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    • Home
    • Benefit Programs
    • Education & Enrollment
    • MEC Menu
    • Advantage MV Plan
    • Premium MV Plan
    • Max MV Plan
    • Minimum Value 6500
    • Support
    • Resources

  • Home
  • Benefit Programs
  • Education & Enrollment
  • MEC Menu
  • Advantage MV Plan
  • Premium MV Plan
  • Max MV Plan
  • Minimum Value 6500
  • Support
  • Resources

Advantage MV Plan

Medical Benefits

This form is a benefit highlight representing a brief description of the coverage available. Additional covered services, exclusions and limitations exist. Specific services including inpatient hospital, maternity and outpatient surgery are subject to pre-certification.

Annual Deductible/Out-of-Pocket Maximum 1

$1,500 individual/$3,000 family annual deductible $9,100/$18,200 OOP max

The out-of-pocket maximum refers to covered services only. Specific services, including emergency and hospital services, are subject to reference-

based pricing (see definition below) and patients may be billed beyond the out-of-pocket maximum for these services.

Unlimited Telehealth

$0 Copay

Offered through Recuro Health

Preventative/Wellness

100% In-Network / 40% Out of Network

Coinsurance applies after the deductible

Primary Care/Specialist Visits

$15 Copay In-Network / 40% Out of Network

Coinsurance applies after the deductible

Urgent Care

$50 Copay In-Network / 40% Out of Network

Coinsurance applies after the deductible

Laboratory Services / Radiology (X-ray, Ultrasound)

$50 Copay In-Network / 40% Out of Network

Coinsurance applies after the deductible

Advanced ImagingRBP (MRI, CT/PET scan) 2

$350 Copay In-Network / 40% Out of Network

Coinsurance applies after the deductible. (limit 1 per year)

Radiology / Advanced Imaging2 (Medmo)3

Covered at 100%

(subject to above limits)

Outpatient Surgery

$250 Copay (after the Ded)

(limit 1 per year) (Subject to Reference-Based Pricing)4

Inpatient Hospitalization & Surgery 2

$500 Copay per admission (after the Ded.)

(limit 5 days & 2 surgeries per year) (Subject to Reference-Based Pricing)4

Emergency Services (excludes ambulance)

$500 Copay

(limit 1 per year) (Subject to Reference-Based Pricing)4

Ambulance (Ground Only)

$500 Copay In-Network / 40% Out of Network

Coinsurance applies after the deductible (limit 1 per year) (Subject to Reference-Based Pricing)4

Physical / Speech / Occupational Therapy

$50 Copay In-Network / 40% Out of Network

Coinsurance applies after the deductible (limit 8 combined per year)  

Chiropractic Services

$50 Copay In-Network / 40% Out of Network

Coinsurance applies after the deductible (limit 10 per year) 

Home Health Care

$50 Copay In-Network / 40% Out of Network

Coinsurance applies after the deductible (limit 10 per year) 

Outpatient Substance Abuse Treatment

$75 Copay

(limit 8 per year) (Subject to Reference-Based Pricing)4

Inpatient Substance Abuse Treatment

$750 Copay per day (after the Ded.)

(limit 5 per year) (Subject to Reference-Based Pricing)4

Chemotherapy / Radiation Therapy / Dialysis

Not Covered

Qualifying event would require a certificate of creditable coverage (COCC) and seek coverage on the individual exchange

Professional Services 2

$350 Copay (after the Ded.)

 (Subject to Reference-Based Pricing)4

Inpatient Facility 2

$1,500 Copay per admission (after the Ded.)

 (Subject to Reference-Based Pricing)4


Prescription Drug Benefits

Prescription drug benefits are subject to the formulary drug list. Copay amounts listed are based on a unit quantity of 30 for a 30-day supply. Pricing may vary based on quantity and supply.

Generic (Tier 1)

$10 Copay

Higher Tier Generics / Preferred / Non-Preferred Brand & Specialty

Discount Only

1The out-of-pocket maximum refers to covered services only. Specific services are subject to Reference-Based Pricing (RBP) and patients may be billed beyond the out-of-pocket maximum for these services. 2Specific services, including advanced imaging, surgical procedures and maternity require pre-certification. Failure to obtain pre-certification will result in a denial of benefits. 3Medmo is a concierge scheduling service for radiology and imaging allowing members to maximize their benefits while minimizing costs to the patient. 4RBP reimburses providers using a percentage of Medicare coverage as the reference point for the reimbursement total. This plan pays up to 125% of the Medicare allowable coverage for applicable services. Patients will be responsible for paying any remaining balance beyond the provider reimbursement amount.

Advantage MV Plan

The plan outlined below is compliant with Employer Penalty “B” as outlined by ACA. It also satisfies the

individual mandate penalty in applicable states.


Minimum participation requirement of 5 lives enrolled in MV plans or 10 lives (5/5) when offered in combination with MEC plans. $750 annual fee paid at the time of

implementation and renewal.

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