The Plan at a Glance
The Plan helps you and your family pay for medical care. You may be required to pay a copayment and get preauthorization for certain services. The chart below contains some important Plan features and coverage information. For more information, see the "Detailed List of Covered Services."
Plan feature
Coverage amount
Deductible
Employee: None
Family members: None
Out-of-pocket maximum
Employee: None
Family members: None
Copayment
Plan pays 100% after the applicable copayments:
  • Primary Physician office visits: $20
  • Specialist visit: $40
  • Mental health/substance abuse office visits: $20
  • Hospital stay: $150 per day, up to a 4 day maximum
  • Outpatient surgery/procedure: $150
  • Emergency room: $125
Prescription Drugs
There is a pharmacy network for retail and Medco by Mail for mail order Prescription Drugs.
Contact Information
For medical services:
If you are a resident of Alaska, California, Connecticut, Delaware, Idaho, Illinois, Indiana, Iowa (except certain locations in Iowa City), Kansas, Kentucky, Maryland, Michigan, Mississippi, New Jersey, New York, Nevada, North Carolina, North Dakota, Pennsylvania, Rhode Island, South Carolina, Vermont, Virginia, Washington, West Virginia, and Wyoming.
Plan availability is based upon your residential zip code.
BlueCross BlueShield (Claims Administrator)
Phone: +1 866 219 8695
Web site: http://www.empireblue.com/mmc/
For prescription drug coverage:
Medco (Pharmacy Benefits Manager)
Phone: +1 800 987 8360
Website (for members): www.medco.com
Marsh & McLennan Companies does not administer this Plan. For medical services, Claims Administrator's decisions are final and binding; for prescription drug services, Pharmacy Benefits Manager's decisions are final and binding.