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.
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
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$1,650 Deductible Plan
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$3,300 Deductible Plan
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Services
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In-Network Coverage
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Out-of-Network Coverage1
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In-Network Coverage
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Out-of-Network Coverage1
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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 $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.
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There is NO out-of-network infertility coverage under the WIN program.
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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.
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There is NO out-of-network infertility coverage under the WIN program.
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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
CT/PET scans subject to preauthorization
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70% after deductible
CT/PET scans subject to preauthorization
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50% of R&C after deductible
CT/PET scans subject to preauthorization
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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
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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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EKG Testing
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80% after deductible. Not considered preventive.
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60% of R&C after deductible. Not considered preventive.
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70% after deductible. Not considered preventive.
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50% of R&C after deductible. Not considered preventive.
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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 excluded by the Plan.
Preauthorization is required for inpatient services.
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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 for inpatient services.
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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 for inpatient services.
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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 for inpatient services.
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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 are covered at 100% when provided as part of a preventive/wellness visit. Covered hearing aids limited to $5,000 every 3 years per covered person (no coverage for hearing aids for degenerative hearing loss). Coverage is combined between in and 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 (no coverage for hearing aids for degenerative hearing loss). Coverage is combined between in and out of network.
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80% after deductible
Routine hearing screenings are covered at 100% when provided as part of a preventive/wellness visit. Covered hearing aids limited to $5,000 every 3 years per covered person (no coverage for hearing aids for degenerative hearing loss). Coverage is combined between in and 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 (no coverage for hearing aids for degenerative hearing loss). Coverage is combined between in and 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
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.
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There is NO out-of-network infertility coverage under the WIN program.
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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
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There is NO out-of-network infertility coverage under the WIN program.
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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
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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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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 Blue Distinction Center provider as determined by the Claims Administrator
80% after deductible for a Non-Blue Distinction participating provider Preauthorization is required if surgery is inpatient
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60% of R&C after deductible
Preauthorization is required if surgery is inpatient
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100% after deductible if care is received at a Blue Distinction provider as determined by the Claims Administrator
70% after deductible for a Non-Blue Distinction participating provider Preauthorization is required if surgery is inpatient
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50% of R&C after deductible
Preauthorization is required if surgery is inpatient
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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
Blue Distinction provider Preauthorization is required
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All services must be obtained from a recognized in-network
Blue Distinction provider
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80% after deductible
Once per lifetime
All services must be obtained from a recognized in-network
Blue Distinction provider Preauthorization is required
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All services must be obtained from a recognized in-network
Blue Distinction provider
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Occupational therapy
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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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Organ transplant
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100% after deductible in Blue Distinction provider as determined by the Claims Administrator
80% after deductible for a Non-Blue Distinction provider Preauthorization is required
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60% of R&C after deductible
Preauthorization is required
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100% after deductible in Blue Distinction provider as determined by the Claims Administrator
70% after deductible for a Non-Blue Distinction provider 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.
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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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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 Routine Prenatal Care covered at 100%
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60% of R&C after deductible
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70% after deductible Routine Prenatal Care covered at 100%
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50% of R&C after deductible
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Prescription drugs – CVS Caremark® (see "Prescription Drugs – CVS Caremark® (Excludes Infertility Prescriptions)"
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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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Prescription drugs-WIN Infertility (see "Prescription Drug – WINFertility ("WIN") – Infertility Prescriptions Only"
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There is a WIN pharmacy network only.
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There is NO out-of-network infertility prescription coverage under the WIN program.
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There is a WIN pharmacy network only.
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There is NO out-of-network infertility prescription coverage under the WIN program.
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Private Duty Nursing
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80% after deductible
Maximum of 60 visits per calendar year
(Combined in-network/out-of-network)
Only covered in the home; visits DO NOT count toward the home health care visit maximum. Visit maximum is combined in-network/out-of-network includes home infusion therapy (services do not count toward the visit maximum).
Preauthorization is required
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60% of R&C after deductible
Maximum of 60 visits per calendar year
(Combined in-network/out-of-network)
Only covered in the home; visits DO NOT count toward the home health care visit maximum. Visit maximum is combined in-network/out-of-network includes home infusion therapy (services do not count toward the visit maximum).
Preauthorization is required
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70% after deductible
Maximum of 60 visits per calendar year
(Combined in-network/out-of-network)
Only covered in the home; visits DO NOT count toward the home health care visit maximum. Visit maximum is combined in-network/out-of-network includes home infusion therapy (services do not count toward the visit maximum).
Preauthorization is required
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50% of R&C after deductible
Maximum of 60 visits per calendar year
(Combined in-network/out-of-network)
Only covered in the home; visits DO NOT count toward the home health care visit maximum. Visit maximum is combined in-network/out-of-network includes home infusion therapy (services do not count toward the visit maximum).
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.
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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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Surgery
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80% after deductible
Preauthorization is required Predetermination of benefits is recommended for multiple surgical procedures
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60% of R&C after deductible
Preauthorization is required Predetermination of benefits is recommended for multiple surgical procedures
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70% after deductible
Preauthorization is required Predetermination of benefits is recommended for multiple surgical procedures
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50% of R&C after deductible
Preauthorization is required 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 |
Not covered
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Not covered
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Not covered
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Not covered
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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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