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APPENDIX A [Note: All charts, pp. 30 -37, to be replaced with current charts] <br />Medical Mutual of Ohio 100% Plan <br />City of Lakewood : Plan 1 <br />Summary of Benefits and Coverage: What This Plan covers & What It coats <br />Coverage. Period: 01MOM - 1 2 /3112 01 4 <br />Coverage for: Single or Family l Plan Type: PPQ <br />This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy in plan document at <br />MedMulml.wWSBC orby alling 800.540.2583. <br />P all <br />$1501single,5300Ifamily Network You must payall the cash up to the d0ducW11eamount before this plan begins to pay forcovered <br />What to the overall $1501smile, services you use. Check your policy or plan document to see when the deductible starts over <br />deductible $300(famity Non- Network ( usually, but net always, January ist). Seethechatstadingmpage2fahowmuchyoupay far <br />Doesal apply to cdnsumnce, copays overed services after you meet the deductible <br />and network preventive are <br />Are there other deductibles <br />No <br />You don't have to meet deductibles for specific services, but see the chart staling on page 2 for <br />for apecl0e services? <br />other costs for services this plan covers. <br />to there an out -of- pocket limit <br />Yes,$1,5001single,S3,0001family <br />The out-of-pocket limit is the mostyou could pay during a average period (usually ore year) for <br />on my expenses? <br />Network <br />yoursham of the costofcovered services. This limit helps you plan for health are expenses. <br />51,500ISingle, <br />$3,000 1family NortNetwork <br />What is not included in the <br />Copays, deductibles, premiums, <br />balance- billed charges and health am <br />Even though you pay these expenses, they don't count toward the out -of- Docket limit . <br />patrol - Racket limit? <br />this plan doesn't cover. <br />Is there an overall annual limit <br />No <br />The chart sterling on page 2 describes any 6mtls on what the plan wig pay for specific covered <br />on what the insurer pays? <br />services, such as office visits. <br />Does this plan use a network <br />Yes, See MedMutual.com(SBC or all <br />If you use an m- network doctor or other health are provider, this plan will pay sane or a8 of the <br />of providers? <br />800.540.2583 forfslofpalicipabig <br />costs of covered services. Be aware. your innetwork doctor or hospital may use an out-of-network <br />providers. <br />provider far some services. Plans use the Fenn in- network, preferred. or participating for providers <br />in their network. See the chat starting an page 2 for how this plan pays dlferenf kirMs of previdara. <br />Do l need a referral to see a <br />No <br />You an see the specialist you choose without permission from this plan <br />specialist? <br />...._ <br />_ <br />Are there services this plan <br />Yes <br />Some of the services this plan doesn't over are listed on page 5. See your policy or plan document <br />doerm cover? <br />faradditionalinformatmaboutgxdudedservices. <br />Questions: Call 800 540 2583 or vise us at MedMutual.comlGBC- <br />It you aren't clear about any of the underlined terms used in this form, see the Glossary. You an view the Glossary <br />at MedMatuai.conri or all 800.540.2583 to request a copy. <br />30 <br />Page I of 5 <br />SeC4A5499 <br />W23 <br />30 <br />