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Re"w4jff UM-7-APPENDIX C <br /> .................................................................................... <br /> Medical Mutual of Ohio 100% Plan <br /> City of Lakewood : Plan 1 PPOIH Plan, 2017 CiDv(mi!lpn :Iinrla&0 V0 G 1213'1 <br /> Summary of IBerrBTii s and Coverage: Viihat,Tbis Plan Covers&What it Costs Coverage for:: Sing1le or Family l Plain Type: PRO <br /> This is only a summary.if you%,art more dalail about Your coverage and costs,you can get the complete textus In the policy or o4n,docuirnent M <br /> MPd1MutuaI.conVSB,C or by calling 800 540 2583. <br /> p� 111 III tIl <br /> $1 501single,$301Yfamilly Network fou must pq y al 11 the cost,up to the dad ju cit Ible a i t befoTe rNs plain begins to pay for covered <br /> What!is tile overall $1501single,$34Wfamilly INDR-Nertwork services you use Check your policy or I document to seewhen,the cleclactilble startls over <br /> clediuctills1le Doesn't apply to coin5urarice,copays (usually,but not always,Jan uary I st�, Sae the chart starling on page 2 for Ihow much you Pay for <br /> and in�etwwO!k Rnev2n!n cP!e covered selvIoI aRer you meet the deductible. <br /> Are there other deductibles, No You don't have to meet deductiblesfor specific seiruces,out see the chart starling or page 2 for <br /> f'or specific services? other costs for services this plain covers <br /> 'IS there all Out-cot Docket"I'M" YeS,S1rfiW1singIe,$3 300ffamily Tlhe amt-of-Docket linnift is the ii you could pay during a coverage.period(usually one year)for <br /> on my expenses? Network$l,650/singIe,S3,3dQJfI your share of the cost of covered scrvius This limit helps you plan for health care expenses. <br /> Nor-Network <br /> What is not included in the, PrernIiurns,balance hilted charges and Even though YOU Pay these P'y'jPPn5I 11hey don't oourt toward the oul-of-ji flialit <br /> out-of-pocket Himit'p healith care this plan doesn't cover. <br /> is there art overaill anritiall I'mit No The chard starting,on page 2 describes any liiimirfs on whal the plain wifl pay for speolifli covered <br /> on What the insurer pays? services,such as officeIvInds. <br /> Does this plain use a network Yes,See MedrAulual.cornfSBC or call H you Use an ini-netwoIrk doctor or,other health careprovider,this plain will I sorne or all of the <br /> of providers? 800.540.2583 fear list afpartuloa1mg costs of ccoviarcid services.Be&I yourin-network doctor or hi may use,an out-of-retwork <br /> prov,ders. pl-ovilder for some services.Plans use the term in-retwork,preferred or joarticipa1rig for I)ravidlers <br /> in therr nietwoA.Sep the chart starting on pap 2 for howthis plan pays different kinds ofitroviders. <br /> Do,I needl a referrall to see a No You can see the suecll you choosewitihici porn nIissionfrom this plain. <br /> WeCialiSt? <br /> Are there services this pian Yes Some or the servicps this p4ar doesn"t cover are lusted an page 5.Sea your policy or plan dccumenit <br /> cower?dr suis d for,additional[information alboul excluded services. <br /> ................ <br /> ..........................."I <br /> 30 <br />