Laserfiche WebLink
Medical Mutual of Ohio 90/10 Plan <br />CITY OF LAKE ,W COD _: Plan 2 - MMO LO Plan <br />Summary of Coverage: What This Plan covers 6 what It costs <br />C ovc: age 'eriod: January I t - f)ecen;ger' 12t <br />Coverage for: Single or Family l Plan Type: PPO <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 or plan document at <br />MedMuNeImMSBC grcallipg,Q002327400, <br />s <br />You mustply allth7": lothe edueObl amount before this planbegint b payforcovered <br />$3777 amily Network <br />Whatia the overall <br />$ 3amily Non- Network <br />cen^ces you use. poligor plandowmenl to see when U)e,de uetlble starts over <br />deductible? <br />Doinsurance, copays <br />( usually, but not alry lsp. See the chart sterling on page 2 for how much you pay for <br />antive care <br />covered services aet ihmi d ctible. <br />Are there other deductibles <br />No <br />You don't have to ctibles for specific services, but see the chart starting on page 2 for <br />for specific services? <br />dher costs forselan covam. <br />Is there an outo600cketlimtt <br />Yes,$1700lsingle,$340Nfamily <br />Theoubof-pocketlimM is the most you could pay during a coverage period (usually one year) for <br />on my expenses? <br />Network <br />your share of tie cost of covered services. This limit helps you plan for health care expenses. <br />$2,0001single, <br />$4,000mmily Non - Network <br />utletl In the <br />Whet Is not Included <br />Deductibles, premium, balansebilled <br />ms, <br />Even though you pay Nose expenses, They ran f wont toward Be out- o(- packetlimtt. <br />oulsoFOOCketlimlt? <br />charges and health core this plan <br />doesnl rover. <br />Is there an overall annual limit <br />No <br />The chart starting on page 2 describes any limits an what the plan will istryfleamolfi covered <br />on what the Insurer pays? <br />services, such as office visits. <br />Does this plan use a network <br />Yes, See MeriMulualmanSBC ormll <br />It you use an in- nettork doctor or other health gate pr2yIdq this plenwill pay some or allof the <br />of rozvidem? <br />800232.7400 for a list of participating <br />costs of covered services. Be aware, your in rework dotter orhorpital may use an onto[ network <br />providem <br />provide rfor some services. Plans use the tenn in-netwo inferred or participating for rovo iders <br />in their network. See the chart sterling an page 2 for how Una plan pays different kinds of Too vldera. <br />Do I need a referral to see a <br />No <br />You on see the a eo eletiat you choose without permission from this plan, <br />special] sl? <br />Are there services this plan <br />Yes <br />Some of the services this plan doesn't cover are listed later in the document. See your policy or plan <br />doesnl cover? <br />document for additional information tdbo excludedeervicee. <br />Questions: Call 800.2327400 or Ast us at MedBiuluaIxom, 86C. <br />If you aren't clear about any of the bolded terms used in this form, see the Glossary . You can view the 1103e0py <br />at MedMUiunlcom/SBC ar call 800 232.7400 to request a Capp. <br />s._. <br />