Page 8 - MB Aerospace Benefit Guide + Notices 2021
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Medical coverage through Centivo
MBA Centivo Plus Plan
Plan Provisions
In-Network
Coinsurance 20%
Annual Deductible
Individual $500
Family $1,000
Out-of-Pocket Maximum (Includes Deductible)
Individual $5,000
Family $10,000
Lifetime Maximum Unlimited
Primary Physician Office Visit $10 copay
Specialist Office Visit $60 copay - requires referral
Inpatient Hospital Services $500 copay; deductible applies
Outpatient Surgery $250 copay; deductible applies
Urgent Care $60 copay
Emergency Room Care $500 copay
Prescription Drugs
Retail (30-day supply) Rx Deductible: Individual $100 / Family $300
΅ Tier 1 $10 Copay
΅ Tier 2 $40 Copay
΅ Tier 3 $80 Copay
΅ Tier 4-Specialty $150 Copay
Mail Order (90-day supply)
CVS Only 2.5 X Retail Copay
Please refer to page 17 to compare payroll deductions for each plan option.
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