• No pre-existing condition limitation

• Minimum essential coverage (MEC)

Coverage under this plan qualifies as minimum essential coverage. Please visit the Internal Revenue Service (IRS) website at www.irs.gov/uac/Questions-and-Answers-on-the-Individual-Shared-Responsibility-Provision for more information on the individual requirement for MEC.

• Minimum value standard

• Where you can get information about enrolling in the FEHB Program

See www.opm.gov/healthcare-insurance for enrollment information as well as:

• Information on the FEHB Program and plans available to you
• A health plan comparison tool
• A list of agencies that participate in Employee Express
• A link to Employee Express
• Information on and links to other electronic enrollment systems

Also, your employing or retirement office can answer your questions, and give you brochures for other plans, and other materials you need to make an informed decision about your FEHB coverage. These materials tell you:

• When you may change your enrollment
• How you can cover your family members
• What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire
• What happens when your enrollment ends
• When the next Open Season for enrollment begins

We don’t determine who is eligible for coverage and, in most cases, cannot change your enrollment status without information from your employing or retirement office. For information on your premium deductions, you must also contact your employing or retirement office.

• Types of coverage available for you and your family

Self Only coverage is for you alone. Self Plus One coverage is an enrollment that covers you and one eligible family member. Self and Family coverage is for you, and one eligible family member, or your spouse, and your dependent children under age 26, including any foster children authorized for coverage by your employing agency or retirement office. Under certain circumstances, you may also continue coverage for a disabled child 26 years of age or older who is incapable of self-support.

If you have a Self Only enrollment, you may change to a Self Plus One or Self and Family enrollment if you marry, give birth, or add a child to your family. You may change your enrollment 31 days before to 60 days after that event. The Self Plus one or Self and Family enrollment begins on the first day of the pay period in which the child is born or becomes an eligible family member. When you change to Self Plus One or Self and Family because you marry, the change is effective on the first day of the pay period that begins after your employing office receives your enrollment form.  Benefits will not be available to your spouse until you are married.  A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee’s FEHB enrollment.

Your employing or retirement office will not notify you when a family member is no longer eligible to receive benefits, however, we will send you a letter notifying you when a dependent reaches the age limit. Please tell us immediately of changes in family member status, including your marriage, divorce, annulment, or when your child reaches age 26.

If you or one of your family members is enrolled in one FEHB plan, you or they cannot be enrolled in or covered as a family member by another enrollee in another FEHB plan.

If you have a qualifying life event (QLE) - such as marriage, divorce, or the birth of a child - outside of the Federal Benefits Open Season, you may be eligible to enroll in the FEHB Program, change your enrollment, or cancel coverage.  For a complete list of QLEs, visit the FEHB website at www.opm.gov/healthcare-insurance/life-events.  If you need assistance, please contact your employing agency, Tribal Benefits Officer, personnel/payroll office, or retirement office.

• Family member coverage

Family members covered under your Self and Family enrollment are your spouse (including a valid common law marriage) and children as described in the chart below.  A Self Plus One enrollment covers you and your spouse, or one other eligible family member as described in the chart below.

Newborns of covered children are insured only for the routine nursery care during the covered portion of the mother's maternity stay.

You can find additional information at www.opm.gov/healthcare-insurance. 

• Children’s Equity Act

OPM has implemented the Federal Employees Health Benefits Children’s Equity Act of 2000. This law mandates that you be enrolled for Self Plus One or Self and Family coverage in the FEHB Program, if you are an employee subject to a court or administrative order requiring you to provide health benefits for your child(ren).

If this law applies to you, you must enroll in Self Plus One or Self and Family coverage in a health plan that provides full benefits in the area where your children live or provide documentation to your employing office that you have obtained other health benefits coverage for your children. If you do not do so, your employing office will enroll you involuntarily as follows:

• If you have no FEHB coverage, your employing office will enroll you for Self Plus One or Self and Family coverage, as appropriate, in the lowest-cost nationwide plan option as determined by OPM.
• If you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves the area where your children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate, in the same option of the same plan; or
• If you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate, in the lowest-cost nationwide plan option as determined by OPM.

As long as the court/administrative order is in effect, and you have at least one child identified in the order who is still eligible under the FEHB Program, you cannot cancel your enrollment, change to Self Only, or change to a plan that does not serve the area in which your children live, unless you provide documentation that you have other coverage for the children.

If the court/administrative order is still in effect when you retire, and you have at least one child still eligible for FEHB coverage, you must continue your FEHB coverage into retirement (if eligible) and cannot cancel your coverage, change to Self Only, or change to a plan that does not serve the area in which your children live as long as the court/administrative order is in effect.  Similarly, you cannot change to Self Plus One if the court/administrative order identifies more than one child.  Contact your employing office for further information.

• When benefits and premiums start

The benefits in this brochure are effective January 1. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. If you changed plans or plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims will be processed according to the 2021 benefits of your prior plan or option.  If you have met (or pay cost-sharing that results in your meeting) the out-of-pocket maximum under the prior plan or option, you will not pay cost-sharing for services covered between January 1 and the effective date of coverage under your new plan or option.  However, if your prior plan left the FEHB Program at the end of the year, you are covered under that plan’s 2020 benefits until the effective date of your coverage with your new plan. Annuitants’ coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the effective date of coverage.

If your enrollment continues after you are no longer eligible for coverage, (i.e. you have separated from Federal service) and premiums are not paid, you will be responsible for all benefits paid during the period in which premiums were not paid. You may be billed for services received directly from your provider. You may be prosecuted for fraud for knowingly using health insurance benefits for which you have not paid premiums. It is your responsibility to know when you, or a family member, are no longer eligible to use your health insurance coverage.

• When you retire

When you retire, you can usually stay in the FEHB Program. Generally, you must have been enrolled in the FEHB Program for the last five years of your Federal service. If you do not meet this requirement, you may be eligible for other forms of coverage, such as Temporary Continuation of Coverage (TCC).

• When FEHB coverage ends

You will receive an additional 31 days of coverage, for no additional premium, when:

• Your enrollment ends, unless you cancel your enrollment, or
• You are a family member no longer eligible for coverage.

