MMC Benefits Handbook
Detailed List of Covered Services
The Plan reimburses medically necessary covered services and supplies for the diagnosis and treatment for an illness or injury. The Claims Administrator determines whether the service or supply is covered and determines the amount to be reimbursed.
The covered services listed are the same under the Broad Network and the Narrow Network.
Most services and supplies are subject to a deductible and coinsurance.
Your costs for out-of-network services apply toward the in-network deductible and out-of-pocket maximum. However, your costs for in-network services do not apply toward the out-of-network deductible and out-of-pocket maximum.
$1,600 Deductible Plan and $3,200 Deductible Plan
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$1,600 Deductible Plan
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$3,200 Deductible Plan
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Services
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In-Network Coverage
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Out-of-Network Coverage
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In-Network Coverage
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Out-of-Network Coverage
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Alcohol and substance use
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Inpatient and Residential Treatment:
80% after deductible Preauthorization is required
Outpatient:
80% after deductible
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Inpatient and Residential Treatment:
60% of R&C after deductible Preauthorization is required
Outpatient:
60% after deductible
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Inpatient and Residential Treatment:
70% after deductible Preauthorization is required
Outpatient:
70% after deductible
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Inpatient and Residential Treatment:
50% of R&C after deductible Preauthorization is required
Outpatient:
50% after deductible
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Allergy testing and treatment
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80% after deductible
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60% of R&C after deductible
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70% after deductible
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50% of R&C after deductible
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Alternative medicine (Acupuncture)
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80% after deductible
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60% of R&C after deductible
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70% after deductible
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50% of R&C after deductible
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Coverage limitations:
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Coverage limitations:
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Ambulance charges
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80% after deductible
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80% of R&C after deductible
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70% after deductible
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70% of R&C after deductible
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Applied Behavioral Analysis (ABA)
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80% after deductible Preauthorization is required
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60% of R&C after deductible Preauthorization is required
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70% after deductible Preauthorization is required
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50% of R&C after deductible Preauthorization is required
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Artificial insemination
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80% after deductible
Limited to overall infertility maximum of $20,000* per lifetime (combined in-network/out-of-network) Preauthorization is required
*Prescription drugs related to infertility are covered under the prescription drug benefit and a separate lifetime maximum benefit cap of $20,000 applies for prescription drugs related to infertility.
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60% of R&C after deductible
Limited to overall infertility maximum of $20,000* per lifetime (combined in-network/out-of-network) Preauthorization is required
*Prescription drugs related to infertility are covered under the prescription drug benefit and a separate lifetime maximum benefit cap of $20,000 applies for prescription drugs related to infertility.
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70% after deductible
Limited to overall infertility maximum of $20,000* per lifetime (combined in-network/out-of-network) Preauthorization is required
*Prescription drugs related to infertility are covered under the prescription drug benefit and a separate lifetime maximum benefit cap of $20,000 applies for prescription drugs related to infertility
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50% of R&C after deductible
Limited overall infertility maximum of to $20,000* per lifetime (combined in-network/out-of-network) Preauthorization is required
*Prescription drugs related to infertility are covered under the prescription drug benefit and a separate lifetime maximum benefit cap of $20,000 applies for prescription drugs related to infertility.
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CT / PET scans
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80% after deductible.
CT/PET scans subject to preauthorization
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60% of R&C after deductible.
Medical Necessity Required.
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70% after deductible.
CT/PET scans subject to preauthorization
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50% of R&C after deductible.
Medical Necessity Required.
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Chiropractors
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80% after deductible for up to 30 visits per calendar year combined in-network/out-of-network
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60% of R&C after deductible for up to 30 visits per calendar year combined in-network/out-of-network
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70% after deductible for up to 30 visits per calendar year combined in-network/out-of-network
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50% of R&C after deductible for up to 30 visits per calendar year combined in-network/out-of-network
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Contraceptive devices (as defined as Preventive Prescriptions)
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Covered at 100%, without deductible
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60% of R&C after deductible
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Covered at 100%, without deductible
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50% of R&C after deductible
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Cosmetic surgery
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Not covered
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Not covered
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Not covered
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Not covered
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Dental treatment
(covered only for accidental injury to sound teeth within 12 months)
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80% after deductible
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60% of R&C after deductible
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70% after deductible
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50% of R&C after deductible
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Doctor delivery charge for newborns
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80% after deductible
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60% of R&C after deductible
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70% after deductible
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50% of R&C after deductible
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Durable medical equipment (DME)
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80% after deductible
Preauthorization is required for purchase or rentals of certain DME
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60% of R&C after deductible
Preauthorization is required for purchase or rentals of certain DME
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70% after deductible
Preauthorization is required for purchase or rentals of certain DME
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50% of R&C after deductible
Preauthorization is required for purchase or rentals of certain DME
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EKG Testing
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Covered at 100% (not subject to deductible). Considered preventive if performed as part of a routine exam or associated with a preventive diagnosis code.
