MMC Benefits Handbook
How the Medical Plan Options Work
All of the medical plan options help you and your family to pay for medical care. As a participant, you may choose, each time you need medical treatment, to use:
- Any physician, hospital or lab, or
- A provider who participates in the Anthem BCBS PPO network and has agreed to charge reduced fees to the Plan members. Using the network is more cost effective than using non-network providers because their fees are typically less than those charged by non-network providers.
If you use an in-network provider, you do not need to submit a claim form. In-network providers bill the Claims Administrator directly.
Under the $1,500 Deductible Plan
- Generally, the Plan's reimbursement is 80% for in-network providers and 60% of reasonable and customary charges for out-of-network providers after the Plan's deductible has been met. You pay the remainder of the fee.
Under the $3,000 Deductible Plan
- Generally, the Plan's reimbursement is 70% for in-network providers and 50% of reasonable and customary charges for out-of-network providers after the Plan's deductible has been met. You pay the remainder of the fee.
See the "Detailed List of Covered Services" for more detailed information.
Certain expenses are not covered or reimbursed by the Plan, such as any deductible you are required to meet and your share of the amounts above the reasonable and customary charge.
Some services have specific limits or restrictions; see individual service for more information.
Refer to the "What's Not Covered" to find out about the services that are not covered under the Plan.
Benefits are only paid for medically necessary charges or for specified wellness care expenses.
Preauthorization may be required in order to receive coverage for certain services. It is the Plan participant's responsibility (not the provider or facility) to obtain preauthorization for out-of-network services. For more information on the preauthorization process and applicable services, refer to the description under "Utilization Review."