Any person covered under the 31 day extension of coverage who is confined in a hospital or other institution for care or treatment on the 31st day of the temporary extension is entitled to continuation of the benefits of the Plan during the continuance of the confinement but not beyond the 60th day after the end of the 31 day temporary extension.

You may be eligible for spouse equity coverage or assistance with enrolling in a conversion policy (a non-FEHB individual policy).

• Upon divorce

If you are divorced from a Federal employee, or annuitant, you may not continue to get benefits under your former spouse’s enrollment. This is the case even when the court has ordered your former spouse to provide health coverage for you. However, you may be eligible for your own FEHB coverage under either the spouse equity law or Temporary Continuation of Coverage (TCC). If you are recently divorced or are anticipating a divorce, contact your ex-spouse’s employing or retirement office to get additional information about your coverage choices. You can also visit OPM's website at www.opm.gov/healthcare-insurance/healthcare/plan-information/.  A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee’s FEHB enrollment.

• Temporary Continuation of Coverage (TCC)

If you leave Federal service, Tribal employment, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC).  The Affordable Care Act (ACA) did not eliminate TCC or change the TCC rule.   For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire, if you lose your Federal or Tribal job, if you are a covered dependent child and you turn 26, etc.

You may not elect TCC if you are fired from your Federal or Tribal job due to gross misconduct.

Enrolling in TCC. Get the RI 79-27, which describes TCC, from your employing or retirement office or from www.opm.gov/healthcare-insurance. It explains what you have to do to enroll.

Alternatively, you can buy coverage through the Health Insurance Marketplace where, depending on your income, you could be eligible for a new kind of tax credit that lowers your monthly premiums.  Visit www.HealthCare.gov to compare plans and see what your premium, deductible, and out-of-pocket costs would be before you make a decision to enroll.  Finally, if you qualify for coverage under another group health plan ( such as your spouse's plan) you may be able to enroll in that plan, as long as you apply within 30 days of losing FEHB Program coverage.

• Converting to individual coverage

If you leave Federal or Tribal service, your employing office will notify you of your right to convert.  You must contact us in writing within 31 days after you receive this notice.  However, if you are a family member who is losing coverage, the employing or retirement office will not notify you.  You must contact us in writing within 31 days after you are no longer eligible for coverage.

Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, a waiting period will not be imposed and your coverage will not be limited due to pre-existing conditions.  When you contact us, we will assist you in obtaining information about health benefits coverage inside or outside the Affordable Care Act's Health Insurance Marketplace in your state.  For assistance in finding coverage, please contact us at 800-315-3144 or visit our website at www.medmutual.com/feds. 

• Health Insurance Marketplace

If you would like to purchase health insurance through the ACA’s Health Insurance Marketplace, please visit www.HealthCare.gov. This is a website provided by the U.S. Department of Health and Human Services that provides up-to-date information on the Marketplace.

Identification cards

We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan provider, or fill a prescription at a Plan pharmacy. Providers may request photo identification together with your ID card to verify identity. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation letter (for annuitants), or your electronic enrollment system (such as Employee Express) confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call Customer Care at 800-315-3144 (TTY: 711) or write to us at: Customer Care, Medical Mutual of Ohio, PO Box 6018, Cleveland, OH 44101-1018. After registering on our Website at www.MedMutual.com/feds, you may also request replacement cards electronically.

Where you get covered care

You get care from “Plan providers” and “Plan facilities.”  You will only pay cost-sharing as defined in Section 10, Definitions of terms we use in this brochure.

Plan providers

Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members. We contract with the MedFlex provider network to provide or arrange covered services for our members. Medical care is provided through physicians, nurse practitioners, physician assistants, and other skilled medical personnel. Specialists in most major specialties are available as part of the medical teams for consultation and treatment. Other necessary medical care, such as physical therapy, laboratory and X-ray services, is also available. We credential Plan providers according to national standards.

We list Plan providers in the Provider Directory, which we update periodically. Directories are available at the time of enrollment or upon request by calling Customer Care at 800-315-3144 (TTY: 711). The list is also on our Website at www.medmutual.com/About-Medical-Mutual/Find-a-Doctor.aspx.

Plan facilities

Plan facilities are hospitals, and other facilities in our service area that we contract with to provide covered services to our members. 

We list Plan facilities in our Provider Directory, with their locations and phone numbers. Directories are updated on a regular basis and are available at the time of enrollment or upon request by calling Customer Care at 800-315-3144  (TTY:711). The list is also on our Website at www.medmutual.com/About-Medical-Mutual/Find-a-Doctor.aspx.

What you must do to get covered care

It depends on the type of care you need. First, you and each covered family member should choose a primary care physician. This decision is important since your primary care physician provides or arranges for most of your health care.

To choose or change your primary care physician, you can either select one from our Provider Directory, from our Website, www.medmutual.com/About-Medical-Mutual/Find-a-Doctor.aspx, or you can call Customer Care at 800-315-3144  (TTY: 711).

• Primary care

We encourage you to choose a primary care physician when you enroll. You may choose any primary care Plan physician who is available to accept you. Parents may choose a pediatrician as the Plan physician for their child. Your primary care physician will provide most of your health care, or give you a referral to see a specialist.

Please notify us of the primary care physician you choose. If you need help choosing a primary care physician, call us. You may change your primary care physician at any time. You are free to see other Plan physicians if your primary care physician is not available, and to receive care at other MedFlex facilities.

Specialty care

Here are some other things you should know about specialty care:

Specialty care is care you receive from providers other than a primary care physician. You may pay different cost-sharing for your specialty care. A referral is not required to see a specialist that is participating in your network. You may make appointments directly with these providers.

You generally must receive your care from a participating Network provider. However, if your Network provider determines that covered services are not available from participating In Network providers, he or she will need to obtain authorization in advance for a referral, you may seek the initial consultation from the specialist to whom you are referred. You must then return to your Network physician after the consultation, unless your referral authorizes a certain number of additional visits without the need to obtain another referral. In order to receive covered follow up care from an Out of Network specialist, the provider must first obtain authorization from us. Do not go to an Out of Network provider for return visits until you have received written authorization from us for additional services. Services, drugs and supplies related to a covered abortion (see Section 6. General exclusions - services, drugs and supplies we do not cover), are covered. Please contact Medical Mutual for information on how to access this coverage including claims related issues at 800-315-3144.

