Service

Medical Mutual Services Comprehensive
Plan

Medical Mutual Services Preferred Provider Organization (PPO)

HomeTown HMO

SummaCare HMO

Kaiser Permanente HMO

Network Providers

Non-Network Providers

Hospital Services

Inpatient

80%of UCR after deductible; Unlimited days semiprivate, ICU, CCU

90% after deductible; Unlimited days semiprivate, ICU, CCU

70% of UCR after deductible; Unlimited days semi-private, ICU, CCU

100% semi-private room; physician services; general nursing care; other services and supplies authorized by your physician

100%

100%

Outpatient

80% of UCR after deductible

90 % after deductible

70% of UCR after deductible

100%

100%

$15 copay per visit

In-Hospital Physician Visits

80% of UCR after deductible

90 % after deductible

70% of UCR after deductible

100%

100%

100%

Surgical

80% of UCR after deductible

90 % after deductible

70% of UCR after deductible

100%

100%

100%

Anesthesia

80% of UCR after deductible

90 % after deductible

70% of UCR after deductible

100%

100%

100%

Pre-Admission Testing

80% of UCR after deductible

90 % after deductible

70% of UCR after deductible

100%

100%

100%

Diagnostic X–Ray and Laboratory

80% of UCR after deductible

90 % after deductible

70% of UCR after deductible

100%

100%

100%

Primary Care Physician Office Visits for Illness/Injury

80% of UCR after deductible

Covered in full less $15 copay per visit

70% of UCR after deductible

$15 copay per visit

$15 copay per visit

$15 copay per visit

Specialist Physician Office Visits for Illness/Injury

80% of UCR after deductible

Covered in full less $15 copay per visit

70% of UCR after deductible

$15 copay per visit; referral required

$15 copay per visit; referral required

$15 copay per visit

Urgent Care Center Visits

80% of UCR after deductible

Covered in full less $25 copay per visit

70% of UCR after deductible

$20 copay per incident

$25 copay at approved network facility

$15 copay at network facility

Emergency Room Visits

80% of UCR after deductible

Covered in full less $50 copay per visit; All other related Institutional and Professional Charges: 90% after deductible

100% of UCR less $50 copay per visit; All other related Institutional and Professional charges: 90% of UCR after deductible

$30 copay per incident

$50 copay; waived if admitted

$50 copay; waived if admitted

Routine Physical Exams

Not Covered

Covered in full less $15 copay for office visit; specific diagnostic tests covered at 90% after deductible; Once per 2 years ages 9–49, One per year ages 50 and older

Not Covered

$15 copay per visit

$15 copay per visit

$15 copay per visit

Well Baby/Child Care/Immunizations

Non-Immunizations: 80% of UCR after deductible; $500 maximum benefit from birth to age 1; $150 maximum benefit per year age 1 to 9 immunizations: 80% of UCR after deductible

Covered in full less $15 copay per visit; $500 maximum benefit from birth to age 1; $150 maximum benefit per year to age 9; maximum includes immunizations

70% of UCR after deductible; $500 maximum benefit from birth to age 1; $150 maximum benefit per year to age 9; maximum includes immunizations

$15 copay per visit

$15 copay per visit

$15 copay per visit

Routine Gynecological Exams

100% of UCR; one per year

100%; one per year

70% of UCR after deductible; One per year

$15 copay per visit

$15 copay per visit

$15 copay per visit

Routine Mammograms

100% of UCR; One baseline age 35 – 39; one per year ages 40 and older; benefit maximum not to exceed 130% of Medicare reimbursement

100%; One baseline age 35 – 39; one per year ages 40 and older; benefit maximum not to exceed 130% of Medicare reimbursement

70% of UCR after deductible; One baseline age 35 to 39; one per year ages 40 and older; benefit maximum not to exceed 130% of Medicare reimbursement

$15 copay per visit

$15 copay per visit

100%

Skilled Nursing Facility Care

80% of UCR after deductible; 120 visits per year maximum

90 % after deductible; 120 days per year maximum

70% of UCR after deductible; 120 days per year maximum

100% 30 days per stay

100% limited to 100 days per calendar year

100% limited to 100 days per calendar year

Home Health Care

80% of UCR after deductible; 120 visits per year maximum

90% after deductible; 120 visits per year maximum

70% of UCR after deductible; 120 visits per year maximum

100% 40 visits per year maximum

100% limited to 30 days per calendar year

100%

Please note: This chart has been prepared by The University of Akron to provide a very broad overview of the medical plan options currently available. Please refer to the specific plan materials provided in your benefits enrollment packet for more detailed information. Should any information differ between this sheet and the official plan documents, the plan documents shall prevail.

