Detailed List of Covered Services

MMC Benefits Handbook

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.

When you receive emergency care or are treated by an out-of-network provider at an in-network hospital, hospital outpatient center, critical access hospital, or ambulatory surgical center or you receive out-of-network air ambulance services, you are protected from surprise billing or balance billing. Refer to Your Rights and Protections Against Surprise Medical Bills section. When you receive these services, your cost sharing will be the same as you would pay at in-network provider or facility. The amount payable to the provider or facility will be the applicable Qualifying Payment Amount.

$1,650 Deductible Plan and $3,300 Deductible Plan


	$1,650 Deductible Plan		$3,300 Deductible Plan
Services	In-Network Coverage	Out-of-Network Coverage	In-Network Coverage	Out-of-Network Coverage
Alcohol and substance use	Inpatient and Residential Treatment: 80% after deductible Preauthorization is required Outpatient: 80% after deductible	Inpatient and Residential Treatment: 60% of R&C after deductible Preauthorization is required Outpatient: 60% after deductible	Inpatient and Residential Treatment: 70% after deductible Preauthorization is required Outpatient: 70% after deductible	Inpatient and Residential Treatment: 50% of R&C after deductible Preauthorization is required Outpatient: 50% after deductible
Allergy testing and treatment	80% after deductible	60% of R&C after deductible	70% after deductible	50% of R&C after deductible
Alternative medicine (Acupuncture)	80% after deductible	60% of R&C after deductible	70% after deductible	50% of R&C after deductible
	Coverage limitations: Performed by a physician as a form of anesthesia in connection with surgery or dental procedure that is covered under the Plan. A form of Alternative Treatment as long as it is rendered by a certified/licensed individual. Limited to 30 visits per calendar year (combined in-network/out-of-network).		Coverage limitations: Performed by a physician as a form of anesthesia in connection with surgery or dental procedure that is covered under the Plan. A form of Alternative Treatment as long as it is rendered by a certified/licensed individual. Limited to 30 visits per calendar year (combined in-network/out-of-network).
Ambulance charges	80% after deductible	80% of R&C after deductible	70% after deductible	70% of R&C after deductible
Applied Behavioral Analysis (ABA)	80% after deductible Preauthorization is required	60% of R&C after deductible Preauthorization is required	70% after deductible Preauthorization is required	50% of R&C after deductible Preauthorization is required
Artificial insemination	80% after deductible Limited to overall infertility maximum of $40,000 per lifetime (combined medical and prescription drug expenses) Preauthorization is required. Coverage requires a diagnosis of infertility, which is solely determined by WIN, the infertility claims administrator.	There is NO out-of-network infertility coverage under the WIN program.	70% after deductible Limited to overall infertility maximum of $40,000 per lifetime (combined medical and prescription drug expenses.) Preauthorization is required. Coverage requires a diagnosis of infertility, which is solely determined by WIN, the infertility claims administrator.	There is NO out-of-network infertility coverage under the WIN program.
CT / PET scans	80% after deductible. CT/PET scans subject to preauthorization	60% of R&C after deductible. Medical Necessity Required.	70% after deductible. CT/PET scans subject to preauthorization	50% of R&C after deductible. Medical Necessity Required.
Chiropractors	80% after deductible for up to 30 visits per calendar year combined in-network/out-of-network	60% of R&C after deductible for up to 30 visits per calendar year combined in-network/out-of-network	70% after deductible for up to 30 visits per calendar year combined in-network/out-of-network	50% of R&C after deductible for up to 30 visits per calendar year combined in-network/out-of-network
Contraceptive devices (as defined as Preventive Prescriptions)	Covered at 100%, without deductible	60% of R&C after deductible	Covered at 100%, without deductible	50% of R&C after deductible
Cosmetic surgery	Not covered	Not covered	Not covered	Not covered
Dental treatment (covered only for accidental injury to sound teeth within 12 months)	80% after deductible	60% of R&C after deductible	70% after deductible	50% of R&C after deductible
Doctor delivery charge for newborns	80% after deductible	60% of R&C after deductible	70% after deductible	50% of R&C after deductible
Durable medical equipment (DME)	80% after deductible Preauthorization is required for purchase or rentals of certain DME	60% of R&C after deductible Preauthorization is required for purchase or rentals of certain DME	70% after deductible Preauthorization is required for purchase or rentals of certain DME	50% of R&C after deductible Preauthorization is required for purchase or rentals of certain DME
EKG Testing	Covered at 100% (not subject to deductible). Considered preventive if performed as part of a routine exam or associated with a preventive diagnosis code.	60% of R&C after deductible. Considered preventive if performed as part of a routine exam or associated with a preventive diagnosis code.	Covered at 100% (not subject to deductible). Considered preventive if performed as part of a routine exam or associated with a preventive diagnosis code.	50% of R&C after deductible. Considered preventive if performed as part of a routine exam or associated with a preventive diagnosis code.
