Important Note: This document is intended to be an easy-to-use reference for members. The Summary Plan Description and Related Amendments will supersede this general information with regard to individual participants' eligibility and benefits.
The benefit levels below apply when provided by a network provider. To find out if your doctor is a network provider, visit www. mustbenefits.org and follow the provider links.
| Group Name: Belgrade School District | Individual/Family Deductible: $1,500/$3,000 |
|---|---|
| Benefit Percentage 80/20% : 80% | Individual/Family OOPM: $3,000/$6,000 |
| Accident benefit: Deductible waived on the first $500 after which the deductible and co-insurance apply; claims must be submitted within 90 days of the date of accident. | Preventive benefit: Deductible waived, paid at 100% (see Preventative Benefit flier for details) |
|---|---|
| Chiropractic/acupuncture visits: deductible waived and no co-insurance, 10 combined visits per benefit period | Office visits (physician/chemical dependency/mental illness): deductible waived
|
Chemical Dependency/mental illness (outpatient): First 3 outpatient office visits paid at 100%
Virtual Visits: $25
| Hospital Services | Rehabilitation therapy: maximum of 50 outpatient visits or 60 inpatient days |
|---|---|
| Diagnostic/chiropractic X-ray | Home healthcare: 180 visit maximum |
| Lab work | Skilled nursing facility: 60 day maximum |
| Chemical Dependency/mental illness (outpatient): First 3 outpatient office visits paid at 100%, then deductible and co-insurance apply | Autism Spectrum disorders |
| Chemical dependency/mental illness (inpatient) | Transplant coverage |
Pharmacy
Pharmacy Plan: See Benefit Summary for details.