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Medical Mutual of Ohio 90/10 Plan -These are the updated charts <br /> III�Y C) 2.......... 'B�IIhJjj() IL.. Il3ll Jjlj IIq,()�q <br /> [2017 (!1Ovoraqc Perla ,I rl P ,I I�v I I I,, I i I ylic!! 'TIC <br /> This is only a summary.if you want more detail about your coverage and costs,you can get the complete tennis in the pi or plan docurnient at <br /> prby calling 3o Q.232.741910. <br /> M/single,$1,1DIDD/family Network You must pay all the costs up to the deductible amount before this plan begins,to pay for covered <br /> VV hat is the S5001single,$1,0001familV NonNetworkservices,you use Check your policyor plan document to see when the' ,deductible starts over <br /> overall Doesnl applyto co-insurance.ooi (usually <br /> ,but not always,January 19n). See the chart slatting on page 2 for how much you pay for <br /> deductible? and network preventive carp covered services after you meet the deductible <br /> Are there other No You don't have to meet deductibles for specific services,but see the chart starting on page 2 for <br /> deductibles for specific other costs forservicos this plan covers <br /> b there an out-of-pocket Yes,$2500/single$50iXtbinnily Nebhurk The out-of-pocketllilmit is the ii you could pay during a coverage period(usually one year)for <br /> Urnit on my expenses? $2,5001single,$5,0001fainnily Non-Network your share of the cost of covered services.This limit helps you plan for health care expenses. <br /> What is not included in Prei"I UITS,balance-billed charges and Even though you pay these expenses:they don't count toward the 2RL-��. <br /> the out-of-pocket limit? health care this plan doesn't cover <br /> Is there an overall annual N® The chart starting on page 2 di any limits on what the plan will pay for,epic covered <br /> limit on what the insurer services,such as office visits. <br /> pays? <br /> Does this plain use a, Yes,See MedtAutual.caii or call if you use an in-network doctor or other health care pLqy_;tsr,this plan will pay sorne or all of the <br /> network of providers?' 800.232,7400 for a list of participating costs of covered services.Be aware,your in-retNork Jodor or hospital i use an out-of-network <br /> providers. provide for scinne services.Plans use the <br /> sethe term in-network,preferred,or pancipartng for providers <br /> in their network.See the chart starting on page 2 for how this plan pays different kinJs qf,pjqXoders. <br /> Do I need a referrall to see No You can see the special'ost you choose without permission from this plan. <br /> a a petla Ilia? <br /> Are there services this Yes Some of the services this plan doesn t cover are listed later in the document See your policy or plan <br /> plain doesn't cover? document for additional inforr"nation alb ut excluded services. <br /> 35 <br />