Page 3 - QCHC.19 Employee Benefits

2019 Medical Benefits

Medical PLAN

Medical Mutual of Ohio
You have the option to enroll in our group health insurance plan through Medical Mutual of Ohio.

The benefits and your cost SMP P2580-3000 Triple Deductible
(contribution) are outline in the
adjacent table. Benefits In-Network Out-of-Network
Annual Deductible $3,000 / $9,000 $6,000 / $18,000
Individual/Family
Out of Pocket Maximum $3,000 / $6,000 $12,000 / $24,000
To check and see if your doctor is
Individual/Family
in your plan click on:
(the annual deductible, copays,
MMO Provider Search premium, balanced billed amounts do
not count towards the out of pocket)
Lifetime Maximum Unlimited Unlimited

Manage your MMO benefits on Preventive Services Paid at 100% Deductible + 20%
line:
• Check benefits PCP Office Visit $25 Deductible + 40%
• Manage Prescriptions
• Estimate Costs Specialist Office Visit $50 Deductible + 40%
• View Claim Status Urgent Care $50 Deductible + 40%
• File Appeal/Grievance
Emergency $200 + 20% $250 + 20%
Register:
MMO On-Line Account Inpatient Deductible + 20% Deductible + 40%

Outpatient Services Deductible + 20% Deductible + 40%

MMO Customer Service Mental Health - Inpatient Deductible + 20% Deductible + 40%
800-382-5729
Mental Health - Outpatient $25 Deductible + 40%
Hours:
MON. - THURS. - 7:30 A.M. - 7:30 P.M. (ET) Short Term Rehabilitation Deductible + 20% Deductible + 40%
FRI. - 7:30 A.M. - 6:00 P.M. (ET) Outpatient
SAT. - 9:00 A.M. - 1:00 P.M. (ET)
Prescriptions
(Generic/Preferred/Non-Preferred)
Retail – 30 day supply $10/$20/$40/25% 50%, min $70

Mail Order – 90 day supply $30/$60/$120/25% Not Covered
Refer to MMO’s detailed plan summary for limitations

For additional plan information, please refer to the detailed plan description provided by the carrier.
In the event of a discrepancy, the carrier Pan Document shall prevail.