SUMMARY OF THE MILA NATIONAL HEALTH PLAN: PREMIER BENEFITS

SUMMARY OF THE MILA NATIONAL HEALTH PLAN: PREMIER BENEFITS
	PREMIER PLAN
FEATURES	IN-NETWORK	OUT-OF-NETWORK
Calendar Year Deductible- This deductible applies to both medial and behavioral benefits.
Individual	None	$300
Family Limit	None	$600

Annual Out-of-Pocket Maximum: Deductible & Coinsurance: Deductible & Coinsurance: This maximum includes your deductible and coinsurance payment for medical and behavioral health benefits.
Individual	None	$6,500
Family Limit	None	$13,000
No Liftime Maximum Benefit
Physician Services Copay/Visit
Primary Care Physician (PCP)	$15 copay/visit	40% of R&C* after deductible plus excess over R&C
Specialist Physician	$30 copay/visit	40% of R&C after deductible plus excess over R&C
Short-Term Rehabilitation (STR)	$10 copay/visit	40% of R&C after deductible plus excess over R&C
Behavioral Health Provider	$15 copay/visit	40% of R&C after deductible plus excess over R&C
Preventative Care	$15 copay/visit	In-Network Only
Maternity Care (one/pregnancy)	$15 copay/pregnancy	40% of R&C after deductible plus excess over R&C
Hospital Care
Hospital Inpatient Care including professional services (Precertification Required)	$0 (Paid in full by Plan)	40% of R&C after deductible plus excess over R&C
Hospital Outpatient Surgery/Testing	$0 (Paid in full by Plan)	40% of R&C after deductible plus excess over R&C
Emergeny Room (true emergency only/waived if admitted)	$25 copay/visit	Treated as In-Network
Urgent Care Center	$25 copay/visit	40% of R&C after deductible plus excess over R&C
Ambulance	$0 (Paid in full by Plan)	40% of R&C after deductible plus excess over R&C
Skilled Nursing (up to 100 days per calendar year)	$0	40% of R&C after deductible plus excess over R&C
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 plus excess over R&C
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		Plus excess over contract cost
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

*R&C means the reasonable and customary charges as defined in the Glossary at the back of this SPD.