Summary of Plan Features and Out-Of-Pocket Expenses
We have prepared a chart that provides a broad comparison of the medical plans: Summary of medical plan benefits.
Medical Mutual of Ohio
800.762.1929
Access Provider Directory - Super Med Plus
Certificate of Coverage Super Med Plus PPO
Certificate of Coverage Traditional Indemnity - Coordination with Medicare
Certificate of Coverage Traditional Indemnity
Certificate of Coverage Super Med Plus- Terminated December 31, 2009
Certificate of Coverage Traditional Indemnity Plan- Terminated December 31, 2009
General Insurance Plan Provisions
Medical Mutual of Ohio Plan Features
Preferred Provider Organization (PPO) deductibles and out-of-pocket maximums
Deductibles | In network | Out of network |
Salary range | Single/family | Single/family |
Less than $25,000 | $150/300 | $300/600 |
$25,000 to $39,999 | $200/400 | $425/850 |
$40,000 to $54,999 | $300/600 | $600/1,200 |
$55,000 to $69,999 | $400/800 | $775/1,550 |
$70,000 to $84,999 | $475/950 | $950/1,900 |
$85,000 and higher | $600/1,200 | $1,200/2,400 |
Out-of-pocket maximums | In network | Out of network |
Salary Range | Single/family | Single/family |
Less than $25,000 | $600/900 | $1800/2,700 |
$25,000 to $39,999 | $850/1,250 | $2,500/3,800 |
$40,000 to $54,999 | $1,200/1,800 | $3,600/5,400 |
$55,000 to $69,999 | $1,550/2,350 | $4,700/7,000 |
$70,000 to $84,999 | $1,900/2,900 | $5,750/8,650 |
$85,000 and higher | $2,400/3,600 | $7,200/10,800 |
Annual deductible and out-of-pocket maximums for comprehensive plan
Salary range | Deductibles: Single/family |
Out-of-pocket maximums: Single/family |
Less than $25,000 | $150/300 | $600/900 |
$25,000 to $39,999 | $200/400 | $850/1,250 |
$40,000 to $54,999 | $300/600 | $1,200/1,800 |
$55,000 to $69,999 | $400/800 | $1,550/2,350 |
$70,000 to $84,999 | $475/950 | $1,900/2,900 |
$85,000 and higher | $600/1,200 | $2,400/3,600 |
Envision Pharmaceutical Services
800.361.4542
Envision Pharmaceutical Services
Prescription drug co-pay amounts
For the comprehensive and PPO plans:
Via retail, 30-day maximum supply | |
Generic, 90% subject to minimums and maximums co-pay amounts as shown. | $10/$20 |
Brand, 80% subject to minimums and maximums co-pay amounts as shown | $20/$50 |
For comprehensive and PPO plans:
Via mail order, 90-day maximum supply | |
Generic - 90% subject to minimums and maximums copay amounts as shown; | $25/$50 |
Brand - 80% subject to minimums and maximums copay amounts as shown | $50/$100 |