• If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will decide what treatment you need. If he or she decides to refer you to a specialist, ask if you can see your current specialist. If your current specialist does not participate with us, you must receive treatment from a specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.
• If you are seeing a specialist and your specialist leaves the Plan, call your primary care physician, who will work with you to identify another specialist for you to see.
• If you have a chronic and disabling condition and lose access to your specialist because we:

- terminate our contract with your specialist for a reason other than cause;

- drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB plan; or

- reduce our service area and you enroll in another FEHB plan you may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us, or if we drop out of the Program, contact your new plan.

If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist until the end of your postpartum care, even if it is beyond the 90 days.

Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or other type of facility.

• If you are hospitalized when your enrollment begins

We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan begins, call Customer Care immediately at 800-315-3144  (TTY: 711). If you are new to the FEHB Program, we will arrange for you to receive care and provide benefits for your covered services while you are in the hospital beginning on the effective date of your coverage.

If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

• you are discharged, not merely moved to an alternative care center;
• the day your benefits from your former plan run out; or
• the 92^nd day after you become a member of this Plan, whichever happens first.

These provisions apply only to the benefits of the hospitalized person. If your plan terminates participation in the FEHB Program in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply. In such cases, the hospitalized family member’s benefits under the new plan begin on the effective date of enrollment.

For certain services your Plan provider must obtain approval from us. Before giving approval, we may consider if the service or item is medically necessary and meets other coverage requirements. We call this review and approval process “precertification.”

Your Plan provider must obtain precertification for:

• Inpatient hospital care services, surgery and procedures
• Certain Outpatient surgeries, call customer service for information 
• Non-emergency Ambulance transport, including air ambulance
• Bariatric surgery and related services
• Chemotherapy
• Clinical trials
• Cosmetic, reconstructive and plastic surgery
• Durable medical equipment (DME) and orthopedic and prosthetic devices
• Home health services
• Inpatient services for behavioral health and alcohol and chemical dependency
• Injections/infusions
• Organ/tissue transplants and related services 
• Skilled Nursing Facility 
• Hyperbaric oxygen  
• Dental Related Procedures due to accident or injury
• Genetic Testing (including but not limited to BRCA1 and BRCA2)
• Services or items from a non-Plan Provider or at non-Plan facilities

When you receive medical services for which you do not have precertification or that you receive from non-Plan providers or from non-Plan facilities that have not been referred by a Plan provider and approved by us, we will not pay for them except in an emergency. Charges for these medical services will be your financial responsibility.

To confirm if your service or item requires precertification, please call Customer Care at 800-315-3144  (TTY: 711).

Your Plan provider submits the request for the services above with supporting documentation. You should call your Plan provider’s office if you have not been notified of the outcome of the review within 5 working days. If your request is not approved, you have the right to ask us in writing to reconsider our initial decision (see Section 8,The disputed claims process).

Precertification determinations are made based on the information available at the time the service or item is requested. We will not cover the service or item unless you are a Plan member on the date you receive the service or item.

Inpatient Hospital Admission

Precertification is the process by which - prior to your inpatient hospital admission - we evaluate the medical necessity of your proposed stay and the number of days required to treat your condition.

First, your physician, your hospital, you, or your representative, must call us at 800-315-3144 before admission or services requiring prior authorization are rendered.

Next, provide the following information:

• enrollee's name and Plan identification number;
• patient's name, birth date, identification number and phone number;
• reason for hospitalization, proposed treatment or surgery;
• name and phone number of admitting physician;
• name of hospital or facility; and
• number of days requested for hospital stay.

Non-urgent care claims

For non-urgent care claims, we will tell the physician and/or hospital the number of approved inpatient days, or the care that we approve for other services that must have prior authorization. We will make our decision within 15 days of receipt of the pre-service claim. If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you of the need for an extension of time before the end of the original 15-day period. Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.

If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information.

Urgent care claims

If you have an urgent care claim (i.e., when waiting for the regular time limit for your medical care or treatment could seriously jeopardize your life, health, or ability to regain maximum function, or in the opinion of a physician with knowledge of your medical condition, would subject you to severe pain that cannot be adequately managed without this care or treatment), we will expedite our review and notify you of our decision within 72 hours. If you request that we review your claim as an urgent care claim, we will review the documentation you provide and decide whether or not it is an urgent care claim by applying the judgment of a prudent layperson that possesses an average knowledge of health and medicine.

If you fail to provide sufficient information, we will contact you within 24 hours after we receive the claim to  let you know what information we need to complete our review of the claim. You will then have up to 48 hours to provide the required information. We will make our decision on the claim within 48 hours of (1) the time we received the additional information or (2) the end of the time frame, whichever is earlier.

We may provide our decision orally within these time frames, but we will follow up with written or electronic notification within three days of oral notification.

You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM.  Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us at  800-315-3144 (TTY: 711).  You may also call OPM's Health Insurance  at 202 606-0755 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review.  We will cooperate with OPM so they can quickly review your claim on appeal.  In addition, if you did not indicate that your claim was a claim for urgent care, call us at 800-315-3144 (TTY: 711).  If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim).

• Concurrent care claims

A concurrent care claim involves care provided over a period of time or over a number of treatments. We will treat any reduction or termination of our pre-approved course of treatment before the end of the approved period of  time or number of treatments as an appealable decision. This does not include reduction or termination due to benefit changes or if your enrollment ends. If we believe a reduction or termination is warranted, we will allow you sufficient time to appeal and obtain a decision from us before the reduction or termination takes effect.

If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, then we will make a decision within 24 hours after we receive the claim.

