Laserfiche WebLink
Medical Mutual of Ohio 90/10 Plan - <br />CAT Y 0'F..LAKE.W00Q: Plan 2 - NIM10 LO Plan NON - AFSCME <br />Oniv Coveraqew frur.- Siin,,,%.i�-u PI an Ty P e: P-R.-D" <br />20-17 <br />-rage and costs, you can get the cc-mplete tem in the policy or plan document at <br />This is only a summary. If you grant more detail aboutyour cove <br />or aI i p_qAQ "12 <br />NfedMutq-al.cq:ffVSBC <br />----------------------------------------- - - --- --- - - - - ---- - --------- <br />Mi y <br />;L ngle;$! Wa I Netmo-tk <br />y U�M'st 4 the;cb,�ts�up:ba:t-he�deductibi6:;arm.u.nt:.bef3,.re.:ffii I i lap�Jdr d <br />pay, an .*,ris covere <br />s;p_ <br />W hat'13: th <br />001s D001farnily. Non-Netwotaor <br />plan ment ta h start <br />seraces.�Wuse.� Check your: polio' -doca see w enibe dedu over <br />:0 Veral <br />Qont app 14i b co-insurance, CC P; <br />(usually, but,not 4f)xar,.,. January 1*),�: See:the thart ttarting o -1-Ja <br />. ..... . ... n <br />U <br />and netwo*: preventi�e, ca <br />care <br />covered <br />cover. services: r you meet e ded up-tible <br />th <br />7 1 <br />:ire 'them'Aer- <br />.;:,No, <br />Yolu don't have b,.rri.eet deductlbles.fbr­pecifi' but On for <br />f <br />de u I es irspepli <br />4 4 1 <br />bti� qi�ts arse th is plan Over's'.. <br />Is there an out-of-pocket <br />Yes, S2500ising le,S500O)fami ly Nemork <br />The out-of-pocketlimit i's the rm-st you could pay during a coverage period (usually one Fear for <br />lim-ft on my expenses? <br />your share <br />are of the cost: of covered seMan-s- This limit helps , u plan r health care expenses - <br />fo <br />Nan-Network <br />................................................................................... <br />What is not included in <br />............................................................................................... <br />Prern, iums, balance -billed charges and <br />health care thisplan-doesn't caver, <br />. ..................................... . .......................................................................... . ...................................................................................................... . .......................... ..... <br />Even though you pay these expenses, theY don"t count toward the out—of—pocket limit - <br />the out-of-pocket ILM-Lit? <br />ere in averali a: I <br />Ig annual <br />AE. Na <br />4 I_ 4 <br />The ch�at� starfi limits on white Plahi:�Wi 1: f <br />N :0 pagepay <br />ll�licon*, what: the :insurer <br />7-77= <br />-e Vis i Es <br />services, such a::Mice <br />Does this plan. use a <br />ye. See MedMutual.coffVSBC or call <br />ff you use an in -network doctor or other- health care orovider, this plan will .pay some or all of the <br />networkof provide <br />i 800,23.21400 to: r a list of pa., rfi d pab n g <br />costs of covered services. Ek�aware, your in -network -Gsp i b-I ma, use an au��netwurk <br />k docto r or h <br />pruviders, <br />providerfor some services.. Plans use the terra in-netwarK.2Etferred, or pattcipatirig tr providers <br />in their network. See the chart starting on page 2 for how this plan pays different kin providera- <br />kinds of <br />fneed:aief raf <br />k Or 1 4 F <br />4 <br />You can see the. soe�a u. choose -'Mtha ftm this <br />Ue ion Ian <br />. . . . . . . . . . . . . ................. . . . . . . . . <br />1: <br />V <br />. . . . . . . . . . . . ............ ........ ........... . . . . . <br />. . . .................................................... ................. ............. . . . . . . . . . . <br />Are there services this <br />Yes <br />. . . . ....... ............ <br />Some of the services this plan doesn't cover are tisted later in the doc=ent. Seeyour poliq y or plan <br />plan d-Gesn"t cGverl? <br />............................................................ <br />............................................................................................................... <br />docu rnent for additional information about excluded seroces. <br />...................................................................... . ..................... ........................................................................................................................................................................ <br />32 <br />