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Medical Mutual of Ohio 90/10 Plan <br />CITY OF LAKEWOOD: Plan 2 — MMO LO Plan AFSCME Cove-dm Per ad_ddna <br />Summary of Coverage: What This Plan Covets&What It Costa 2017 Coverage for: Sha !ems:=znilgi Plan Type: PPt} <br />This is only a summary. It you want more detail about your coverage and costs, you can get the complete terms in the polio/ or plan document at <br />rfedMuWat_cnafS@C or by caliin-9 80 ,P2 ME <br />a <br />E5001sirgie,E1,000/family Network <br />You must pay all the costs up to as deductible amount before this plan begins fo pay kr mrered <br />What is the <br />Nan Network <br />55001sirapply <br />services you use. Check your policyor plan document to see when Ili deductbe starts over i <br />l <br />overall <br />to co-inamily <br />Wesn4 apply to m-insurance, mpays <br />(usually, but not always, January lst) See the chart sterling on page 2[of howmuch you pay for , <br />deductible? <br />and network preventive ore <br />covered services after you meet the deductible <br />Are there other <br />No <br />You don't have to most deductibles, for specific services, but see the chart staitmg on page 2 for j <br />deductibles forspecific <br />other costs fdrservicesthis plan covers-1 <br />G Is there an out-of-pocket <br />Yes, E25001single,E5000ttamilyNehvork <br />Theout-of-pocketlimh is the most you could pay during a coverage fished {usually one year) for <br />limb on my expenses? <br />your share of the cost of covered services. This limit helps you plan for health care expenses. <br />E2.6001single,S5,000,Yamily Non-Netwnik <br />What is not included in <br />Premiums, balance -billed charges and <br />Even bough you pay Chase expenses, they don't moot toward iheout—alpocket limit. <br />I the out -of pocket Iimlt? <br />health rare This plan doesn't rover. <br />Is there an overall annual <br />No <br />The chart starling on page 2 describes any limits on what the plan will pay LqC a I cover etl <br />Wit on what the Insurer <br />services, such as office visits. <br />pays? <br />Does this plan use a <br />Yes, See MedidulualonwSBC or call <br />If you use an in- network doctor or other health taintlLoi this plan wail pay some or all of go <br />network of row? <br />8002327400 for a list of participating <br />costs ofmveredservices, Beaware,your in -network doctor orhosptalmayuseanouW[network <br />providers. <br />provide rfor some services. Plans use the term in-nekvmk, preferred ar paNcipafing for row <br />in their network. See the chart starting on page 2 for how this plan pay different kinds of row. <br />Bo I need a referral to see <br />No <br />You can see the specialist you choose wi routpermission from this plan. <br />as ap cfalnt? <br />' Arethere services this <br />You <br />Some ofihe services this plan doesn't cover we listed later in the domment See your polio/er plan <br />Iplan doesn't cover'do <br />manloraddionalinormationglhgdexcludedservices- <br />52 <br />