Laserfiche WebLink
APPENDIX B <br />Medical Mutual of Ohio 100% Plan <br />City of Lakewood .- Plan I PPO Hi Plan <br />2017 av, rasie 0111 - 1' 1 <br />Summary of Beilefits. and <br />Coverage: What Thi's Pian Covers & What it Costs Coverage for: Single -sr Fam-KY, I Plan Type: PPO <br />is s o <br />ThiMy a sium mary. ff you wanf. mo re detail about yourcolsee'rage and.- costs, you. canget the comprete tas-fm S in the policy or plan:.- docum-ent at <br />MedMutualquo n-USBC or -by calling 800,:54-0-2583. <br />!I! I mg <br />----------- <br />M q st p4y: a I I th e co_f U p to th e, d 6 du c t ib i e a m durt befdm th Is: p I an. oqetd ay f b r co as re d <br />-what is t ovem--ft <br />.......... <br />Ch I t <br />U, 8 "uW d-acuanent. d see WherZ, te -- d"uttible:Sarts Wer <br />or P: <br />Yrou - #�Y,:,: * ::. -, �:.: :­ .: : :�_. : : <br />P0 t <br />:dedurtibW <br />:Ddesn' I b,-' <br />I app. y: toinsurrance �ca -ays �: <br />T Lml� but not alwa �'Janu�iy:Tst' & <br />� U-� ... i _ .,. : , *1 1 1 , 9 - , , , . 10 ay.-t r <br />-A: 71 j.�.:: S-jee:the aftsta diti. pa p Vorhaw MUO: YoU: p d <br />n d. e4b. <br />n rk preventve cam <br />C ry- ire., S&W Ted t. &d flbl <br />you: meet - e UCI <br />........ ... .. <br />k6there'::other* "deductibles <br />ed, c sery _R ur - , ,�: 2: -Or:: <br />You don1bavelb mcet.dedUc1bIeSf0* thy' dad <br />icim -see e. <br />t.7 <br />for S 6 W-1 <br />T: cos L�z T rseroea" <br />Is there an Gut-of-pgaet limit <br />Yes:Sl, 6-5,01sing-Je, $3,300fl-amflily <br />The ou"f pqcket 11. Wt is the. frz- st couldi. p. y dF-,ring a coveragepe-6D-d (=ally nee dear'; for <br />on my expenses? <br />Network <br />your share of the rfist -of -cavered services. This limit: helps you plan far heafth careae�,xpenses, <br />Non-Netwo* <br />What is not included in the <br />Frem�.ums, balance-bilfc-44 charges and <br />health -care th-is plantdoesn't-cover. <br />Even thaugh you pq blase eypersea, they dw't c^. umttmvaid the out-of­pocket limit. <br />out-of-amket limit? <br />IsRthewjn*-overa'It.arma-Iffinit <br />hb: .. . .. <br />dhArt stath <br />fT <br />Y <br />prer <br />. . ...... . .. . ... ...... <br />Does this plan use a, network <br />Yes., See MedMut!jaLCoMJ`.3B;0 atcajj <br />if you use ar, in-netvicl* doctor -or other health - cam provider, this plan will pay sotme or alI of the <br />of providers?. <br />800,54G.25H.3 far fist cf;participa it' <br />costs) of cower. -d"', 3erliceas. Be aware, your in -netwoWdodto, r or hospits.4 may use an o. ul-of-network <br />Provider, <br />Provide for some servicasm. Plans use the batm to-n- eitwo*, preferred or participadrg fir prov. iders <br />in their netwo irk.. See the &a.-Tt Starting: art .ipsga 2 for how -.this- ptan pays different kinds of RE2njders.. <br />D�J: e'ed a refeiTal' to--.�ee a; <br />N& <br />Y Ou jz—an th takf y 00 0 : <br />see :e qucb -s#wft, ut:pemis8ion:ftm1hi's-plat <br />j W 1 i i <br />i <br />Are there services this plan <br />Yes <br />Some of the services this plan doesn" ezve r are lirted on page 5. See your policy ar pfani document <br />additional i fflormation about exciuded services. <br />W <br />