Page 8 - 2022 MLB Benefit Guide 08.2022

Medical Plan Benefits Summary Continued

Benefit In-Network Out-of-Network
Physical Medicine $15 Copay 80% after deductible
Speech Therapy $15 Copay 80% after deductible
Occupational Therapy $15 Copay 80% after deductible
Rehabilitation Services Combined Limit: 70 visits per calendar year
Durable Medical Equipment, 100% 80% after deductible
Orthotics, Prosthetics
100% 80% after deductible
Skilled Nursing Facility Care
Combined Limit: 100 days per calendar year
Home Health Care 100% 80% after deductible
Allergy Injections 100% 80% after deductible
Private Duty Nursing 100%
Hospice 100% 80% after deductible
Inpatient Mental Health 100% 80% after deductible
Outpatient Mental Health $15 Copay 80% after deductible

Inpatient Substance Abuse
Detoxification 100% 80% after deductible
Rehabilitation 100% 80% after deductible
Outpatient Substance Abuse $15 Copay 80% after deductible
Hearing Care Services 100% 80% after deductible
• Frequency up to age 18 is 1 hearing aid per year every 2 years
• Frequency for over age 18 is 1 hearing aid per ear per year
every 5 years
Precertification is your responsibility; $1,000 penalty may apply if
Precertification Requirements
you don’t pre-certify your care
Premier Prescription Drug Program Retail Drugs (30-day Supply)
(Defined by Premier Gold Pharmacy $10 Copay / $20 Copay / $35 Copay
Network; not by the physician
network) Maintenance Drugs through Mail Order (90-day Supply)
(Generic / Brand-Formulary / Brand- $20 Copay / $40 Copay / $70 Copay
Formulary Mandatory Generic)

Click here for a detailed Medical Plan Summary

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