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.
1-817-813-4562, TTY 711