The Federal Flexible Spending Account Program –FSAFEDS

• Health Care FSA (HCFSA)–Reimburses you for eligible out-of-pocket health care expenses (such as copayments, deductibles, physician prescribedover-the-counter drugs and medications, vision and dental expenses, and much more) for you and your tax dependents, including adult children(through the end of the calendar year in which they turn 26).
• FSAFEDS offers paperless reimbursement for your HCFSA through a number of FEHB and FEDVIP plans. This means that when you or your provider files claims with your FEHB or FEDVIP plan, FSAFEDS will automatically reimburse your eligible out-of-pocket expenses based on the claim information it receives from your plan.

Emergency services do not require precertification. However, if you are admitted to a non-Plan facility, you or your family member must notify the Plan as soon as reasonably possible, or your claims may be denied.

You must obtain precertification from us for post-stabilization care you receive from non-Plan providers.

See Section 5(d), Emergency services/accidents for more information.

If your treatment needs to be extended

If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, then we will make a decision within 24 hours after we receive the claim.

Under extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case, we will make all reasonable efforts to provide you with the necessary care.

If you have a pre-service claim and you do not agree with our prior approval decision, you may request a review in accord with the procedures detailed below.

If you have already received the service, supply, or treatment, then you have a post-service claim and must follow the entire disputed claims process detailed in Section 8.

To reconsider a non-urgent care claim

Within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision. Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure.

In the case of a pre-service claim and subject to a request for additional information, we have 30 days from the date we receive your written request for reconsideration to do one of the following:

1. Precertify your hospital stay or, if applicable, arrange for the health care provider to give you the care or grant your request for prior approval for a service, drug, or supply.

2. Ask you or your provider for more information.

You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days.

If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due. We will base our decision on the information we already have. We will write to you with our decision.

3. Write to you and maintain our denial.

In the case of an appeal of a pre-service urgent care claim, within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision. Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure.

Unless we request additional information, we will notify you of our decision within 72 hours after receipt of your reconsideration request. We will expedite the review process, which allows oral or written request for appeals and the exchange of information by telephone, electronic mail, facsimile, or other expeditious methods.

After we reconsider your pre-service claim, if you do not agree with our decision, you may ask OPM to review it by following Step 3 of the disputed claims process detailed in Section 8 of this brochure.

Copayments

A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive certain services. The amount of copayment will depend upon whether you are enrolled in the Standard or Basic Option, the type of provider, and the service or supply that you receive.

You pay a primary care provider copayment when you visit any primary care provider as described in Section 3, How you get care. You pay a specialist copayment when you receive care from a specialist as described in Section 3.

For example, for diagnostic and treatment services as described in Section 5(a):

• Under the Standard Option, you pay a $25 copayment when you receive diagnostic and treatment services from a primary care provider and a $45 coppayment when you receive these services from a specialty care provider.
• Under the Basic Option, you pay a $30 copayment when you receive diagnostic and treatment services from a primary care provider and a $60 copayment when you receive these services from a specialty care provider.

Deductible

A deductible is a fixed expense you must incur for certain covered services and supplies before we start paying benefits for them.  Copayments do not count toward any deductible.

• We do not have a calendar year deductible for the Standard Option.
• The Basic Option calendar year deductible is $750 per person.  Under a Self Only enrollment, the deductible is considered satisfied and benefits are payable for you when your covered expenses applied to the calendar year deductible for your enrollment reach $750 under Basic Option.  Under a Self Plus One enrollment, the deductible is considered satisfied and benefits are payable for you and one other eligible family member when the combined covered expenses applied to the calendar year deductible for your enrollment reach $1,500 under Basic Option.  Under a Self and Family enrollment, the deductible is considered satisfied and benefits are payable for all family members when the combined covered expenses applied to the calendar year deductible for family members reach $1,500 under Basic Option.
• Financial assistance programs also known as “Patient Assistance Programs,” “Fee Forgiveness,” “Not Out-of-Pocket,” “Manufacturers Coupons,”, “Discount programs,” for Specialty Drugs will not count towards the member’s out-of-pocket maximum or deductible, if you have one. (See page 62)

Coinsurance

Coinsurance is the percentage of our allowance that you must pay for certain services you receive.  Coinsurance does not begin until you have met your calendar year deductible.

Example: In our Plan, you pay 30% of our allowance for infertility services.

Your catastrophic protection out-of-pocket maximum

After your out-of-pocket expenses, including any applicable deductible, copayments and coinsurance total $6,000 for Self Only, or $12,000 for Self Plus One or Self and Family enrollment (for the Standard Option) or $6,500 for Self Only, or $13,000 for Self Plus One or Self and Family enrollment (for the Basic Option) in any calendar year, you do not have to pay any more for certain covered services. The maximum annual limitations on cost sharing listed under Self Only of $6,000 applies to each individual, regardless of whether the individual is enrolled in a Self Only, Self Plus One or a Self and Family.

Example Scenario (Standard Option): Your plan has a $6,000 Self Only Maximum out-of-pocket limit and a $12,000 Self Plus One or Self and Family maximum out-of-pocket limit.  If you or one of your eligible family members has out-of-pocket qualified medical expenses of $6,000 or more for the calendar year, any remaining qualified medical expenses for that individual will be covered fully by your health plan.  With a Self and Family or Self Plus One enrollment out-of-pocket maximum of $12,000, a second family member, or an aggregate of other eligible family members, will continue to accrue out-of-pocket qualified medical expenses up to a maximum of $12,000 for the calendar year before their qualified medical expenses will begin to be covered in full.

Be sure to keep accurate records and receipts of your copayments and coinsurance to ensure the plan's calculation of your out-of-pocket maximum is reflected accurately.

Carryover

If you changed to this Plan during Open Season from a plan with a catastrophic protection benefit and the effective date of the change was after January 1, any expenses that would have applied to that plan’s catastrophic protection benefit during the prior year will be covered by your prior plan if they are for care you received in January before your effective date of coverage in this Plan. If you have already met your prior plan’s catastrophic protection benefit level in full, it will continue to apply until the effective date of your coverage in this Plan. If you have not met this expense level in full, your prior plan will first apply your covered out-of-pocket expenses until the prior year’s catastrophic level is reached and then apply the catastrophic protection benefit to covered out-of-pocket expenses incurred from that point until the effective date of your coverage in this Plan. Your prior plan will pay these covered expenses according to this year’s benefits; benefit changes are effective January 1.

