Page 17 - Guide
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A summary of the PAI MVP plan is shown in the table below.
MVP Covered Beneits In-Network Out-of-Network Covered Services Description
Deductible $0/$0 $500/$1,000
Coinsurance 100% 40%
Out-of-pocket maximum $1,850/$12,700 N/A
Preventive care/screening/ 100% covered Deductible/ The preventive care/screening/immunization beneit
immunization coinsurance covers all of the services listed under the MEC
covered beneits.
Primary care visit to $15 copay Deductible/ The primary care visit beneit covers all physician
Treat an injury or illness coinsurance visits including ofice, outpatient, and inpatient
(excluding well baby, charges. Copays apply to the physician visit charge
preventive, and x-rays) only and do not include any other services rendered
at the time of the visit.
Specialist visit $25 copay Deductible/ The specialist visit beneit covers all physician visits
coinsurance including ofice, outpatient, and inpatient charges.
Copays apply to the physician visit charge only and
do not include any other services rendered at the
time of the visit.
Emergency room services $400 copay $400 copay The emergency room beneit covers all services
performed in an emergency room including the
hospital facility and physician charges. If an MRI
is performed during the emergency room visit,
separate copay will not be applied. If surgery,
physical therapy, or DME are performed during the
emergency room visit, they will be covered under
the emergency room beneit.
Imaging (CT, PET scans, MRIs) $400 copay Deductible/ The imaging beneit covers charges for CT, PET
coinsurance scans, and MRIs, and the charges for related
supplies.
Laboratory outpatient and $50 copay Deductible/ The laboratory outpatient and professional services
professional services coinsurance beneit covers the professional components of
labs including the ofice, outpatient, and inpatient
charges. The copay will apply to each individual lab.
X-rays and diagnostic imaging $50 copay Deductible/ The x-rays and diagnostic imaging beneit covers
coinsurance the professional components of the x-rays including
the ofice, outpatient, and inpatient charges. A
copay will apply to each individual x-ray or imaging.
Chronic disease management (CDM) 100% covered Deductible/ The chronic disease management beneit covers
beneit coinsurance the minimum standards of care services for the 25
chronic diseases identiied through AHDI.
Prescription Drugs
Generics $15 copay Deductible/ The mail order copays are 2.5 times the retail copay.
coinsurance
Preferred brand drugs $25 copay Deductible/ The mail order copays are 2.5 times the retail copay.
coinsurance
Non-preferred brand drugs $75 copay Deductible/ The mail order copays are 2.5 times the retail copay.
coinsurance
Note: specialty drugs are not covered.
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MVP Covered Beneits In-Network Out-of-Network Covered Services Description
Deductible $0/$0 $500/$1,000
Coinsurance 100% 40%
Out-of-pocket maximum $1,850/$12,700 N/A
Preventive care/screening/ 100% covered Deductible/ The preventive care/screening/immunization beneit
immunization coinsurance covers all of the services listed under the MEC
covered beneits.
Primary care visit to $15 copay Deductible/ The primary care visit beneit covers all physician
Treat an injury or illness coinsurance visits including ofice, outpatient, and inpatient
(excluding well baby, charges. Copays apply to the physician visit charge
preventive, and x-rays) only and do not include any other services rendered
at the time of the visit.
Specialist visit $25 copay Deductible/ The specialist visit beneit covers all physician visits
coinsurance including ofice, outpatient, and inpatient charges.
Copays apply to the physician visit charge only and
do not include any other services rendered at the
time of the visit.
Emergency room services $400 copay $400 copay The emergency room beneit covers all services
performed in an emergency room including the
hospital facility and physician charges. If an MRI
is performed during the emergency room visit,
separate copay will not be applied. If surgery,
physical therapy, or DME are performed during the
emergency room visit, they will be covered under
the emergency room beneit.
Imaging (CT, PET scans, MRIs) $400 copay Deductible/ The imaging beneit covers charges for CT, PET
coinsurance scans, and MRIs, and the charges for related
supplies.
Laboratory outpatient and $50 copay Deductible/ The laboratory outpatient and professional services
professional services coinsurance beneit covers the professional components of
labs including the ofice, outpatient, and inpatient
charges. The copay will apply to each individual lab.
X-rays and diagnostic imaging $50 copay Deductible/ The x-rays and diagnostic imaging beneit covers
coinsurance the professional components of the x-rays including
the ofice, outpatient, and inpatient charges. A
copay will apply to each individual x-ray or imaging.
Chronic disease management (CDM) 100% covered Deductible/ The chronic disease management beneit covers
beneit coinsurance the minimum standards of care services for the 25
chronic diseases identiied through AHDI.
Prescription Drugs
Generics $15 copay Deductible/ The mail order copays are 2.5 times the retail copay.
coinsurance
Preferred brand drugs $25 copay Deductible/ The mail order copays are 2.5 times the retail copay.
coinsurance
Non-preferred brand drugs $75 copay Deductible/ The mail order copays are 2.5 times the retail copay.
coinsurance
Note: specialty drugs are not covered.
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