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APPENDIX A <br />Medical Mutual of Ohio 100%Plan <br />City of Lakewood: Plan 1 PPO Hi Plan 2017 Careraaa Nmd: otgl- ta31 <br />Summary of Benefits and Coverage: Yfnat This Plan CovmaMaUtComr CovErage for. & a a fanaly l Plan Type: PM <br />I <br />t This lsontyaaummary. nyaa temr8aetag aeamywrmvemgeanamss,>'w can 9N@e cmpaaa armsm vepdsyorpu: daumentat <br />M(A)AWIN.oxN3BC akyoT7fig awsfa2�3_ <br />•• " <br />i <br />1f5a rgIES3aan miyNrork <br />You r.:u tP Yap Uxmsbvpts,h dmadbleamtmlCBbreffus P�^k`--3ira@paY lormvEree <br />Mar is lle!ovo a] <br />S150ryrj1 Sl11M mj'h Netxwk <br />sEnKes you cM1¢ajwrr ptfcY Pdnda`JTPMbsEe +En tl'8 detlacliulesW(savet <br />Cetlurdiltle? <br />ere I.Wr Nm@svr onays <br />(aswly,tNndahva}s, dantrzry fd) See Vre UaRsbrfngen Fage2tahwmxM1Youpay fcr <br />aMnefxtiA reeeh[ve tore <br />:Ira'°-rstlsEn^<as ReryovmeetF deJuq@le <br />Pie Isere ader de, dnatibus <br />No <br />�Yeu CanlhaveWmeettletletl@IeglaripEEfiicserwses Edsee Ne tliartsUrtr4tlnfege2(a <br />forspe<Igc servkes? <br />ic@ermstskrearvl�s Pfs planwers <br />Is@ereaneaeefasdmtlimlt <br />Yes,SLE50#lrg:e,El,3W,r, .'ry <br />The cu[,A.a.cW ffirait iS Pa rrc5t y. dd pay adng amvEiegepe6xf(awaU/mey,a,) fa <br />srs, a"nses? <br />Ke*e5vk 1185otage,$1,1a0.+fanulY <br />iyWeshare dua meldmxaaetlsertikes.Tta NntiehElps you plan faheal@carz expenus. <br />Non NeWo k <br />WM1af is son inclodedmlha <br />P.-au,.balsnceLEef rtayE58N <br />M1eat@care@ln <br />Evan ft h,ou pay vnne pmx„ Ney ant sent D.,a Me eN oFoackH llml4. <br />ouidoocketlimh? <br />pNnbaesnl rovas. <br />r <br />[a on. aovesag.. uI I and <br />Na <br />ithe cFaNSUrurgon page 2desanbea any4rrcbobwhaltlrzplabxigpay (as�elfe_covared l <br />op wfiaEmeimmerpays? <br />lxrvkes, hasc@sema3s. <br />Goes ihi Aran use a nelvmrk <br />Y See Ahdd:PWW HCOrnl <br />I gya as° 9 M rkd b @ tealNcaey avlder.OYs pl owls ps .soralld Re <br />atwovrders? <br />8005:g2$83 for 6sl otp a-pasg <br />bd d .e a ,Yvs ie:vrakda@r A gamay u<s.n a;lcAnemM <br />pto 1a@n. <br />p vide orps+lapaM,bIrus d,rs <br />h Vrt'arrelwaa.9ee d:e rhart larlagon,sge Rla Mr Sb plan say ShcaenlNrAs cl rarrtlers <br />q Ineed n-u-1 to seea <br />No <br />r Ya, can Sae ma S.dgs Ycv rQ wetovt PE sfao tris pss <br />o Ia(stp <br />I <br />Px Nereurvlees lM1isplan <br />Yes <br />�Saned Vesm^.ses lhlspan eoesnlmcer arofizetl on yage $. See yourpdrycr Susne -wrc+d <br />doesn'I cover? <br />,Iwadiepiul N:mmatim aEevl esdutled sen <br />30 <br />