Note: If you change options in this Plan during the year, we will credit the amount of covered expenses already accumulated toward the catastrophic out-of-pocket limit of your old option to the catastrophic protection limit of your new option.

When Government facilities bill us

Facilities of the Department of Veterans Affairs, the Department of Defense and the Indian Health Services are entitled to seek reimbursement from us for certain services and supplies they provide to you or a family member. They may not seek more than their governing laws allow. You may be responsible to pay for certain services and charges.  Contact the government facility directly for more information.

Medical, hospital and drug benefits

In most cases, providers and facilities file claims for you. Providers must file on the form CMS-1500, Health Insurance Claim Form. Your facility will file on the UB-04 form. For claims questions and assistance, call us at 800-315-3144 (TTY :711) or visit or website at https://MedMutual.com/feds.

When you must file a claim – such as for services you received outside of the Plan’s service area – submit it on the CMS-1500 or an invoice or billing statement from the provider that includes the information shown below. Bills and receipts should be itemized and show:

• Covered member’s name, date of birth, address, phone number and ID number
• Name and address of the provider or facility that provided the service or supply
• Dates you received the services or supplies
• Diagnosis
• Type of each service or supply
• The charge for each service or supply
• Follow up services rendered out-of-area
• A copy of the explanation of benefits, payments, or denial from any primary payor – such as the Medicare Summary Notice (MSN)
• Receipts, if you paid for your services

Note: Canceled checks, cash register receipts, or balance due statements are not acceptable substitutes for itemized bills.

Submit your claims to:

Claims Administration
Medical Mutual of Ohio
PO Box 6018
Cleveland, OH 44101-1018

If your pharmacy will not file your prescription claim electronically, you can complete and submit a Prescription Drug Claim Form.  To get a claim form, log in to My Health Plan at medmutual.com/member and select Resources & Tools, then Forms.  You can also call Customer care at the number on your member ID card and ask for a form to be mailed to you.  Please follow the instructions on the form.  Your must submit receipts/labels when sending in a claim.  Your pharmacist at the pharmacy where you filled the prescription can help you fill out information.  A separate claim form must be submitted for each person or pharmacy.  After completing the form, send it to the address on the form: Express Scripts Inc.; P.O. Box 14711; Lexington, KY 40512.

Send us all of the documents for your claim as soon as possible. You must submit the claim by December 31 of the year after the year you received the service, unless timely filing was prevented by administrative operations of Government or legal incapacity, provided the claim was submitted as soon as reasonably possible.

We will notify you of our decision within 30 days after we receive your post-service claim. If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you before the expiration of the original 30-day period. Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.

If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information.

If you do not agree with our initial decision, you may ask us to review it by following the disputed claims process detailed in Section 8 of this brochure.

If you live in a county where at least 10 percent of the population is literate only in a non-English language (as determined by the Secretary of Health and Human Services), we will provide language assistance in that non-English language. You can request a copy of your Explanation of Benefits (EOB) statement, related correspondence, oral language services (such as telephone customer assistance), and help with filing claims and appeals (including external reviews) in the applicable non-English language. The English versions of your EOBs and related correspondence will include information in the non-English language about how to access language services in that non-English language.

Any notice of an adverse benefit determination or correspondence from us confirming an adverse benefit determination will include information sufficient to identify the claim involved (including the date of service, the health care provider, and the claim amount, if applicable), and a statement describing the availability, upon request, of the diagnosis and procedure codes.

1

Ask us in writing to reconsider our initial decision. You must:

a) Write to us within 6 months from the date of our decision; and

b) Send your request to us at: Member Appeal, Medical Mutual, 01-4B-4809, P.O. Box 94580, Cleveland, OH 44101-4580; and

c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and

d) Include copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms.

We will provide you, free of charge and in a timely manner, with any new or additional evidence considered, relied upon, or generated by us or at our direction in connection with your claim and any new rationale for our claim decision. We will provide you with this information sufficiently in advance of the date that we are required to provide you with our reconsideration decision to allow you a reasonable opportunity to respond to us before that date. However, our failure to provide you with new evidence or rationale in sufficient time to allow you to timely respond shall not invalidate our decision on reconsideration. You may respond to that new evidence or rationale at the OPM review stage described in step 4.

In the case of a post-service claim, we have 30 days from the date we receive your request to:

a) Pay the claim or

b) Write to you and maintain our denial or

c) Ask you or your provider for more information.

You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days.

If we do not receive the information within 60 days we will decide within 30 days of the date the information was due. We will base our decision on the information we already have. We will write to you with our decision.

3

If you do not agree with our decision, you may ask OPM to review it.

You must write to OPM within:

• 90 days after the date of our letter upholding our initial decision; or
• 120 days after you first wrote to us - if we did not answer that request in some way within 30 days; or
• 120 days after we asked for additional information.

Write to OPM at: United States Office of Personnel Management, Healthcare and Insurance, Federal Employee Insurance Operations, FEHB 3, 1900 E Street NW, Washington, DC 20415-3630.

Send OPM the following information:

• A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
• Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;
• Copies of all letters you sent to us about the claim;
• Copies of all letters we sent to you about the claim;
• Your daytime phone number and the best time to call; and
• Your email address, if you would like to receive OPM's decision via email. Please note that by providing your email address, you may receive OPM's decision more quickly.

Note: If you want OPM to review more than one claim, you must clearly identify which documents apply to which claim.

Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the review request. However, for urgent care claims, a health care professional with knowledge of your medical condition may act as your authorized representative without your express consent.

Note: The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons beyond your control.

OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no other administrative appeals.

If you do not agree with OPM’s decision, your only recourse is to sue. If you decide to file a lawsuit, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs, or supplies or from the year in which you were denied precertification or prior approval. This is the only deadline that may not be extended.

OPM may disclose the information it collects during the review process to support their disputed claim decision. This information will become part of the court record.

You may not file a lawsuit until you have completed the disputed claims process. Further, Federal law governs your lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was before OPM when OPM decided to uphold or overturn our decision. You may recover only the amount of benefits in dispute.

