|
|
 |
Contents of this page:
Medical Coverage Overview | Summary of Plan Features
Link to Physician Directories | Applications and Change Forms
MEDICAL COVERAGE - OVERVIEW
You may choose among these providers:
- Medical Mutual of Ohio, for PPO and comprehensive
- SummaCare HMO (access to Summa Health System)
- The Health Plan (access to Akron General Network)
- Kaiser Permanente HMO
Questions to the health provider companies can be answered by visiting their Web sites or by calling their customer service numbers.
Health Plan Contributions by Employees
As a group, employees pay 15 percent of the cost of the medical benefits package. Individual employee contributions are determined by two factors: the plan that you choose and the level of coverage that you choose. You can estimate your contribution by reviewing this table.
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.
Here is a summary of out-of-pocket expenses:
1. Co-pay amounts for office calls
| Preferred Provider Organization (PPO) |
$15 |
| Health Maintenance Organizations (HMO) |
$15 |
2. 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 |
3. 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 |
4. 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 |
For health maintenance organizations:
Applicable to Kaiser Permanente HMO:
| Via retail, 30-day maximum supply |
| Generic |
$10 |
| Brand |
$20 |
| Via mail order, 62-day maximum supply |
| Generic |
$10 |
| Brand |
$20 |
Applicable to SummaCare:
| Via retail, 30-day maximum supply |
| Generic |
$10 |
| Preferred Brand |
$20 |
| Non-Preferred Brand |
$40 |
| Via mail, 90-day maximum supply |
| Generic |
$20 |
| Preferred Brand |
$40 |
| Non-Preferred Brand |
$80 |
Applicable to The Health Plan:
| Via retail, 30-day maximum supply |
| Generic |
$10 |
| Preferred Brand |
$20 |
| Non Preferred Brand |
$50 |
| Via mail, 90-day maximum supply |
| Generic |
$20 |
| Preferred Brand |
$40 |
| Non-Preferred Brand |
$100 |
Other specific benefit plan features vary by individual HMO. Refer to our general summary of the HMO plans for complete details.
LINKS TO PHYSICIAN DIRECTORIES
APPLICATIONS AND CHANGE FORMS
The Health Plan
Application (Use this if you are signing up for this coverage for the first time.)
Change form (Use this if you are adding a dependent or changing your primary care physician.)
Kaiser Permanente
Application and change form
SummaCare
Application (Use this if you are signing up for this coverage for the first time.)
Change form (Use this to add or remove someone from your coverage.)
Medical Mutual of Ohio
MMO does not have applications or change forms. Additions or changes can be made via eBenefits or on your paper Personal Enrollment Forms.
|
|
