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Medical Mutual of Ohio - SuperMed One – SuperMed One Standard 2500 w/ Office Copay with Rx – OHIO
A comparison of the SuperMed One Standard 2500 w/ Office Copay with Rx offered by Medical Mutual of Ohio - SuperMed One is detailed out below for both Network and Non-Network coverage.
| Network | Non-Network | |
|---|---|---|
|
||
| Network | See Provider | See Provider |
| Application | SuperMed One Standard 2500 w/ Office Copay with Rx Application | SuperMed One Standard 2500 w/ Office Copay with Rx Application |
| Brochure | SuperMed One Standard 2500 w/ Office Copay with Rx Brochure | SuperMed One Standard 2500 w/ Office Copay with Rx Brochure |
| Copay | N/A | N/A |
| Office Visit | $25 Copay, then 100% | 50% after deductible |
| Deductible | Individual: $2,500, Family: $5,000 | Individual: $5,000, Family: $10,000 |
| Coinsurance | 80% | 50% |
| Coinsurance Limit | See OOP Maximum | See OOP Maximum |
| Out-of-Pocket Maximum | (Excluding the deductible) Single:$2,000 Family: $4,000 | (Excluding the deductible) Single: $4,000, Family: $8,000 |
| Lifetime Maximum | $7,500,000 | $7,500,000 |
| Prescription Drugs | Prescription Drug Lifetime Maximum: $2,500,000;Retail- 30 Day Supply: $15 Generic/$30 Formulary/$45 Non-Formulary;Home Delivery- 90 Day Supply: $30 Generic/$60 Formulary/$90 Non-Formulary | Prescription Drug Lifetime Maximum: $2,500,000;Retail- 30 Day Supply: $15 Generic/$30 Formulary/$45 Non-Formulary;Home Delivery- 90 Day Supply: $30 Generic/$60 Formulary/$90 Non-Formulary |
| Emergency Room | 80% after deductible | 80% after deductible (50% after deductible if it is a non-emergency) |
| Adult Preventative Care | 80% after deductible | $500 maximum per benefit period; 50% after deductible (Coinsurance does not apply) |
| Child Preventative Care | $500 maximum per benefit period; Well Child Exam: $25 Copay, then 100%; Well Child Immunizations and Labs: 80% after deductible | $500 maximum per benefit period; 50% after deductible (Coinsurance does not apply) |
| Lab / X-Ray | 80% after deductible | 50% after deductible |
| Maternity | Optional benefit | Optional benefit |
| Physical Therapy | 20 visits per benefit period, 80% after deductible | 20 visits per benefit period, 50% after deductible |
| Skilled Nursing | $10,000 maximum per benefit period, 80% after deductible | $10,000 maximum per benefit period, 50% after deductible |
| Home Health Care | 60 visits per benefit period, 80% after deductible | 60 visits per benefit period, 50% after deductible |
| Mental Health | Inpatient: 30 days per benefit period, 80% after deductible; Outpatient: 20 visits per benefit period, 50% after deductible | Inpatient: 30 days per benefit period, 50% after deductible; Outpatient: 20 visits per benefit period, 50% after deductible |
| Hospital Care | 80% after deductible | 50% after deductible |
| Optional Benefits | Maternity | Maternity |