When you have other health coverage

You must tell us if you or a covered family member has coverage under any other health plan or has automobile insurance that pays health care expenses without regard to fault. This is called “double coverage.”

When you have double coverage, one plan normally pays its benefits in full as the primary payor and the other plan pays a reduced benefit as the secondary payor. We, like other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners’ (NAIC) guidelines. For more information on NAIC rules regarding the coordinating of benefits, visit our website at www.MedMutual.com/feds.

When we are the primary payor, we will pay the benefits described in this brochure.

When we are the secondary payor, we will determine our allowance. After the primary plan pays, we will pay what is left of our allowance, up to our regular benefit. We will not pay more than our allowance. If we are the secondary payor, and you received your services from Plan providers, we may bill the primary carrier.

• TRICARE and CHAMPVA

TRICARE is the health care program for eligible dependents of military persons, and retirees of the military. TRICARE includes the CHAMPUS program. CHAMPVA provides health coverage to disabled Veterans and their eligible dependents. If TRICARE or CHAMPVA and this Plan cover you, we pay first. See your TRICARE or CHAMPVA Health Benefits Advisor if you have questions about these programs.

• Workers’ Compensation

We do not cover services that:

• You (or a covered family member) need because of a workplace-related illness or injury that the Office of Workers’ Compensation Programs (OWCP) or a similar federal or state agency determines they must provide; or
• OWCP or a similar agency pays for through a third-party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws.

Once OWCP or similar agency pays its maximum benefits for your treatment, we will cover your care.

• Medicaid

When you have this Plan and Medicaid, we pay first.

Suspended FEHB coverage to enroll in Medicaid or a similar state-sponsored program of medical assistance: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these state programs, eliminating your FEHB premium. For information on suspending your FEHB enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under the state program.

When other Government agencies are responsible for your care

We do not cover services and supplies when a local, state, or federal government agency directly or indirectly pays for them.

When you receive money to compensate you for medical or hospital care for injuries or illness caused by another person, you must reimburse us for any expenses we paid. However, we will cover the cost of treatment that exceeds the amount you received in the settlement.

If you do not seek damages you must agree to let us try. This is called subrogation. If you need more information, contact us for our subrogation procedures.

If you obtain a judgment or settlement from or on behalf of a third party who allegedly caused or is responsible for an injury or illness for which you received covered health care services or benefits (“Services”), you must pay us Charges for those Services. “Charges” are: 1) for Services that we pay the provider on a fee-for-service basis, the payments that we made for the Services; and 2) for all other Services, the charges in the provider’s schedule of charges for Services provided to Members less any cost share payments that you made to the provider. Our payments for Services in these circumstances are expressly conditioned on your agreement to comply with this paragraph.

You must also pay us Charges for such Services if you receive or are entitled to receive a recovery from any insurance for an injury or illness alleged to be based on a third party’s fault, such as from uninsured or underinsured motorist coverage. You must also pay us Charges for such Services if you receive or are entitled to receive recovery from any Workers' Compensation benefits.

To secure our rights, we will have a lien on the proceeds of any judgment or settlement you or we obtain against a third party. The proceeds of any judgment or settlement that you or we obtain shall first be applied to satisfy our lien, regardless of whether the total amount of the proceeds is less than the actual losses and damages you incurred. We are entitled under our first-priority lien to be paid Charges for Services even if you are not "made whole" for all of your damages in the recoveries that you receive.

In order for us to determine the existence of any rights we may have and to satisfy those rights, you must complete and send us all consents, releases, authorizations, assignments, and other documents, including lien forms directing your attorney, the third party, and the third party's liability insurer to pay us directly. You may not agree to waive, release, or reduce our rights under this provision without our prior, written consent. You must cooperate in doing what is reasonably necessary to assist us with our right of recovery.  You must notify us within 30 days of the date you or someone acting on your behalf notifies anyone, including an insurer or attorney, of your intention to pursue or investigate a claim to recover damages or obtain compensation due to your injury or illness. You must not take any action that may prejudice our right of recovery.

If your estate, parent, guardian, or conservator asserts a claim against a third party based on your injury or illness, that person or entity and any settlement or judgment recovered by that person or entity shall be subject to our liens and other rights to the same extent as if you had asserted the claim against the third party. We may assign our rights to enforce our liens and other rights.

We have the option of becoming subrogated to all claims, causes of action, and other rights you may have against a third party or an insurer, government program, or other source of coverage for monetary damages, compensation, or indemnification on account of the injury or illness allegedly caused by the third party. We will be so subrogated as of the time we mail or deliver a written notice of our exercise of this option to you or your attorney, but we will be subrogated only to the extent of the total of Charges for the relevant Services.

We will reduce our lien pro rata to share in your legal fees and costs under the common fund doctrine. This net lien will not be more than (1) one-third of your total gross recovery from all third-party sources if you engaged an attorney to obtain that recovery; or (2) one-half of such recovery if you did not.

Contact us if you need more information about recovery or subrogation.

Some FEHB plans already cover some dental and vision services. When you are covered by more than one vision/dental plan, coverage provided under your FEHB plan remains as your primary coverage. FEDVIP coverage pays secondary to that coverage. When you enroll in a dental and/or vision plan on BENEFEDS.com, or by phone at 877-888-3337.(TTY 877-889-5680), you will be asked to provide information on your FEHB plan so that your plans can coordinate benefits. Providing your FEHB information may reduce your out-of-pocket cost.

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is either Federally funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration; or is a drug trial that is exempt from the requirement of an investigational new drug application.

We will cover routine care costs not provided by the clinical trial in accordance with Section 5 when Plan physicians provide or arrange for your care.

• Routine care costs are costs for routine services, such as doctor visits, lab tests, x-rays and scans, and hospitalizations related to treating the patient’s condition whether the patient is in a clinical trial or is receiving standard therapy. We cover routine care costs not provided by the clinical trial.

The Plan does not cover extra care costs and research costs.

• Extra care costs are costs related to taking part in a clinical trial, such as additional tests that a patient may need as part of the trial, but not as part of the patient’s routine care. We do not cover these costs.
• Research costs are costs related to conducting the clinical trial, such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes. These costs are generally covered by the clinical trials. This plan does not cover these costs.

