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MUST $1500 Plan

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.

MUST 1500 Plan

The benefit levels below apply when provided by a network provider.  To find out if your doctor is a network provider, visit www. and follow the provider links. 

Group Information
Group Name: Belgrade School District Individual/Family Deductible: $1,500/$3,000
Benefit Percentage 80/20% : 80% Individual/Family OOPM: $3,000/$6,000
Medical Benefits: Deductible Waived
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
  • In-Network: $25 co-pay
  • Out-of-Network: 80/20%

Chemical Dependency/mental illness (outpatient): First 3 outpatient office visits paid at 100%

Virtual Visits: $25

Medical Benefits: Deductible Applies
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 Plan: See Benefit Summary for details.