MVR-COG Summary of Benefits

Covered Benefits Network Non-Network

Deductible

Single: $5,500 Single: $11,000
Embedded Family: $11,000 Family: $22,000
The single deductible applies to the Family deductible. Once the single deductible has been satisfied, benefits for that member are payable subject to coinsurance. Once the family deductible has been satisfied, benefits for the family are payable subject to coinsurance.

Out-of-Pocket Limit (includes medical and drug cost shares, deductibles and coinsurance)

Single: $6,500 Single: $33,000
Family: $13,000 Family: $66,000

Physician Home and Office Services

10% 30%
  • Including Office Surgeries, allergy serum, allergy injections and allergy testing

Preventive Care Services

No cost share 30%
Services include but are not limited to: Routine Exams, Mammograms, Pelvic Exams, Pap testing, PSA tests, Immunizations, Annual diabetic eye exam and Hearing screenings.

Emergency and Urgent Care

Emergency Room Services @ Hospital (facility/other covered services

10% 10%

Urgent Care Center Services

10% 30%

Inpatient and Outpatient Professional Services

10% 30%
Include but are not limited to:
  • Medical Care visits (1 per day), Intensive Medical Care, Concurrent Care, Consultations, Surgery and administration of general anesthesia and Newborn exams

Inpatient Facility Services (Network/Non-Network combined) Unlimited days except for:

  • Unlimited days for physical medicine/rehab (limit includes Day Rehabilitation Therapy Services on an outpatient basis)
  • 120 days for skilled nursing facility
10% 30%

Outpatient Surgery Hospital/Alternative Care Facility

  • Surgery and administration of general anesthesia
10% 30%

Other Outpatient Services
including but not limited to:

10% 30%
  • Non Surgical Outpatient Services For example: MRIs, C-Scans, Chemotherapy, Ultrasounds, and other diagnostic outpatient services
  • Home Care Services 90 visits (excludes IV Therapy) (Network/Non-Network combined)
  • Durable Medical Equipment
  • Physical Medicine Therapy Day Rehabilitation programs
  • Hospice Care
10% 30%
  • Ambulance Services
10% 10%
Accidental Dental Services Unlimited per accident (Network and Non-network combined) 10% 30%

Outpatient Therapy Services
(Combined Network & Non-Network limits apply)

  • Physician Home and Office Visits
10% 30%
  • Other Outpatient Services @ Hospital/Alternative Care Facility
10% 30%
Limits apply to:
  • Cardiac Rehabilitation Unlimited
  • Pulmonary Rehabilitation Unlimited
  • Physical Therapy: 30 visits
  • Occupational Therapy: 30 visits
  • Manipulation Therapy: 36 visits
  • Speech Therapy: 20 visits

Behavioral Health Services:
Mental Illness and Substance Abuse(1)

  • Physician Home and Office Visits
  • Other Outpatient Services @ Hospital/Alternative Care Facility

Benefits provided in accordance with Federal Mental Health Parity

30%

Human Organ and Tissue Transplants

  • Acquisition and transplant procedures, harvest and storage
10% 30%

Prescription Drugs

  • Network Retail Pharmacies:
    (90-day supply)
10% 10%
  • Home Delivery Service:
    (90-day supply)
10% Not covered

Specialty medications are limited up to a 30 day supply regardless of whether they are retail or mail service.
Member may be responsible for additional cost when not selecting the available generic drug.

Medicare Rx - Wrap

Notes:

  • All medical and drug cost shares, deductibles and precentage (%) coinsurance apply toward the out-of-pocket maximum.
  • Deductible(s) apply to covered services listed with a percentage (%) coinsurance, including 0%
  • Deductible applies to all prescription drug expenses for Rx plans. Once the deductible is met the appropriate copayment/coinsurance applies. Copayments/coinsurance accumulate to the Medical OOP max. Once the Medical OOP max is met, no additional costshare applies.
  • Network and Non-network Deductible, copayments, coinsurance, and out-of-pocket maximums do accumulate toward each other.
  • Dependent Age: to end of the month which the child attains age 26
  • 0% means no coinsurance up to the maximum allowable amount. However, when choosing a Non-network provider, the member is responsible for any balance due after the plan payment.
  • No Cost Share (NCS): No deductible/copayment/coinsurance up to the maximum allowable amount.
  • Live Health Online (LHO) is covered at the PCP costshare.
  • Benefit period = calendar year
  • Behavioral Health Services: Mental Health and Substane Abuse benefits provided in accordance with Federal Mental Health Parity.
  • Preventive Care Services that meet the requirements of federal and state law, including certain screenings, immunizations and physician visits are covered.
  • Private Duty Nursing - unlimited visits/Calendar Year
  • Plan to cover surgical treatment of morbid obesity, medical, $30,000 Lifetime
  • Plan to cover Rx for surgical treatment of morbid obesity
  • Plan to cover sexual dysfunction, medical and Rx.
  • Exclude elective abortions

(1) We encourage you to review the Schedule of Benefits for limitations.

Precertification:
Members are encouraged to always obtain prior approval when using non-network providers. Precertification will help the member know if the services are considered not medically necessary.

Pre-existing Exclusion Period: none

This summary of benefits has been updated to comply with federal and state requirements, including applicable provisions of the recently enacted federal health care reform laws. As we receive additional guidance and clarification on the new health care reform laws from the U.S. Department of Health and Human Services

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