What is Medicare?

For more detailed information on "What is Medicare?" and "Should I Enroll in Medicare?" please contact 1-800-MEDICARE (1-800-633-4227) (TTY 1-877-486-2048) or at www.medicare.gov.

• The Original Medicare Plan (Part A or Part B)

The Original Medicare Plan (Original Medicare) is available everywhere in the United States. It is the way everyone used to get Medicare benefits and is the way most people get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay your share.

All physicians and other providers are required by law to file claims directly to Medicare for members with Medicare Part B, when Medicare is primary.  This is true whether or not they accept Medicare.

When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care.

Claims process when you have the Original Medicare Plan – You will probably not need to file a claim form when you have both our Plan and the Original Medicare Plan.

When we are the primary payor, we process the claim first.

When Original Medicare is the primary payor, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. To find out if you need to do something to file your claim, call us at 800-315-3144 (TTY:711), 7:30 a.m. to 7:30 p.m. (EST), Friday 7:30 a.m. to 6:00 p.m. (EST), Saturday 9:0 a.m. to 1:00 p.m. (EST), or visit our Website at www.MedMutual.com/feds.

We do not waive any costs if the Original Medicare Plan is your primary payor.

Please review the following table. It illustrates your cost share if you are enrolled in Medicare Part B.  Medicare will be primary for all Medicare eligible services.  Members must use providers who accept Medicare's assignment.

Compare for STANDARD and BASIC Option:

Benefit: Out of Pocket Maximum
Member Cost STANDARD Option without Medicare: $6,000/$12,000
Member cost STANDARD Option with Medicare parts A and B: $6,000/$12,000
Member Cost BASIC Option without Medicare: $6,500/$13,000
Member cost BASIC Option with Medicare parts A and B: $6,500/$13,000

Benefit: Primary Care
Member Cost STANDARD Option without Medicare: $25
Member cost STANDARD Option with Medicare parts A and B: $25
Member Cost BASIC Option without Medicare: $30
Member cost BASIC Option with Medicare parts A and B: $30

Benefit: Specialist
Member Cost STANDARD Option without Medicare: $45
Member cost STANDARD Option with Medicare parts A and B: $45
Member Cost BASIC Option without Medicare: $60
Member cost BASIC Option with Medicare parts A and B: $60

Benefit: Inpatient Hospital
Member Cost STANDARD Option without Medicare: $650
Member cost STANDARD Option with Medicare parts A and B: $650
Member Cost BASIC Option without Medicare: 20% after deductible
Member cost BASIC Option with Medicare parts A and B: 20% after deductible

Benefit: Outpatient Surgery
Member Cost STANDARD Option without Medicare: $375
Member cost STANDARD Option with Medicare parts A and B: $375
Member Cost BASIC Option without Medicare: 20% after deductible
Member cost BASIC Option with Medicare parts A and B: 20% after deductible

Benefit: Rx
Member Cost STANDARD Option without Medicare: All Generic $15; Preferred brand $75; Non-preferred brand $180; Specialty 25% up to $500 through a contracted specialty pharmacy
Member cost STANDARD Option with Medicare parts A and B: All Generic $15; Preferred brand $75; Non-preferred brand $180; Specialty 25% up to $500 through a contracted specialty pharmacy
Member Cost BASIC Option without Medicare: All Generic $10; Preferred brand 40% coinsurance up to $250; Non-preferred brand 60% coinsurance up to $350; Specialty 30% up to $500 through a contracted specialty pharmacy
Member cost BASIC Option with Medicare parts A and B: All Generic $10; Preferred brand 40% coinsurance up to $250; Non-preferred brand 60% coinsurance up to $350; Specialty 30% up to $500 through a contracted specialty pharmacy

Benefit: Rx mail order (90 day supply)
Member Cost STANDARD Option without Medicare: 2 x Retail Copay
Member cost STANDARD Option with Medicare parts A and B: 2 x Retail Copay
Member Cost BASIC Option without Medicare: 2 x Retail Copay
Member cost BASIC Option with Medicare parts A and B: 2 x Retail Copay

• Tell us about your Medicare coverage

• Medicare Advantage (Part C)

If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare Advantage or a Medicare Managed Care plan. These are private health care choices (like HMOs and regional PPOs) in some areas of the country. To learn more about Medicare Advantage plans, contact Medicare at-800-MEDICARE (800-633-4227) (TTY: 877-486-2048) or at www.medicare.gov.

If you enroll in a Medicare Advantage plan, the following options are available to you:

This Plan and our Medicare Advantage plan:  We do not offer a Medicare Advantage plan.

This Plan and another plan’s Medicare Advantage plan: You may enroll in another plan’s Medicare Advantage plan and also remain enrolled in our FEHB plan. We will still provide benefits when your Medicare Advantage plan is primary, even out of the Medicare Advantage plan’s network and/or service area (if you use our Plan providers), however we will not waive any of our copayments, coinsurance, or deductibles. If you enroll in a Medicare Advantage plan, tell us. We will need to know whether you are in the Original Medicare plan or in a Medicare Advantage plan so we can correctly coordinate benefits with Medicare.

Suspended FEHB coverage to enroll in a Medicare Advantage plan: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a Medicare Advantage plan, eliminating your FEHB premium. (OPM does not contribute to your Medicare Advantage plan premium.) For information on suspending your FEHB enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage or move out of the Medicare Advantage plan’s service area.

• Medicare prescription drug coverage (Part D)

When we are the primary payor, we process the claim first. If you enroll in another plan's Medicare Part D plan and we are the secondary payor, when you fill your prescription at a Plan pharmacy that is not in the network we will review claims for your prescription drug costs that are not covered by Medicare Part D and consider them for payment under the FEHB plan. 

You will still need to follow the rules in this brochure for us to cover your care. We will only cover your prescription if it is written by a Plan provider and obtained at a Plan pharmacy or through our Plan mail service delivery program, except in an emergency or urgent care situation.

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is either Federally funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration; or is a drug trial that is exempt from the requirement of an investigational new drug application.