Emergency room	80% after deductible for life-threatening injury or illness (See "Life-threatening Illness or Injury in the "Glossary").	80% of R&C after deductible for life-threatening injury or illness (See "Life-threatening Illness or Injury in the "Glossary").	70% after deductible for life-threatening injury or illness (See "Life-threatening Illness or Injury in the "Glossary").	70% of R&C after deductible for life-threatening injury or illness (See "Life-threatening Illness or Injury in the "Glossary").
Gender Affirming Surgery (and related costs)	80% 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	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	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	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
Gynecology visits	Covered at 100% (not subject to deductible) for one routine exam each calendar year Subsequent visits – 80% after deductible	60% of R&C after deductible	Covered at 100% (not subject to deductible) for one routine exam each calendar year Subsequent visits – 70% after deductible	50% of R&C after deductible
Hearing care	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).	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).	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).	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).
Home health care	80% after deductible for up to 120 home health care aid visits per calendar year for homebound patients Preauthorization is required	60% of R&C after deductible for up to 120 home health care aid visits per calendar year for homebound patients Preauthorization is required	70% after deductible for up to 120 home health care aid visits per calendar year for homebound patients Preauthorization is required	50% of R&C after deductible for up to 120 home health care aid visits per calendar year for homebound patients Preauthorization is required
Hospice care	80% after deductible Preauthorization is required	60% of R&C after deductible Preauthorization is required	70% after deductible Preauthorization is required	50% of R&C after deductible Preauthorization is required
Immunizations (routine)	Covered at 100% (not subject to deductible)	60% of R&C after deductible	Covered at 100% (not subject to deductible)	50% of R&C after deductible
Infertility Services	80% after deductible Limited to overall infertility maximum of $40,000 per lifetime (combined medical and prescription drug expenses). Preauthorization is required. Coverage requires a diagnosis of infertility, which is solely determined by WIN, the infertility claims administrator.	There is NO out-of-network infertility coverage under the WIN program.	70% after deductible Limited to overall infertility maximum of $40,000 per lifetime (combined medical and prescription drug expenses) Preauthorization is required. Coverage requires a diagnosis of infertility, which is solely determined by WIN, the infertility claims administrator.	There is NO out-of-network infertility coverage under the WIN program.
Inpatient hospital services	80% after deductible Preauthorization is required	60% of R&C after deductible Preauthorization is required	70% after deductible Preauthorization is required	50% of R&C after deductible Preauthorization is required
Laboratory charges	80% after deductible	60% of R&C after deductible	70% after deductible	50% of R&C after deductible
Magnetic resonance imaging – MRI	80% after deductible Preauthorization is required for MRIs	60% of R&C after deductible is required	70% after deductible Preauthorization is required for MRIs	50% of R&C after deductible is required
Mammograms, including 3D mammograms (Routine)	Covered at 100% (not subject to deductible)	60% of R&C after deductible	Covered at 100% (not subject to deductible)	50% of R&C after deductible
Mastectomy – reconstructive surgery	80% after deductible	60% of R&C after deductible	70% after deductible	50% of R&C after deductible
Maternity hospital stay	80% after deductible	60% of R&C after deductible	70% after deductible	50% of R&C after deductible
Mental health	Inpatient and Residential Treatment 80% after deductible Subject to preauthorization Outpatient: 80% after deductible	Inpatient and Residential Treatment 60% of R&C after deductible Subject to preauthorization Outpatient: 60% of R&C after deductible	Inpatient and Residential Treatment 70% after deductible Subject to preauthorization Outpatient: 70% after deductible	Inpatient and Residential Treatment 50% of R&C after deductible Subject to preauthorization Outpatient: 50% of R&C after deductible
Musculoskeletal surgery	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	60% of R&C after deductible Preauthorization is required	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	50% of R&C after deductible Preauthorization is required
Obesity Surgery	80% after deductible Once per lifetime All services must be obtained from a recognized in-network IOQ Preauthorization is required	All services must be obtained from a recognized in-network IOQ	80% after deductible Once per lifetime All services must be obtained from a recognized in-network IOQ Preauthorization is required	All services must be obtained from a recognized in-network IOQ
Occupational therapy	80% after deductible. Medical Necessity Required.	60% of R&C after deductible. Medical Necessity Required.	70% after deductible. Medical Necessity Required.	50% of R&C after deductible. Medical Necessity Required.
Organ transplant	100% after deductible in IOQ as determined by the Claims Administrator 80% after deductible in Non-IOQ Preauthorization is required	60% of R&C after deductible Preauthorization is required	100% after deductible in IOQ as determined by the Claims Administrator 70% after deductible in Non-IOQ Preauthorization is required	50% of R&C after deductible Preauthorization is required