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60% of R&C after deductible. Considered preventive if performed as part of a routine exam or associated with a preventive diagnosis code.
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Covered at 100% (not subject to deductible). Considered preventive if performed as part of a routine exam or associated with a preventive diagnosis code.
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50% of R&C after deductible. Considered preventive if performed as part of a routine exam or associated with a preventive diagnosis code.
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Emergency room
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80% after deductible for life-threatening injury or illness (See "Life-threatening Illness or Injury in the "Glossary").
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80% of R&C after deductible for life-threatening injury or illness (See "Life-threatening Illness or Injury in the "Glossary").
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70% after deductible for life-threatening injury or illness (See "Life-threatening Illness or Injury in the "Glossary").
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70% of R&C after deductible for life-threatening injury or illness (See "Life-threatening Illness or Injury in the "Glossary").
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Gender Affirming Surgery (and related costs)
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80% after deductible
Call the Claims Administrator at the number on the back of your ID card for specifics on what is covered and excludeda by the Plan.
Preauthorization is required
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60% of R&C after deductible
Call the Claims Administrator at the number on the back of your ID card for specifics on what is covered and excluded by the Plan.
Preauthorization is required
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70% after deductible
Call the Claims Administrator at the number on the back of your ID card for specifics on what is covered and excluded by the Plan.
Preauthorization is required
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50% of R&C after deductible
Call the Claims Administrator at the number on the back of your ID card for specifics on what is covered and excluded by the Plan.
Preauthorization is required
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Gynecology visits
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Covered at 100% (not subject to deductible) for one routine exam each calendar year
Subsequent visits – 80% after deductible
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60% of R&C after deductible
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Covered at 100% (not subject to deductible) for one routine exam each calendar year
Subsequent visits – 70% after deductible
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50% of R&C after deductible
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Hearing care
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80% after deductible.
Routine hearing screenings performed by a PCP (such as whispered voice, tuning fork), which do not utilize calibrated instrument are covered at 100% when provided as part of a preventive/wellness visit. Hearing exams utilizing calibrated instruments not covered. Covered hearing aids limited to $5,000 every 3 years per covered person (combined in-network/out-of-network).
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60% of R&C after deductible
Covered hearing aids limited to $5,000 every 3 years per covered person.(combined in-network/out-of-network).
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80% after deductible.
Routine hearing screenings performed by a PCP (such as whispered voice, tuning fork), which do not utilize calibrated instruments are covered at 100% when provided as part of a preventive/wellness visit. Hearing exams utilizing calibrated instruments not covered. Covered hearing aids limited to $5,000 every 3 years per covered person (combined in-network/out-of-network).
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60% of R&C after deductible
Covered hearing aids limited to $5,000 every 3 years per covered person (combined in-network/out-of-network).
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Home health care
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80% after deductible for up to 120 home health care aid visits per calendar year for homebound patients Preauthorization is required
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60% of R&C after deductible for up to 120 home health care aid visits per calendar year for homebound patients Preauthorization is required
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70% after deductible for up to 120 home health care aid visits per calendar year for homebound patients Preauthorization is required
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50% of R&C after deductible for up to 120 home health care aid visits per calendar year for homebound patients Preauthorization is required
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Hospice care
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80% after deductible
Preauthorization is required
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60% of R&C after deductible
Preauthorization is required
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70% after deductible
Preauthorization is required
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50% of R&C after deductible
Preauthorization is required
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Immunizations
(routine)
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Covered at 100% (not subject to deductible)
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60% of R&C after deductible
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Covered at 100% (not subject to deductible)
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50% of R&C after deductible
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Infertility Services
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80% after deductible
Artificial Insemination and Advanced Reproductive Technology are limited to overall infertility maximum of $20,000* per lifetime maximum (combined in-network/out-of-network)
Coverage requires a diagnosis of infertility. Preauthorization is required
*Prescription drugs related to infertility are covered under the prescription drug benefit and a separate lifetime maximum benefit cap of $20,000 applies for prescription drugs related to infertility.
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60% of R&C after deductible
Artificial Insemination and Advanced Reproductive Technology are limited to overall infertility maximum of $20,000* per lifetime maximum (combined in-network/out-of-network)
Coverage requires a diagnosis of infertility. Preauthorization is required
*Prescription drugs related to infertility are covered under the prescription drug benefit and a separate lifetime maximum benefit cap of $20,000 applies for prescription drugs related to infertility.
