Copay- up to 30-day supply (Generic)	$5	$5
Retail Copay- up to 30-day supply (Preferred Brand)	$10	$10
Retail Copay- up to 30-day supply (Non-Preferred Brand)	$25	$25
For Retail: Up to 30-day supply- First fill plus one refill per prescription
Maintenance Choice or Mail Order
Mail Order Copay- up to 90-day supply (Generic)	$5	Not Covered
Mail Order Copay- up to 90-day supply (Preferred Brand)	$15	Not Covered
Mail Order Copay- up to 90-day supply (Non-Preferred Brand)	$50	Not Covered
For Mail Order & Maintenance Choice: Up to 90-day supply- First fill plus one refill per prescription