Page 6 - QCHC.19 Employee Benefits

Coverage Period: 01/01/2017 - 12/31/2017
Coverage for: Single or Family | Plan Type: PPO
common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost
Page 1 of 6 OHPSMP BEN1711538792887-00044
This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call 800-540-2583. For general definitions of

for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services

Why This Matters: Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your ded

the Glossary at MedMutual.com/SBC or call 800-540-2583 to request a copy.

$3,000/single,$9,000/family Network

$6,000/single,$18,000/family Yes. Certain preventive care and all services with copayments are covered and paid by the plan before you meet your deductible. $3,000/single,$6,000/family Network $12,000/single,$24,000/family Copays, deductibles, premiums, balance-billed charges and health care this plan doesn't cover. Yes, See MedMutual.com/SBC or call 800-540-2583 for a list of participating
Medical Mutual : SMP P2580-3000 TRIPLE DEDUCTIBLE

Answers Non-Network No Non-Network providers. No

Important Questions What is the overall deductible? Are there services covered before you meet your deductible? Are there other deductibles for specific services? What is the out-of-pocket limit for this plan? What is not included in the out-of-pocket limit? Will you pay less if you use a network provider? Do you need a referral to see a specialist?