Outpatient physician services	80% after deductible	60% of R&C after deductible	70% after deductible	50% of R&C after deductible
Physical exams for adults (routine)	Covered at 100% (not subject to deductible) for one physical exam each calendar year	60% of R&C after deductible for one physical exam each calendar year	Covered at 100% (not subject to deductible) for one physical exam each calendar year	50% of R&C after deductible for one physical exam each calendar year
Physical exams for children (routine)	Covered at 100% (not subject to deductible) Subject to Plan limits	60% of R&C after deductible Subject to Plan limits	Covered at 100% (not subject to deductible) Subject to Plan limits	50% of R&C after deductible Subject to Plan limits
Physical therapy	80% after deductible. Medical Necessity Required.	60% of R&C after deductible. Medical Necessity Required.	70% after deductible. Medical Necessity Required.	50% of R&C after deductible. Medical Necessity Required.
Digital Physical Therapy (Sword Health)	Prior to deductible: $29/month for unlimited sessions per month. After meeting deductible: subject to coinsurance on $29/month for unlimited sessions per month.	Not covered – all services must be provided by Sword Health	Prior to deductible: $29/month for unlimited sessions per month. After meeting deductible: subject to coinsurance on $29/month for unlimited sessions per month.	Not covered – all services must be provided by Sword Health
Pregnancy termination	80% after deductible	60% of R&C after deductible	70% after deductible	50% of R&C after deductible
Prenatal visits	80% after deductible first visit only Routine Prenatal Care covered at 100%	60% of R&C after deductible	70% after deductible first visit only Routine Prenatal Care covered at 100%	50% of R&C after deductible
Prescription drugs CVS Caremark® (see "Prescription Drugs – CVS Caremark® (Excludes Infertility Prescriptions)"	There is a pharmacy network for 30-day and 90-day prescription drugs.	There is a pharmacy network for 30-day and 90-day prescription drugs.	There is a pharmacy network for 30-day and 90-day prescription drugs.	There is a pharmacy network for 30-day and 90-day prescription drugs.
Prescription drugs-WIN Infertility (see "Prescription Drugs – WINFertility ("WIN") – Infertility Prescriptions Only")	There is a WIN pharmacy network only.	There is NO out-of-network infertility prescription coverage under the WIN program.	There is a WIN pharmacy network only.	There is NO out-of-network infertility prescription coverage under the WIN program.
Private Duty Nursing	80% after deductible Maximum of 60 visits (8-hour shifts) per calendar year (Combined in-network/out-of-network) Preauthorization is required	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	70% after deductible Maximum of 60 visits (8-hour shifts) per calendar year (Combined in-network/out-of-network) Preauthorization is required	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
Prostate specific antigen test – PSA (routine)	Covered at 100% (not subject to deductible)	60% of R&C after deductible	Covered at 100% (not subject to deductible)	50% of R&C after deductible
Skilled nursing facility	80% after deductible for up to 120 days per calendar year (combined in-network/out-of-network) Preauthorization is required.	60% of R&C after deductible for up to 120 days per calendar year (combined in-network/out-of-network) Preauthorization is required.	70% after deductible for up to 120 days per calendar year (combined in-network/out-of-network) Preauthorization is required.	50% of R&C after deductible for 120 days per calendar year (combined in-network/out-of-network) Preauthorization is required.
Speech therapy	80% after deductible. Medical Necessity Required.	60% of R&C after deductible. Medical Necessity Required.	70% after deductible. Medical Necessity Required.	50% of R&C after deductible. Medical Necessity Required.
Surgery	80% after deductible Preauthorization is required if in-patient	60% of R&C after deductible Preauthorization is required if in-patient Predetermination of benefits is recommended for multiple surgical procedures	70% after deductible Preauthorization is required if in-patient	50% of R&C after deductible Preauthorization is required if in-patient Predetermination of benefits is recommended for multiple surgical procedures
Tubal ligation	Covered at 100%, deductible does not apply	60% of R&C after deductible	Covered at 100%, deductible does not apply	50% of R&C after deductible
Urgent Care	80% after deductible	60% of R&C after deductible	70% after deductible	50% of R&C after deductible
Vasectomy	80% after deductible	60% of R&C after deductible	70% after deductible	50% of R&C after deductible
Virtual Medicine	80% after deductible	Not covered	70% after deductible	Not covered
Vision care (routine eye care)	Not covered	Not covered	Not covered	Not covered
Vision Therapy/ Orthoptics	80% after deductible (maximum of 12 vision therapy visits or sessions medically necessary for treatment of convergence insufficiency)	60% of R&C after deductible (maximum of 12 vision therapy visits or sessions medically necessary for treatment of convergence insufficiency)	70% after deductible (maximum of 12 vision therapy visits or sessions medically necessary for treatment of convergence insufficiency)	50% of R&C after deductible (maximum of 12 vision therapy visits or sessions medically necessary for treatment of convergence insufficiency)
X-rays	80% after deductible	60% of R&C after deductible	70% after deductible	50% of R&C after deductible