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MEDICAL AND PHARMACY

MEDICAL AND PHARMACY

Medical Mutual of Ohio – Medical Plan Options

Choose from one of two medical plans to cover yourself and your dependents. Both plans are offered through Medical Mutual of Ohio and include prescription coverage.

Core HSA Plan

With this high-deductible plan, you will:

  • Enjoy lower per pay period premiums
  • Have preventive services covered at 100%
  • Be eligible for a Health Savings Account through OPTUM bank – tax-free deposits
  • *Note, HSA Plan has an Aggregate deductible: the total family deductible must be met before any individuals can begin receiving post-deductible benefits

Buy-Up Plan

With this traditional plan, you will:

  • Have a higher per pay period premiums
  • Enjoy the predictability of set copay amounts
  • Be subject to a lower deductible
  • Have preventive services covered 100%
  • Embedded deductible: individuals in a family work toward the individual deductible not to exceed the family deductible
 
Resources
Buy Up PPO Plan SBC
Core HSA Plan (Family) SBC
Core HSA Plan (Single) SBC
Medical Mutual Application
MedMutual Find a Provider and Cost Estimate
MedMutual Maturity App Flyer
MMO Enrollment Change Form EE plus Children Only OE
MMO Insurance Enrollment Change Form Spouse Application OE
MMO SWORD flyer
MMO SWORD poster
Express Scripts
Select Home Delivery Active Choice Flyer
Mail Order Infographic

Medical Plan Details

  Core HSA Plan
 Buy-up PPO Plan
  In-Network Out-of-Network In-Network Out-of-Network
Deductible – Single $2,500 $5,000 $1,000 $2,000
Deductible – Family $5,000 $10,000 $2,000 $4,000
Coinsurance 100% after deductible 70% after deductible 80% 60%
Coinsurance Limit Single $1,000 $2,000 $3,000 $6,000
Coinsurance Limit – Family $2,000 $4,000 $6,000 $12,000
Maximum
Out-of-Pocket – Single
(Deductible + Coinsurance +Copays)		 $3,500 $7,000 $6,350 $8,000
Maximum
Out-of-Pocket – Family
(Deductible + Coinsurance + Copays)		 $7,000 $14,000 $12,700 $16,000
Primary Care Visits 100% after deductible 70% after deductible $25 copay 60% after deductible
Preventive Care No Charge No Charge No Charge No Charge
Specialist Visits 100% after deductible 70% after deductible $50 copay 60% after deductible
Emergency Room 100% after deductible 70% after deductible $200 copay $200 copay
Urgent Care 100% after deductible 70% after deductible $75 copay 60% coinsurance
Rx Retail Copay
Generic $10 75% $10  75%
Formulary $30 75% $25  75%
Non-Formulary $50 75% $40  75%
Specialty 25% up to $250 maximum of available manufacturer-funded copay assistance 75% 25% up to $250 maximum after deductible or the max of any available manufacturer-funded copay assistance  75%
Rx Mail Order
Generic $10 You pay the entire amount at the Pharmacy and file a claim form with Medical Mutual. Medical Mutual will reimburse you based on the Allowed Amount of the Prescription Drug, minus the Prescription Drug Copayment or Coinsurance, as indicated. You may be responsible for any amount in excess of the Prescription Drug Covered Charges. If the Prescription Drug is not available from a Network Pharmacy, you will not be subject to this reduced reimbursement. $10 You pay the entire amount at the Pharmacy and file a claim form with Medical Mutual. Medical Mutual will reimburse you based on the Allowed Amount of the Prescription Drug, minus the Prescription Drug Copayment or Coinsurance, as indicated. You may be responsible for any amount in excess of the Prescription Drug Covered Charges. If the Prescription Drug is not available from a Network Pharmacy, you will not be subject to this reduced reimbursement.
Formulary $75 $65
Non-Formulary $150 $120
Specialty 25% up to $250 maximum of any available manufacturer-funded copay assistance 25% up to $250 maximum after deductible or the max of any available manufacturer-funded copay assistance

*For Out-of-Network Benefits please refer to the Summary of Benefits* 

Employee Cost Per Pay Deduction

  Core HSA Plan
 Buy-up PPO Plan
  Full Time
Employees		 Part Time
Employees		 Full Time
Employees		 Part Time
Employees
Employee $0.00 $0.00 $158.61 $158.61
Employee + Spouse $0.00 $175.03 $331.97 $507.00
Employee + Child(ren) $0.00 $149.99 $278.46 $428.45
Employee + Spouse + Child(ren) $0.00 $250.95 $471.66 $722.61