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MedMutual

Market HMO 2500 - Adena

Plan Overview

Medical Deductable
  • Individual: $2,500
  • Family: $5,000
  • Per Person: $2,500
Prescription Drug Deductible
  • Individual: $0
  • Family: $0
  • Per Person: $0
Combined Medical and Drug Out of Pocket Maximum
  • Individual: $5,750
  • Family: $11,500
  • Per Person: $5,750

Office Visit

Primary Doctor
  • CoPay: $25.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: On Demand Telemedicine: 0% after $0 Copay
Specialist
  • CoPay: $50.00
  • CoInsurance: Not Applicable
  • Covered: Covered

Prescription Drug Information

Preferred Brand Drugs
  • CoPay: $40.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: Preferred Brand-name drugs, your second cost-share tier, are included in Medical Mutual's formulary and are typically less expensive than similar Non-preferred Brand-name drugs. They are safe, effective alternatives to other brand-name drugs that may cost more. If you fill a Preferred Brand-name drug at an out-of-network pharmacy, you must pay the entire amount and file a claim form with Medical Mutual.
Non Preferred Brand Drugs
  • CoPay: Not Applicable
  • CoInsurance: 50.00%
  • Covered: Covered
  • Benefit Explanation: Non-preferred Brand-name drugs, your third cost-share tier, are included in Medical Mutual’s formulary but are typically more expensive than similar Preferred Brand-name drugs. If you fill a Non-preferred Brand-name drug at an out-of-network pharmacy, you must pay the entire amount and file a claim form with Medical Mutual.
Generic Drugs
  • CoPay: $0.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: Tier 1 Generics include only the drugs listed on the Medical Mutual Standard Plus Preventive Medications List. Tier 2 Generics are all other generic medications listed on Comprehensive High Performance Plus Formulary under Tier 1. To view the Standard Plus Preventive Medications list, visit https://www.MedMutual.com/StandardPlus. Generic drugs are copies of brand-name drugs that contain the same active ingredients but are usually less expensive. They also must meet the same strict U.S. Food and Drug Administration (FDA) standards for quality, strength and purity. If you fill a Generic drug at an out-of-network pharmacy, you must pay the entire amount and file a claim form with Medical Mutual.
Specialty Drugs
  • CoPay: Not Applicable
  • CoInsurance: 50.00%
  • Covered: Covered
  • Benefit Explanation: Specialty drugs must be obtained through a contracted specialty pharmacy, and are limited to a 30-day supply.

Inpatient Coverage

Hospital Services
  • CoPay: Not Applicable
  • CoInsurance: 25.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: Limited to a combined 60 days per Benefit Period maximum for both Inpatient and outpatient day rehabilitation therapy services.
Inpatient Services
  • CoPay: Not Applicable
  • CoInsurance: 25.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: One (1) Inpatient visit per day per Physican or other Professional Provider

Emergency and Urgent Care

Emergency Room
  • CoPay: $250.00
  • CoInsurance: Not Applicable
  • Covered: Covered
Urgent Care Facility
  • CoPay: $60.00
  • CoInsurance: Not Applicable
  • Covered: Covered

Maternity

Labor and Delivery Hospital Stay
  • CoPay: Not Applicable
  • CoInsurance: 25.00% Coinsurance after deductible
  • Covered: Covered
Pre and Postnatal Office Visit
  • CoPay: Not Applicable
  • CoInsurance: 25.00% Coinsurance after deductible
  • Covered: Covered

Vision

Routine Eye Exams For Children
  • CoPay: Not Applicable
  • CoInsurance: No Charge
  • Covered: Covered
  • Benefit Explanation: Preventive services only.  See plan certificate for more information.

Major Dental Care

Routine Dental Checkups for Children
  • CoPay: Not Applicable
  • CoInsurance: No Charge
  • Covered: Covered
  • Limit Quantity: 2
  • Limit Unit : Exam(s) per Benefit Period
Routine Dental Checkups for Adults
  • Covered: Not Covered
Basic Dental Care - Adult
  • Covered: Not Covered
Basic Dental Care - Child
  • CoPay: Not Applicable
  • CoInsurance: No Charge
  • Covered: Covered
Major Dental Care - Adult
  • Covered: Not Covered
Major Dental Care - Child
  • CoPay: Not Applicable
  • CoInsurance: No Charge
  • Covered: Covered
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