MILA : BENEFITS SUMMARY

	Benefits Summary

Out-of-Network Service

In-Network Plan Benefits

Prescription Drug Benefits

Out-of-Pocket Expense Maximum

Wrap-Around Plan

Dental Plan

Vision Plan


	What Is Covered


	What is Not Covered


	Participation Under the Plan


	Claims and Appeals


	Your Rights Under ERISA


	Administrative Information


	Glossary

BENEFITS SUMMARY

MILA Core Plan – Provides Only In-Network Benefits

Summary Benefits Chart

Shown below is the MILA Core Plan Summary Benefits Chart for active Members. This chart allows you to see at-a-glance the key Plan features. The copay, deductible and coinsurance amounts below reflect what you pay. MILA pays the balance of covered charges.

SUMMARY OF THE MILA NATIONAL HEALTH PLAN: CORE BENEFITS
	CORE PLAN
FEATURES	IN-NETWORK
Calendar Year Deductible- This deductible applies to both medial and behavioral benefits.
Individual	$750
Family Limit	$1,500
Annual Out-of-Pocket Maximum: Deductible & Coinsurance: Deductible & Coinsurance: This maximum includes your deductible and coinsurance payment for medical and behavioral health benefits.
Individual	$7,500
Family Limit	$15,000
No Lifetime Maximum Benefit
Physician Services Copay/Visit
Primary Care Physician (PCP)	$35 copay/visit
Specialist Physician	$50 copay/visit
Behavioral Health Provider	$35 copay/visit
Preventative Care	$35 copay/visit
Maternity Care (one/pregnancy)	$35 copay/visit
Hospital Care
Hospital Inpatient Care including professional services (Precertification Required)	$500 copay/40% of the network charge after deductible
Hospital Outpatient Surgery/Testing	40% of the network charge after deductible
Emergeny Room (true emergency only/waived if admitted)	$75 copay/visit
Urgent Care Center	$50 copay/visit
Ambulance	40% of the network charge after deductible
Skilled Nursing (up to 100 days per calendar year)	40% 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	40% 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
Retail
Retail Copay- up to 30-day supply (Generic)	$10	$10
Retail Copay- up to 30-day supply (Preferred Brand)	$20	$20
Retail Copay- up to 30-day supply (Non-Preferred Brand)	$50	$50
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)	$20	Not Covered
Mail Order Copay- up to 90-day supply (Preferred Brand)	$50	Not Covered
Mail Order Copay- up to 90-day supply (Non-Preferred Brand)	$125	Not Covered
For Mail Order & Maintenance Choice: Up to 90-day supply- First fill plus one refill per prescription