MEDICAL

$3,000 Deductible PPO Plan

All covered expenses (except preventive care), including prescription drugs, are first applied to the deductible before Medical Mutual will start to pay.

Preventive Care (according to appropriate age and gender guidelines) covered at 100%

Charges for Non-emergency services in the Emergency Room are not covered

$2,800 Deductible HSA Plan

This High Deductible Health Plan (HDHP) qualifies for participation in a Health Savings Account (HSA). These tax advantaged accounts can be used to pay for qualified medical expenses as defined by the IRS.

All covered expenses (except preventive care), including prescription drugs, are first applied to the deductible before Medical Mutual will start to pay. Once you have met the deductible under the plan, prescription copays will apply.

The company will contribute $300 for singles and $600 for family to your HSA account. Contributions will be distributed every 6 months.

Preventive Care (according to appropriate age and gender guidelines) is covered at 100%.

Charges for Non-emergency services in the Emergency Room are not covered

www.medmutual.com

800-382-5729

Resources

3000 PPO SBC

2800 HSA SBC

MMO My Care Compare

MMO NurseLine

MMO Online Tools

MMO QuitLine

MMO Telehealth

MMO Telemedicine Express Care Online

MMO Weight Watchers

MMO Chronic Condition Management

MMO Fitness Discounts

$3,000 Deductible PPO Plan

	In-Network	Out-of-Network
Deductible	$3,000/$6,000	$5,000/$10,000
Maximum Out-of-Pocket	$6,350 / $12,700	$10,000 / $20,000
Primary Care Visits	40% after deductible	50% after deductible
Preventive Care	100%	50% after deductible
Specialist Visits	40% after deductible	50% after deductible
Emergency Room	40% after deductible	40% after deductible
Urgent Care	40% after deductible	50% after deductible
Rx Retail Copays
Generic	40% after deductible	Not Covered
Preferred Brand	40% after deductible	Not Covered
Non-Preferred Brand	40% after deductible	Not Covered
Rx Mail Order
Generic	40% after deductible	Not Covered
Preferred Brand	40% after deductible	Not Covered
Non-Preferred Brand	40% after deductible	Not Covered

Employee Level	Bi-Weekly Rate
Employee	$59.39
Employee + Spouse	$153.09
Employee + Child(ren)	$130.17
Family	$164.61

$2,800 Deductible HSA Plan

	In-Network	Out-of-Network
Deductible	$2,800/ $5,600	$5,000/$10,000
Maximum Out-of-Pocket	$3,800 / $7,600	$10,000 / $20,000
Primary Care Visits	0% after deductible	30% after deductible
Preventive Care	100%	30% after deductible
Specialist Visits	0% after deductible	30% after deductible
Emergency Room	0% after deductible	0% after deductible
Urgent Care	0% after deductible	30% after deductible
Rx Retail Copays
Generic	$10 copay after deductible	Not Covered
Preferred Brand	$30 copay after deductible	Not Covered
Non-Preferred Brand	$50 copay after deductible	Not Covered
Specialty	25% up to $150 after deductible	Not Covered
Rx Mail Order
Generic	$10 copay after deductible	Not Covered
Preferred Brand	$75 copay after deductible	Not Covered
Non-Preferred Brand	$150 copay after deductible	Not Covered

Employee Level	Bi-Weekly Rate
Employee	$70.13
Employee + Spouse	$177.44
Employee + Child(ren)	$153.95
Family	$194.68

As a plan member, you have access to many consumer education tools and programs designed to help you manage you and your dependents’ medical care 24 hours a day, 7 days a week. You can log into www.medmutual.com and tour the site. Once enrolled you may register for your individual login and password and take advantage of even more tools.