State of ohio ohio med ppo

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State of Ohio: Ohio Med PPO

Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Coverage Period: 07/01/2014 ? 6/30/2015 Coverage for: All Coverage Tiers | Plan Type: PPO

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan

document at or by calling 1-877-440-5977 (for UHC); or at or by calling 1-800-822-1152 (for Medical Mutual).

Important Questions What is the overall deductible?

Are there other deductibles for specific services? Is there an out?of?pocket limit on my expenses? What is not included in the out?of?pocket limit? Is there an overall annual limit on what the plan pays? Does this plan use a network of providers?

Do I need a referral to see a specialist? Are there services this plan doesn't cover?

Answers Network: $200 Individual/$400 Family Out-of-Network: $400 Individual/$800 Family Does not apply to copays, network preventive care, or prescription drugs.

No.

Yes. Network: $1,500 Individual/$3,000 Family Out-of-Network: $3,000 Individual/$6,000 Family Premiums, balance-billed charges, amounts greater than maximum benefits, penalties for failure to obtain preauthorization of services, prescription drugs, and health care this plan doesn't cover. No. Yes. See or call 1-800-822-1152 for a list of Medical Mutual network providers, or see or call 1-877-440-5977 for a list of UHC network providers. No. You don't need a referral to see a specialist. Yes.

Why this Matters: You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st; July 1st for this plan). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. You don't have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Even though you pay these expenses, they don't count toward the out-of-pocket limit.

The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. If you use a network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. You can see the specialist you choose without permission from this plan. Some of the services this plan doesn't cover are listed on page 6. See your policy or plan document for additional information about excluded services.

Questions: Call 1-800-409-1205 or visit us at das.benefits. If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at ebsa/healthreform or call 1-800-409-1205 to request a copy.

Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan's

allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven't met your deductible.

The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed

amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)

This plan may encourage you to use network providers by charging you lower deductibles, copayments and coinsurance amounts.

Common Medical Event If you visit a health care provider's office or clinic

If you have a test

Services You May Need Primary care visit to treat an injury or illness Specialist visit Other practitioner office visit Preventive care/ screening/immunization

Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRIs)

Your Cost If You Use a

Network Provider

Out-of-Network Provider

$20 copay/visit

$30 copay/visit,

then 40% coinsurance

$20 copay/visit

$30 copay/visit,

then 40%

coinsurance

20% coinsurance for 40% coinsurance for

chiropractor;

chiropractor;

acupuncture is not covered

acupuncture is not covered

No charge

Office visits $30 copay/visit,

then 40%

coinsurance up to

age 21; not covered

if age 22-40; $30

copay/visit if age 40

or over

Other 40% coinsurance

20% coinsurance

40% coinsurance

Limitations & Exceptions No deductible applies to in-network services. Copays do not apply toward deductible. No deductible applies to in-network services. Copays do not apply toward deductible. ???????????none???????????

No deductible for in-network preventive care. Routine physical and routine mammogram limited to once per plan year (in- and out-of-network combined). Frequency and age limitations may apply.

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20% coinsurance

40% coinsurance ???????????none???????????

Common Medical Event

If you need drugs to treat your illness or condition More information about prescription drug coverage is available at .

Services You May Need

Generic drugs

Preferred brand-name drugs Non-preferred brandname drugs

Your Cost If You Use a

Network Provider

Out-of-Network Provider

Retail: 30-day supply Not covered $10 copay/ prescription

Retail: 90-day supply $30 copay/

prescription Mail-Order $25 copay/90-day supply

Retail: 30-day supply $25 copay/ prescription Retail: 90-day supply $75 copay/ prescription Mail-Order $62.50 copay/90-day supply Retail: 30-day supply $50 copay/ prescription Retail: 90-day supply $150 copay/ prescription Mail-Order $125 copay/90-day supply

Not covered Not covered

Limitations & Exceptions

No charge for generic oral contraceptives (retail and mail-order available). No charge for certain diabetic and tobacco cessation medications if plan requirements are met. Some generics are categorized as "single-source" and may result in a brand copay of $25. A singlesource generic drug is more expensive than other generics because the drug is generally made by only one pharmaceutical company (often the brandname manufacturer). Once the drug is produced by multiple pharmaceutical companies, it may be moved to the generic copay level. Drugs not listed in the formulary, investigational drugs, and drugs in clinical trials are not covered. No charge for preferred brand oral contraceptives when a generic is not available (retail and mailorder available). No charge for certain diabetic and tobacco cessation medications if plan requirements are met. Drugs not listed in the formulary, investigational drugs, and drugs in clinical trials are not covered.

If brand-name medication is requested when generic equivalent is available, you will pay the difference in price in addition to your copay. No charge for non-preferred brand oral contraceptives when a generic is not available (retail and mail-order available). No charge for certain diabetic medications if plan requirements are met. Drugs not listed in the formulary, investigational drugs, and drugs in clinical trials are not covered.