Hospice Care

80% of UCR after deductible; Unlimited for life expectancies of six months or less

90% after deductible; Unlimited for life expectancies of six months or less

70% of UCR after deductible; Unlimited for life expectancies of six months or less

100%; Unlimited for life expectancies of six months or less

100%

100%

Radiation  Therapy/

Chemotherapy

80% of UCR after deductible

90% after deductible

70% of UCR after deductible

100%

100%

100%

Ambulance

80% of UCR after deductible

90% after deductible

70% of UCR after deductible

100% if medically necessary

100%

100% with limitations

Durable Medical Equipment

80% of UCR after deductible

90% after deductible

70% of UCR after deductible

Varies – see materials

100%

100%

Therapy Services

80% of UCR after

deductible; 60 services per year maximum; includes outpatient cardiac rehabilitation, occupational, chiropractic, physical and speech therapy services

90% after deductible; 60 services per year

maximum; includes outpatient cardiac rehabilitation, occupational, chiropractic, physical and speech therapy services

70% of UCR after deductible; 60 services per year maximum; includes outpatient cardiac rehabilitation, occupational, chiropractic, physical and speech therapy services

100% Physical therapy; 30 visits maximum per year; Occupational therapy 15 visits maximum per year; Speech therapy 50 visits per lifetime

$15 copay; 30 days per calendar year maximum; includes physical, and occupational, speech; 36 visits per calendar year for   cardio/pulmonary therapy services

$15 copay; 30 visits or two months whichever is greater, per condition; includes physical, occupational, and speech therapy services

Allergy Testing

80% of UCR after deductible

90% after deductible

70% of UCR after deductible

$15 copay per visit

$15 copay per visit

100%

Private Duty Nursing

80% of UCR after deductible

90% after deductible

70% of UCR after deductible

Limitations – Contact HomeTown

Limitations – Contact SummaCare

Not Covered

Mental & Nervous

Inpatient

80% of UCR after

deductible; 30 days per year maximum

90% after deductible; 30 days per year maximum

70% of UCR after deductible; 30 days per year maximum

100% limit 60 days lifetime

100% limited to 21 days per calendar year

100% limited to 30 days per calendar year

Partial Hospitalization

80% of UCR after

deductible; 60 visits per year maximum

90% after deductible; 60 visits per year maximum

70% of UCR after deductible; 60 visits per year maximum

Not available under plan coverage

Not available under plan coverage

Not available under plan coverage

Outpatient

50% of UCR after deductible; 50 visits per year maximum

50 visits per year maximum covered in full less $15 copay visits 1-13; covered in full less

$30 copay visits 14-50

50% of UCR after deductible; 50 visits per year maximum

$15 copay per visit; 20 visit limit per calendar year

$20 copay per visit; 20 visit limit per calendar year

$15 copay per visit; 40 visit limit per calendar year

Substance Abuse

Inpatient

80% of UCR after

deductible; 30 days per year maximum

90% after deductible; 30 days per year maximum

70% of UCR after deductible; 30 days per year maximum

100% up to 8 days per lifetime

100% limited to 21 days per contract year

See Plan Materials

Partial Hospitalization

80% of UCR after

deductible; 60 visits per year maximum

90% after deductible; 60 visits per year maximum

70% of UCR after deductible; 60 visits per year maximum

Not available under plan coverage

Not available under plan coverage

Not available under plan coverage

Outpatient

50% of UCR after

deductible; 50 visits per year maximum;

limited to $1,000

50 visits per year maximum covered in full less $15 copay visits 1-13; covered in full less $30 copay visits 14-50

50% of UCR after deductible; 50 visits per year maximum

$15 copay per visit; 40 visits per lifetime  Intensive outpatient up to 20 days lifetime

$20 copay per visit; 20 visit limit per contract year

$15 copay

Deductibles & Coinsurance Limits

See Plan Materials

See Plan Materials

See Plan Materials

None / $1500 Single; $3000 Family

None/ NA

None/ Maximum 30% of total costs

Lifetime Benefit Maximum

Unlimited

Unlimited

Unlimited

Unlimited

Unlimited

Unlimited

Prescription Drugs

Retail
(30-day maximum supply)

10%, minimum $10 maximum $20 Generic; 20%, minimum $20 maximum $50 Brand

10%, minimum $10 maximum $20 Generic; 20%, minimum $20 maximum $50 Brand

10%, minimum $10 maximum $20 Generic; 20%, minimum $20 maximum $50 Brand

$10 Generic Formulary; $20 Brand Formulary; $50 Brand Non-Formulary

$10 Generic Formulary; $20 Brand Formulary; $40 Brand Non-Formulary

$10 Generic; $20 Brand Formulary

Mail order
(90-day maximum supply)

10%, minimum $25 maximum $50 Generic; 20%, minimum $50 maximum $100 Brand

10%, minimum $25 maximum $50 Generic; 20%, minimum $50 maximum $100 Brand

10%, minimum $25 maximum $50 Generic; 20%, minimum $50 maximum $100 Brand

$20 Generic Formulary; $40 Brand Formulary; $100 Brand Non-Formulary

$20 Generic Formulary; $40 Brand Formulary; $80 Brand Non-Formulary

$10 Generic; $20 Brand Formulary

(Note: 62 day supply maximum)

Please note: This chart has been prepared by The University of Akron to provide a very broad overview of the medical plan options currently available. Please refer to the specific plan materials provided in your benefits enrollment packet for more detailed information. Should any information differ between this sheet and the official plan documents, the plan documents shall prevail.