Laserfiche WebLink
APPENDIX C <br />Medical Mutual of Ohio 100% Plan <br />City of Lakewood : Plan 1 PPO Hi Plan 2017 <br />Summary of Benefits and Coverage: What This Plan Covers &What it Costs <br />Coverage Period: 01101-12131 <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 />Medhfalual.cem/SBC or by calling 800.540.2583. <br />$1601smille,$300tlamity Network <br />You must pay all the costs up to the deductible amount before this plan begins to pay for covered <br />What is the overall <br />$1501strgleA3008amily Non -Network <br />services you use. Check your policy or plan document to see when the deductible stadsover <br />deductible? <br />Doesrft apply to coinsurancecopays <br />(usually, but not always, January 1st).. Sae the Chad starting on page 2 for how much you pay for <br />and network preventive rare <br />covered services after you meet the deductible <br />Are there other deductibles <br />No <br />You don't have to meet deductibles for specific services, hot see the chart starting on page 2 for <br />for specific services? -: <br />other costs for services this plan covers. <br />Is there an out-of-pocket limit <br />Yes,$1,660hingie,$3,3009andy <br />The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for <br />on my expenses? <br />Network$1,6501single.$3,j041family <br />your share of the cast ofcovemd services. This limit helps you plan for health care expenses <br />Nan -Network <br />What is not Included in the <br />Premiums, balance billed charges and <br />healih care this plan doerrot cover <br />Even though you pay those expenses, they don't count toward the out—of—pocket limit <br />out-of-pocket limit <br />Is there an overall annual limit <br />No <br />The chat starting on page 2 describes any limits on what the plan will pay for specific covered <br />on what the insurer pays? <br />services, such as office visits - <br />Does this plan useanatwor <br />Yes, See MedMutualcom1SBC or call <br />if you use an in -network doctoror other health care provide r this plan will pay some or all Onto <br />pf ros�viders? <br />800540,2583 for list of participating <br />costs ofcovemd services. Be aware, your moetwork doctor or hospital may use an outof-network <br />providers <br />provider for some services. Plans use the term m-nelwork Preferred or participating for providers <br />_ <br />in their network See the chair staling on page 2 for how this plan pays different kinds of roves. <br />Do l need a referral to see a <br />1No <br />Youcanseethes ep ciallst you choose without permission from Ibis plan <br />Are the re services this plan <br />Yes <br />Some of the services this plan doesn't cover are listed on page 5. See your policy or plan document <br />doesn'tcover? <br />L <br />for additional nominated about excluded services. <br />Questions: Call 800 540 2583 or visit us at MedMutual consISBC. <br />If you aren't clear about any of the underlined fears used in this form, see the Glossary. You can view the Glossary <br />at MedMufual.cori or call 800.5402583 to request a copy. <br />49 <br />Fage 1 .(a <br />5N935996 <br />eEN14316505Te02MOM <br />