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HSA Plan

Network

100% coverage

Non-Network

40% coinsurance after deductible

PPO 750 Plan

Network

100% coverage

Non-Network

40% coinsurance after deductible

PPO 1250 Plan

Network

100% coverage

Non-Network

40% coinsurance after deductible

There are certain medications that MCHCP will cover at 100% when accompanied by a prescription and filled at a network pharmacy. Covered drugs are those described in the U.S. Preventive Services Task Force (categories A and B) and Health Resources and Services Administration (HRSA) Guidelines for women, as well as infants, children and adolescents, including the American Academy of Pediatrics Bright Futures periodicity guidelines.

  • Aspirin, 81mg for women up to age 55 with preeclampsia risk, generic
  • Aspirin, for adults 50-59 years of age for the prevention of cardiovascular disease and colorectal cancer, generic
  • Birth control, preferred1 (non-preferred may be covered in limited situations)
  • Bowel prep (preferred1 and Over-the-Counter [OTC]), generic
  • Flouride for children aged 6 months through 12 years
  • Folic Acid, 400 to 800 mcg/day for women up to age 50, generic
  • Iron Supplement for members aged 6-12 months
  • Nicotine replacement therapy, OTC
  • Quit tobacco medications for members aged 18 and over, preferred1
  • Statins for adults 40-75 years of age for the prevention of cardiovascular disease, generic low-to-moderate dose, when certain medical criteria are met
  • Tamoxifen (generic), Raloxifene (generic), and Soltamox (brand — Tamoxifen liquid for patients who have difficulty swallowing the tablets) for the prevention of breast cancer
  • Vaccinations (see Vaccinations section below).

Medical Coverage

Preventive services are designed to help identify potential health risks, allowing for early diagnosis and treatment. When done regularly, members not only save valuable time and money, but also experience better overall health outcomes. View Medical Benefit Details > Preventive Services for more information.

Vaccinations

Vaccinations recommended by the Advisory Committee for Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) are covered.

Non-network vaccinations are covered 100% for ages from birth to 72 months, 40% coinsurance after deductible for persons age 6 and older. When preventive vaccinations are obtained from a non-network provider or pharmacy, the member must submit a receipt and a Vaccine Reimbursement (Non-network) form to their medical plan to receive reimbursement up to $25.

1Preferred drug as determined by ESI


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