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70% after deductible
Artificial Insemination and Advanced Reproductive Technology are limited to overall infertility maximum of $20,000* per lifetime maximum (combined in-network/out-of-network)
Coverage requires a diagnosis of infertility. Preauthorization is required
*Prescription drugs related to infertility are covered under the prescription drug benefit and a separate lifetime maximum benefit cap of $20,000 applies for prescription drugs related to infertility.
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50% of R&C after deductible
Artificial Insemination and Advanced Reproductive Technology are limited to overall infertility maximum of $20,000* per lifetime maximum (combined in-network/out-of-network)
Coverage requires a diagnosis of infertility. Preauthorization is required
*Prescription drugs related to infertility are covered under the prescription drug benefit and a separate lifetime maximum benefit cap of $20,000 applies for prescription drugs related to infertility.
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Inpatient hospital services
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80% after deductible
Preauthorization is required
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60% of R&C after deductible
Preauthorization is required
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70% after deductible
Preauthorization is required
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50% of R&C after deductible
Preauthorization is required
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Laboratory charges
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80% after deductible
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60% of R&C after deductible
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70% after deductible
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50% of R&C after deductible
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Magnetic resonance imaging – MRI
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80% after deductible
Preauthorization is required for MRIs
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60% of R&C after deductible
is required
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70% after deductible
Preauthorization is required for MRIs
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50% of R&C after deductible
is required
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Mammograms, including 3D mammograms
(Routine)
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Covered at 100% (not subject to deductible)
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60% of R&C after deductible
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Covered at 100% (not subject to deductible)
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50% of R&C after deductible
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Mastectomy – reconstructive surgery
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80% after deductible
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60% of R&C after deductible
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70% after deductible
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50% of R&C after deductible
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Maternity hospital stay
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80% after deductible
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60% of R&C after deductible
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70% after deductible
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50% of R&C after deductible
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Mental health
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Inpatient and Residential Treatment
80% after deductible
Subject to preauthorization
Outpatient:
80% after deductible
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Inpatient and Residential Treatment
60% of R&C after deductible
Subject to preauthorization
Outpatient:
60% of R&C after deductible
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Inpatient and Residential Treatment
70% after deductible
Subject to preauthorization
Outpatient:
70% after deductible
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Inpatient and Residential Treatment
50% of R&C after deductible
Subject to preauthorization
Outpatient:
50% of R&C after deductible
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Musculoskeletal surgery
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100% after deductible if care is received at a IOQ as determined by the Claims Administrator
80% after deductible for Non-IOQ Preauthorization is required
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60% of R&C after deductible
Preauthorization is required
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100% after deductible if care is received at a IOQ as determined by the Claims Administrator
70% after deductible for Non-IOQ Preauthorization is required
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50% of R&C after deductible
Preauthorization is required
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Obesity Surgery
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80% after deductible
Once per lifetime
All services must be obtained from a recognized in-network
IOQ
Preauthorization is required
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All services must be obtained from a recognized in-network
IOQ
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80% after deductible
Once per lifetime
All services must be obtained from a recognized in-network
IOQ
Preauthorization is required
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All services must be obtained from a recognized in-network
IOQ
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Occupational therapy
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80% after deductible. Medical Necessity Required.
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60% of R&C after deductible. Medical Necessity Required.
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70% after deductible. Medical Necessity Required.
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50% of R&C after deductible. Medical Necessity Required.
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Organ transplant
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100% after deductible in IOQ as determined by the Claims Administrator
80% after deductible in Non-IOQ Preauthorization is required
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60% of R&C after deductible
Preauthorization is required
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100% after deductible in IOQ as determined by the Claims Administrator
70% after deductible in Non-IOQ Preauthorization is required
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50% of R&C after deductible
Preauthorization is required
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Outpatient physician services
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80% after deductible
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60% of R&C after deductible
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70% after deductible
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50% of R&C after deductible
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Physical exams for adults
(routine)
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Covered at 100% (not subject to deductible) for one physical exam each calendar year
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60% of R&C after deductible for one physical exam each calendar year
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Covered at 100% (not subject to deductible) for one physical exam each calendar year
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50% of R&C after deductible for one physical exam each calendar year
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Physical exams for children
(routine)
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Covered at 100% (not subject to deductible)
Subject to Plan limits
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60% of R&C after deductible
Subject to Plan limits
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Covered at 100% (not subject to deductible)
Subject to Plan limits
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50% of R&C after deductible
Subject to Plan limits
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Physical therapy
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80% after deductible. Medical Necessity Required.