Common Medical Event

If you have outpatient surgery If you need immediate medical attention

If you have a hospital stay If you have mental health, behavioral health, or substance abuse needs

Services You May Need Specialty drugs

Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees Emergency room services

Emergency medical transportation Urgent care Facility fee (e.g., hospital room) Physician/surgeon fee Mental/Behavioral health outpatient services

Your Cost If You Use a

Network Provider See your costs above for preferred and non-

Out-of-Network Provider

Not covered

preferred brand-name drugs

20% coinsurance

40% coinsurance

20% coinsurance $75 copay/visit; copay waived if admitted, then 20% coinsurance

20% coinsurance

40% coinsurance $75 copay/visit; copay waived if admitted, then 20% coinsurance 20% coinsurance

$25 copay 20% coinsurance

$30 copay, then 40% coinsurance 40% coinsurance

20% coinsurance $20 copay/office visit

40% coinsurance $30 copay/office visit, then 40% coinsurance

Mental/Behavioral health 20% coinsurance inpatient services

40% coinsurance after deductible

Substance use disorder outpatient services Substance use disorder inpatient services

$20 copay/office visit

$30 copay/office visit, then 40% coinsurance

20% coinsurance

40% coinsurance after deductible

Limitations & Exceptions Some specialized medications must be obtained from the specialty pharmacy through Catamaran after your first fill. For additional information, visit das.prescriptiondrug. ???????????none??????????? ???????????none??????????? ???????????none???????????

No deductible applies. No deductible applies to in-network services. Copays do not apply toward deductible. Preauthorization required for out-of-network care. $350 penalty may apply for failure to preauthorize. ???????????none??????????? No deductible applies to in-network services. Copays do not apply toward deductible. More information can be found at . Out-of-network copay does not apply toward deductible. $350 penalty may apply for failure to preauthorize. More information can be found at . No deductible applies to in-network services. Copays do not apply toward deductible. More information can be found at . Out-of-network copay does not apply toward deductible. $350 penalty may apply for failure to preauthorize. More information can be found at .

Common Medical Event If you are pregnant If you need help recovering or have other special health needs

If you need help recovering or have other special health needs

If your child needs dental or eye care

Services You May Need Prenatal and postnatal care Delivery and all inpatient services Home health care

Rehabilitation services Habilitation services Skilled nursing care

Durable medical equipment Hospice service Eye exam

Glasses Dental check-up

Your Cost If You Use a

Network Provider

Out-of-Network Provider

No charge for initial $30 copay/office

visit, then 20% coinsurance

visit, then 40% coinsurance

20% coinsurance

40% coinsurance

Limitations & Exceptions Deductible does not apply for initial in-network visit. Out-of-network copay does not apply toward deductible. ???????????none???????????

20% coinsurance

20% coinsurance 20% coinsurance; office visit copay may apply 20% coinsurance for first 180 days/plan year, then 40% coinsurance 20% coinsurance

40% coinsurance

40% coinsurance 40% coinsurance: office visit copay may apply 20% coinsurance for first 180 days/plan year, then 40% coinsurance 40% coinsurance

Must be noncustodial. Limited to 100 visits/plan year or 180 days (whichever is greater), in- and outof-network combined. Preauthorization required five business days before receiving services for outof-network care. Financial penalty may apply or no benefit will be provided for failure to preauthorize. ???????????none??????????? Coverage limited to diagnosis only of Autism Spectrum Disorder. Must be noncustodial. Must follow a hospital confinement or to avoid a hospitalization which would otherwise be necessary. Preauthorization for out-of-network care required and no benefit will be provided for failure to preauthorize. ???????????none???????????

No charge No charge

Not covered Not covered

No charge $30 copay/office visit, then 40% coinsurance

Not covered Not covered

???????????none??????????? Covered up to age 21 if in-network without deductible if eye exam is part of a preventive care/wellness examination. Out-of-network copay does not apply to deductible. ???????????none??????????? ???????????none???????????

Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isn't a complete list. Check your policy or plan document for other excluded services.)

Acupuncture

Infertility treatment

Routine eye care (Adult)

Cosmetic surgery Dental care (Adult + Child)

Long-term care Non-emergency care when traveling outside the U.S.

Routine foot care (unless medically necessary as a result of diabetes)

Weight loss programs

Other Covered Services (This isn't a complete list. Check your policy or plan document for other covered services and your costs for these services.)

Bariatric surgery (medically necessary only) Hearing aids (participant pays 20% coinsurance for covered accident,

Chiropractic care

illness, or injury; natural hearing loss covered at 50% coinsurance up

to $1,000 and limited to once per lifetime)

Your Rights to Continue Coverage:

If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at 1-800-409-1205, option 5. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or iio..

Your Grievance and Appeals Rights:

If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can visit or call 1-877-440-5977 (for UHC); or visit or call 1-800-822-1152 (for Medical Mutual). You can also contact the Department of Labor's Employee Benefits Security Administration at 1-866-444EBSA (3272) or visit ebsa/healthreform. Additionally, a consumer assistance program can help you file your appeal. A list of states with Consumer Assistance Programs is available at ebsa/healthreform.

Does this Coverage Provide Minimum Essential Coverage?

The Affordable Care Act requires most people to have health care coverage that qualifies as "minimum essential coverage." This plan or policy does provide minimum essential coverage.

Does this Coverage Meet the Minimum Value Standard?

The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides.

??????????????????????To see examples of how this plan might cover costs for a sample medical situation, see the next page.??????????????????????

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