| Premium |
$0 |
$0 |
$30 |
$0 |
| MOOP |
$4,200 |
$4,900 |
$4,200 |
$0 OON Deductible
$6,050 IN
$11,000 OON
|
| PCP |
$0 |
$5 |
$0 |
$0 IN
$10 OON
|
| Specialist |
$35 |
$40 |
$30 |
$40 IN
$55 OON
|
| Inpatient |
$325 (Day 1-6)
|
$300 (Day 1-7)
|
$335 (Day 1-6)
|
$375 (Day 1-5) IN
40% OON
|
Outpatient
(Surgical) |
$335 |
$360 |
$375 |
$350 IN
$400 OON
|
| Diagnostic |
CT: $100
MRI: $125
PET: $125
|
CT: $100
MRI: $175
PET: $175
|
CT: $100
MRI: $175
PET: $175
|
CT: $100 IN
CT: 40% OON
MRI: $175 IN
MRI: 40% OON
PET: $175 IN
PET: 40% OON
|
| ER |
$90 |
$90 |
$90 |
$90 |
| Urgent |
$35 |
$35 |
$30 |
$40 |
Rx Deductible
(excl. T1 & T2)
|
$0 |
$95 |
$95 |
$0 |
Preferred Rx Copays – 30 Day Retail
|
Tier 1: $4
Tier 2: $8
Tier 3: $42
Tier 4: 50%
Tier 5: 33%
Tier 6: $0
|
Tier 1: $0
Tier 2: $5
Tier 3: $42
Tier 4: 50%
Tier 5: 31%
Tier 6: N/A
|
Tier 1: $0
Tier 2: $5
Tier 3: $42
Tier 4: 50%
Tier 5: 31%
Tier 6: N/A
|
Tier 1: $4
Tier 2: $8
Tier 3: $42
Tier 4: 50%
Tier 5: 33%
Tier 6: $0
|
Preferred Rx Copays – 90 Day Mail Order
|
Tier 1: $0
Tier 2: $0
Tier 3: $110
Tier 4: 50%
Tier 5: N/A
Tier 6: $0
|
Tier 1: $0
Tier 2: $0
Tier 3: $110
Tier 4: 50%
Tier 5: N/A
Tier 6: N/A
|
Tier 1: $0
Tier 2: $10
Tier 3: $110
Tier 4: 50%
Tier 5: N/A
Tier 6: N/A
|
Tier 1: $0
Tier 2: $0
Tier 3: $110
Tier 4: 50%
Tier 5: N/A
Tier 6: $0
|
| MedMutual Advantage Travel Plus™ |
$2,500 coverage for care received outside of Ohio |
$2,500 coverage for care received outside of Ohio |
$2,500 coverage for care received outside of Ohio |
$2,500 coverage for care received outside of Ohio |
| Dental |
$750 incl. preventive
|
Preventive |
$500 incl. preventive |
$1,000 incl. preventive
|
| OTC |
See MedMutual MyChoice™ |
See MedMutual MyChoice™ |
$52.50 quarterly |
See MedMutual MyChoice™ |
| MedMutual MyChoice™ |
Included
Option A: $1,000 additional dental coverage
Option B: $350 to cover hearing and vision expenses, over-the-counter items, transportation and meal delivery
|
Included
Option A: $500 additional dental coverage
Option B: $250 to cover hearing and vision expenses, over-the-counter items, transportation and meal delivery
|
Not included |
Included
Option A: $250 additional dental coverage
Option B: $150 to cover copays and coinsurance, hearing and vision expenses, over-the-counter items, transportation and meal delivery
|
| Extra Benefits |
These programs and services are included with all MedMutual Advantage plans and are designed to help members stay healthy, get better and recover comfortably.
• SilverSneakers® fitness membership – Access to 17,000+ facilities and numerous fitness classes
• WW® (Weight Watchers Reimagined) – Discounted membership rates for enrolling in a Digital, Digital + Studio and WW for Diabetes programs.
• Chronic Condition Management Program - Helps members manage chronic conditions and maintain their independence by providing a trained health coach to develop a personalized plan supplementing the care you get from your doctor.
• Member Assistance Program – High-risk members are paired with a personal advocate who can help coordinate in-network care and connect them with resources to help them better manage their health and remove barriers to care.
• Tobacco Cessation Program – One-on-one sessions with a trained coach who works with members on a quit plan and provides support.
• 24-Hour Nurse Line – A clinical expert provides answers to health questions 24 hours a day, seven days a week.
• Telemedicine – Members can connect with a health provider electronically to ask a medical question, get help with diagnosing common illnesses and get prescriptions.
• Palliative Care – Care coordination and home-based support services to help improve quality of life for members with serious illnesses.
|