Summary of Benefits for MCAC Medical Access Program (MAP)

Service Comments Co-Pay Amounts

• Primary care provider visits Includes routine physicals and health examinations; administration of therapeutic injections (injectables not included)*; local treatment of burns; destruction of lesions; administration of allergy injections (serum not included)*; pulmonary assessment; EKG, blood pressure, rhythm strip; auditory procedures, simple laboratory screens; hospital admissions, discharges and visits 0$

*some supplies not covered

• Specialty care visits and services Services must be prior authorized by your physicain (Includes Chiropractic Care)

• Urgent Care LIMITED AVAILABILITY
(Please call MCAC at 906.226-4400 or the clinic at 906.226.2233 for availability) Provided to patients after hours when they can not be seen by their Primary Care Physician. Only through Superior Walk-in Center at the UP Medical Center Suite 134

• Outpatient laboratory services donated to MAP members:
Coronary Risk Panel
Complete Blood Count
Glycosylated Hemoglobin
Basic Metabolic PA or Comprehensive Metabolic PA
Urinalysis Routine
Prothrombin Time (PT)
Occult Blood Feces
Thyroid Stim Hormone
Pap Smear Gyn

• Outpatient prescription drug services:
Generic medication: $4.00
Branded mediations available via samples: free through Patient Care Programs

• Outpatient hospital services: Not Covered

• Outpatient radiology services: Limited x-rays Only covered if performed at Marquette Radiology at the UP Medical Center Suite 122

• Ambulance services: Not Covered

• Durable medical supplies: Not Covered

• Emergency Room Services: Not Covered

Non-Covered Services

• Services for sickness or injury to the extent that are covered under no-fault law, worker’s compensation, Occupational Disease Law or similar legislation

• Medical or hospital services needed as a result or related to a motor vehicle accident

• Custodial care, rest therapy, and care in a nursing or rest home facility

• Any service, supply or treatment performed related to infertility or sterilization

• Any experimental or investigational treatment, supplies, devices, drugs, or any treatment not considered to be reasonable and effective for the specific medical condition

• Items for personal comfort or convenience

• Durable medical equipment, prosthetics, orthotics, corrective shoes, and wigs (note: needles and strips for diabetics are listed on the formulary)

• Speech, physical, and occupational therapy

• Examinations, preparation, fitting, or procurement of hearing aids

• Weight reduction by diet control or surgery

• Services considered to be cosmetic

• Home health care services

• Hospice care

• Services or supplies related to sex or gender changes

• Vision exams (except for referrals related to chronic illnesses or as part of a routine physical performed by the member’s assigned primary care site), eyeglasses, contact lenses, and other vision care

• Dialysis services

• Podiatry services, except for referrals related to chronic illnesses

• Outpatient services for primary diagnosis of tuberculosis or to rule out tuberculosis

• Oral surgery related to dental problems

• Substance abuse diagnosis and/or treatment

• Mental health services and/or treatment

• Organ transplants

• Medical services provided to any person incarcerated in a local, city, state or federal penal institution

• Diagnosis and/or treatment of an injury, illness, or disability which occurs or arises from an act of war, declared or undeclared or from the member’s actions in conjunction with the commission of a felony, an attempt to commit a felony, or an illegal business or occupation

• Maternity or obstetrical services related to any pregnancy

• Services to pregnant women whether or not such services are pregnancy related

• Contraceptive methods, devices or aids, or fertility drugs

• Any condition for which member is eligible to receive health care services or benefits through a public or private health care benefit, program or insurance plan (examples include, but are not limited to, Family Planning, Healthy Kids for pregnant women and infants, TB services, and the Breast and Cervical Cancer Control Program)

• Lodging expenses incurred in connection with receiving medical services

• Hospital facility charges for inpatient services including, but not limited to general nursing care, medical and surgical supplies, and room and board

• Emergency transportation by air to a hospital or emergency room

• Office visits, exams, treatments, tests, and reports related to requirements or documentation of health medical status for employment, SSI certification, insurance, travel, marriage license, surrogate parenting arrangements, school, sports participation, citizenship, or for legal proceedings and court-related services such as pretrial and court testimony and exams or tests related to legal proceedings in the preparation of court- related reports

• Services received before the effective date of coverage or after termination of coverage

• Any standard “medicine cabinet” items not listed on the formulary including first aid supplies, over-the-counter drugs, and vitamins

• Any service provided by the assigned primary care provider or specialist not specifically listed as a primary care or specialty care service

• Any covered service not deemed medically necessary

• Medical services not approved by a Plan provider

• Any service provided by a non-authorized provider

• Emergency Room Services