Page 5 - ECRM 2022 Benefit Guide (OH)

MEDICAL BENEFITS | cost effective peace of mind

As we all know, the cost of quality health coverage has increased over
the past few years. At the same time, we need health care that protects
our physical health as much as health care that protects our financial
well-being. That is why ECRM believes it is important to invest in a
quality plan that is cost effective, easy to use and valuable to you. ECRM
provides the following plan options:
BENEFIT Medical Mutual / Gold Medical Mutual / Silver Medical Mutual / Bronze
(IN/OUT OF NETWORK) (IN/OUT OF NETWORK) (IN/OUT OF NETWORK)
Annual Deductible
Single $1,250 / $2,500 $2,000 / $4,000 $3,000 / $6,000
Family $2,500 / $5,000 $4,000 / $8,000 $6,000 / $12,000

Out-of-Pocket Maximum*
Single $4,000 / $8,000 $5,000 / $10,000 $6,600 / $13,200
Family $8,000 / $16,000 $10,000 / $20,000 $13,200/ $26,400
Office Visit $25/$45 / 40%** $30/$50 / 40%** $35/$50 / 40%**
Diagnostic X-ray, Labs, 20% / 40%** 20%**/40%** 20% / 40%**
Etc.
Well-Child Care 100% / 40%** 100% / 40% 100% / 40%**
(immunizations, check-ups)
Adult Preventive Care 100% / 40%** 100% / 40% 100% / 40%**
(Routine Exams, Physicals, etc.)
Mammogram / PAP Tests 100% / 40%** 100% / 40% 100% / 40%**
Emergency Treatment
Ambulance 20% / 20% 20%** / 20%** 20%** / 20%**
ER (actual emergency) $250 / $250 $250 / $250 $250 / $250
Urgent Care $75 / 40%** $75 / 40%** $75 / 40%**
Prescription drugs
Retail (30-day supply)
Generic $10 $10 $10
Formulary Brand $40 $40 $40
Non-Formulary Brand $80 $80 $80
Specialty 25% to $250 max 25% to $250 max 25% to $250 max
Mail Order (90-day supply)
Generic $25 $25 $25
Formulary Brand $100 $100 $100
Non-Formulary Brand $200 $200 $200
* Deductibles, copays and coinsurance apply towards the out-of-pocket maximum; ** After you pay the
deductible; *** Dependent Age 28 (restrictions apply)
Important Note
The Plan does not require you to use a primary care physician, it remains your responsibility
to make sure you are using In-Network providers in order to enjoy the benefits of the plan’s
In-Network benefit schedule.

Copayments are not subject to and do not apply to the annual deductible.

This chart shows how much you pay for certain products and services. Please note, that your Medical benefit
booklet will provide a comprehensive explanation of all benefit provisions associated with your Medical plan.

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