• Routine care costs – costs for routine services, such as doctor visits, lab tests, x-rays and scans, and hospitalizations related to treating the patient’s condition whether the patient is in a clinical trial or is receiving standard therapy.
• Extra care costs – costs related to taking part in a clinical trial, such as additional tests that a patient may need as part of the trial, but not as part of the patient’s routine care.
• Research costs – costs related to conducting the clinical trial, such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes. These costs are generally covered by the clinical trials.  This plan does not cover these costs.

We do not cover a service, supply, item, or drug that we consider experimental. We consider a service, supply, item, or drug to be experimental when the service, supply, item or drug:

(1) has not been approved by the FDA; or

(2) is the subject of a new drug or new device application on file with the FDA; or

(3) is part of a Phase I or Phase II clinical trial, as the experimental or research arm of a Phase III clinical trial; or is intended to evaluate the safety, toxicity, or efficacy of the service; or

(4) is available as the result of a written protocol that evaluates the service’s safety, toxicity, or efficacy; or

(5) is subject to the approval or review of an Institutional Review Board; or

(6) requires an informed consent that describes the service as experimental or investigational.

We carefully evaluate whether a particular therapy is safe and effective or offers a reasonable degree of promise with respect to improving health outcomes. The primary source of evidence about health outcomes of any intervention is peer-reviewed medical or dental literature.

Our allowance is the amount we use to determine our payment and your coinsurance for covered services. We determine our allowance as follows:

• The amount a Contracting Institutional Provider or a Participating Professional Provider has agreed with the Carrier to accept as payment in full for Covered Services.

Plan facilities

Plan facilities are hospitals and other facilities in the service area that the Carrier contracts with to provide covered services to members.

Plan providers

Plan providers are physicians and other health care professionals in the services area that the Carrier contract with to provide covered services to members.

Urgent care claims

A claim for medical care or treatment is an urgent care claim if waiting for the regular time limit for non-urgent care claims could have one of the following impacts:

• Waiting could seriously jeopardize your life or health;
• Waiting could seriously jeopardize your ability to regain maximum function; or
• In the opinion of a physician with knowledge of your medical condition, waiting would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.

Urgent care claims involve Pre-service claims and not Post-service claims. We will determine whether or not a claim is an urgent care claim by applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine.

If you believe your claim qualifies as an urgent care claim, please contact Customer Care at 800-315-3144. You may also prove that your claim is an urgent care claim by providing evidence that a physician with knowledge of your medical condition has determined that your claim involves urgent care.

Us/We

Us and We refer to Medical Mutual of Ohio.

Medical services provided by physicians and other health care professionals: Diagnostic and treatment services provided in the office

$25 per primary care office visit
$45 per specialty care office visit

27

Services provided by a hospital: Inpatient

$650 per admission

44

Services provided by a hospital: Outpatient

$375 per outpatient surgery

45

Emergency benefits: In-area

$250 per visit

48

Emergency benefits: Out-of-area

$250 per visit

48

Mental health and substance use disorder treatment:

Regular cost-sharing

49-50

Prescription drugs: Retail pharmacy

Tier 1 - $15 per prescription or refill for all generic drugs

Tier 2 - $75 per prescription or refill for Preferred brand-name drugs

Tier 3 - $180 per prescription or refill for Non-Preferred brand-name drugs

Tier 4 - Specialty 25% up to $500 through a contracted specialty pharmacy

53

Prescription drugs: Mail order

Tier 1 - $30 per prescription or refill for mail-order generic drugs for up to 90-day supply

Tier 2 - $150 per prescription or refill for mail-order preferred brand-name drugs for up to 90-day supply

Tier 3 - $360 per prescription or refill for mail-order non-preferred brand-name drugs for up to 90-day supply

Tier 4 - Mail order not available for Specialty medications

53-54

Dental care:

No benefit. Except for Accidental Injury to teeth

56

Vision care:

Refractions;
$25 per primary care office visit
$45 per specialty care office visit

33

Special features: 

24/7 Nurse Line; Centers of Excellence; Services for the deaf, hard or hearing or speech impaired, Wellness, Disease and Maternity Management 

57-58

Protection against catastrophic costs (your catastrophic protection out-of-pocket maximum):

Nothing after $6,000/Self Only or $12,000/per Self Plus One or Self and Family enrollment per year. Some costs do not count toward this protection.

22-23

Services provided by a hospital: Outpatient

20% after deductible

45

Services provided by a hospital: Inpatient

20% after deductible

44

Emergency benefits: Out-of-area

$250 per visit

48

Emergency benefits: In-area

$250 per visit

48

Mental health and substance misuse disorder treatment:

Regular cost-sharing

49-50

Prescription drugs: Retail pharmacy

Tier 1 - $10 per prescription or refill for all generic drugs

Tier 2 - 40% coinsurance up to $250 per prescription or refill for Preferred brand-name drugs

Tier 3 - 60% coinsurance up to $350 per prescription or refill for Non- Preferred brand-name drugs

Tier 4 - Specialty 30% up to $500 through a contracted specialty pharmacy

53

Prescription drugs: Mail Order

Tier 1 - $20 per prescription or refill for mail order generic drugs for up to a 90-day supply

Tier 2 - 40% coinsurance up to $500 maximum for mail order preferred brand for up to a 90-day supply

Tier 3 - 60% up to $700 maximum for mail order for non-preferred brand-name drugs for up to a 90-day supply

Tier 4 - Mail order not available for Specialty medications

53-54

Dental care:

No benefit. Except for Accidental Injury to teeth

56

Vision care:

Refractions;
$30 per primary care office visit
$60 per specialty care office visit

33

Special features: 

24/7 Nurse Line; Centers of Excellence; Services for the deaf, hard or hearing or speech impaired, Wellness, Disease and Maternity Management

57-58

Protection against catastrophic costs (your catastrophic protection out-of-pocket maximum):

The deductible accumulates towards the out-of-pocket maximum.

Nothing after $6,500/Self Only or $13,000/per Self Plus One or Self and Family enrollment per year. Some costs do not count toward this protection.

22-23