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60% of R&C after deductible. Medical Necessity Required.
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70% after deductible. Medical Necessity Required.
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50% of R&C after deductible. Medical Necessity Required.
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Digital Physical Therapy (Sword Health)
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Prior to deductible: $29/month for unlimited sessions per month.
After meeting deductible: subject to coinsurance on $29/month for unlimited sessions per month.
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Not covered – all services must be provided by Sword Health
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Prior to deductible: $29/month for unlimited sessions per month.
After meeting deductible: subject to coinsurance on $29/month for unlimited sessions per month.
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Not covered – all services must be provided by Sword Health
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Pregnancy termination
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80% after deductible
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60% of R&C after deductible
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70% after deductible
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50% of R&C after deductible
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Prenatal visits
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80% after deductible first visit only
Routine Prenatal Care covered at 100%
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60% of R&C after deductible
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70% after deductible first visit only
Routine Prenatal Care covered at 100%
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50% of R&C after deductible
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Prescription drugs (see "Prescription Drugs")
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There is a pharmacy network for 30-day and 90-day prescription drugs.
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There is a pharmacy network for 30-day and 90-day prescription drugs.
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There is a pharmacy network for 30-day and 90-day prescription drugs.
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There is a pharmacy network for 30-day and 90-day prescription drugs.
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Private Duty Nursing
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80% after deductible
Maximum of 60 visits (8-hour shifts) per calendar year
(Combined in-network/out-of-network)
Preauthorization is required
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60% of R&C after deductible
Maximum of 60 visits (8-hour shifts) per calendar year
(Combined in-network/out-of-network)
Preauthorization is required
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70% after deductible
Maximum of 60 visits (8-hour shifts) per calendar year
(Combined in-network/out-of-network)
Preauthorization is required
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50% of R&C after deductible
Maximum of 60 visits (8-hour shifts) per calendar year
(Combined in-network/out-of-network)
Preauthorization is required
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Prostate specific antigen test – PSA
(routine)
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Covered at 100% (not subject to deductible)
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60% of R&C after deductible
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Covered at 100% (not subject to deductible)
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50% of R&C after deductible
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Skilled nursing facility
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80% after deductible for up to 120 days per calendar year (combined in-network/out-of-network)
Preauthorization is required.
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60% of R&C after deductible for up to 120 days per calendar year (combined in-network/out-of-network)
Preauthorization is required.
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70% after deductible for up to 120 days per calendar year (combined in-network/out-of-network)
Preauthorization is required.
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50% of R&C after deductible for 120 days per calendar year (combined in-network/out-of-network)
Preauthorization is required.
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Speech therapy
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80% after deductible. Medical Necessity Required.
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60% of R&C after deductible. Medical Necessity Required.
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70% after deductible. Medical Necessity Required.
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50% of R&C after deductible. Medical Necessity Required.
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Surgery
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80% after deductible
Preauthorization is required if in-patient
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60% of R&C after deductible
Preauthorization is required if in-patient
Predetermination of benefits is recommended for multiple surgical procedures
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70% after deductible
Preauthorization is required if in-patient
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50% of R&C after deductible
Preauthorization is required if in-patient
Predetermination of benefits is recommended for multiple surgical procedures
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Tubal ligation
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Covered at 100%, deductible does not apply
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60% of R&C after deductible
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Covered at 100%, deductible does not apply
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50% of R&C after deductible
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Urgent Care
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80% after deductible
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60% of R&C after deductible
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70% after deductible
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50% of R&C after deductible
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Vasectomy
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80% after deductible
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60% of R&C after deductible
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70% after deductible
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50% of R&C after deductible
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Virtual Medicine
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80% after deductible
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Not covered
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70% after deductible
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Not covered
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Vision care
(routine eye care)
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Not covered
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Not covered
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Not covered
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Not covered
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Vision Therapy/
Orthoptics |
80% after deductible (maximum of 12 vision therapy visits or sessions medically necessary for treatment of convergence insufficiency)
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60% of R&C after deductible (maximum of 12 vision therapy visits or sessions medically necessary for treatment of convergence insufficiency)
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70% after deductible (maximum of 12 vision therapy visits or sessions medically necessary for treatment of convergence insufficiency)
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50% of R&C after deductible (maximum of 12 vision therapy visits or sessions medically necessary for treatment of convergence insufficiency)
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X-rays
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80% after deductible
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60% of R&C after deductible
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70% after deductible
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50% of R&C after deductible
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