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MUST $3500 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 3500 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: $3,500/$7,000
Benefit Percentage 100/0% :100% Individual/Family OOPM: $3,500/$7,000

Embedded deductible: in this plan, any one member of the family can meet the individual deductible, at which point the plan starts to pay its share of claims for that member.

Medical Benefits: Deductible Waived
Preventive benefit: Deductible waived, paid at 100% (see Preventative Benefit flier for details)
Virtual Visits: $44 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.
Medical Benefits: Deductible Applies
Office visits (physician/chemical dependency/mental illness) Chemical dependency/mental illness (outpatient)
Diagnostic/acupuncture visits: Deductible applies, no co-insurance, but limited to 10 combined visits per benefit period Chemical dependency/mental illness (inpatient)
Chiropractic X-ray: Deductible applies, no co-insurance Rehabilitation therapy: maximum of 50 outpatient visits or 60 inpatient days
Hospital services Home healthcare: 180 visit maximum
Diagnostic X-ray Skilled nursing facility: 60 day maximum
Lab work Autism Spectrum disorders
Transplant coverage  

Prescription charges apply to medical deductible and co-insurance, and once deductible is met, the plan pays prescription claims at benefit percentage level.