MEDICAL

MedMutual Plan Options

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

PPO Plan

Choice Plus PPO Plans

With this traditional plan, you will:

Have a higher per pay period medical plan cost
Enjoy the predictability of set copay amounts
Be subject to a lower deductible
Have preventive services covered 100%

Consumer-Driven High-Deductible Health Plans

Basic Plan with Health Savings Account (HSA) or Enhanced Plan with Health Savings Account (HSA)

With the high-deductible plan, you will:

Enjoy lower per pay period medical plan costs
Have preventive services covered at 100%
Be eligible for a Health Savings account through Medical Mutual for tax free deposits
Receive City of Brooklyn quarterly contributions to your Health Savings Account

Preferred Provider Organization Plan (PPO)

Designed for those who prefer the predictability of set payments for doctor appointments and other medical services.

$250 PPO Plan

Designed for those who prefer the predictability of set payments for doctor appointments and other medical services.

Services	In-Network	Out-of-Network
Deductible	$250 / $500	$500 / $1,000
Annual Out-of-Pocket Maximum	$6,600 / $13,200	Unlimited
Coinsurance	10% after Deductible	30% after Deductible
Primary Care Visits	$20 Copay	30% after Deductible
Preventive Care	Covered at 100%	30% after Deductible
Specialist Visits	$20 Copay	30% after Deductible
Inpatient Visit	10% after Deductible	30% after Deductible
Outpatient Services	10% after Deductible	30% after Deductible
Emergency Room	10% coinsurance	10% coinsurance
Urgent Care	$20 Copay	30% after Deductible
Rx Retail
Generic	20% coinsurance	Not Covered
Preferred Brand	20% coinsurance	Not Covered
Non-Preferred Brand	20% coinsurance	Not Covered
Rx Mail Order
Generic	20% coinsurance	Not Covered
Preferred Brand	20% coinsurance	Not Covered
Non-Preferred Brand	20% coinsurance	Not Covered

$1,000 PPO Plan

Designed for those who prefer the predictability of set payments for doctor appointments and other medical services.

Services	In-Network	Out-of-Network
Deductible	$1.000 / $2,000	$2,000 / $4,000
Annual Out-of-Pocket Maximum	$6,600 / $13,200	Unlimited
Annual Out-of-Pocket Maximum Coinsurance	$2,000 / $4,000	$4,000 / $8000
Coinsurance	10% after Deductible	30% after Deductible
Primary Care Visits	$20 Copay	30% after Deductible
Preventive Care	Covered at 100%	30% after Deductible
Specialist Visits	$20 Copay	30% after Deductible
Inpatient Visit	10% after Deductible	30% after Deductible
Outpatient Services	10% after Deductible	30% after Deductible
Emergency Room	10% coinsurance	10% coinsurance
Urgent Care	$20 Copay	30% after Deductible
Rx Retail
Generic	20% coinsurance	Not Covered
Preferred Brand	20% coinsurance	Not Covered
Non-Preferred Brand	20% coinsurance	Not Covered
Rx Mail Order
Generic	20% coinsurance	Not Covered
Preferred Brand	20% coinsurance	Not Covered
Non-Preferred Brand	20% coinsurance	Not Covered

Resources

$250 PPO Plan SBC

$1000 PPO Plan SBC

Explanation of Benefits Guide

Express Care Online (Telemedicine) Member Flier

Make the Most of Your Membership Brochure

Member Discounts Flier

Online Tools Flier

Preventive Care Services Guide

Specialty Drug Solutions Flier

Urgent Care Facts

Where to Find Care

Preventive Care Guideline

Where to Find Care

Chronic Condition Management Brochure

Case Management

MedMutual Find a Provider and Cost Estimate

Member Guide FAQ Rx Brochure

Nurse Line

Sword MMO Toolkit Flyer

MMO Medical Plans & Resources

Health Savings Account Plan (HSA)

Allows you to minimize the premium you pay from your paycheck while saving for the future with pre-tax contributions to a Health Savings Account.

Services	In-Network	Out-of-Network
Deductible	$3,300 / $6,000	$5,000 / $10,000
Annual Out-of-Pocket Maximum	$3,300 / $6,000	$7,000 / $14,000
Coinsurance	0% after Deductible	30% after Deductible
Primary Care Visits	0% after Deductible	30% after Deductible
Preventive Care	0% after Deductible	30% after Deductible
Specialist Visits	0% after Deductible	30% after Deductible
Inpatient Visit	0% after Deductible	30% after Deductible
Outpatient Services	0% after Deductible	30% after Deductible
Emergency Room	0% after Deductible	0% after Deductible
Urgent Care	0% after Deductible	30% after Deductible
Rx Retail
Generic	0% after Deductible	Not Covered
Preferred Brand	0% after Deductible	Not Covered
Non-Preferred Brand	0% after Deductible	Not Covered
Rx Mail Order
Generic	0% after Deductible	Not Covered
Preferred Brand	0% after Deductible	Not Covered
Non-Preferred Brand	0% after Deductible	Not Covered

Resources

$3300 HSA Plan SBC

Explanation of Benefits Guide

Express Care Online (Telemedicine) Member Flier

HSA Enrollment Form

Make the Most of Your Membership Brochure

Member Discounts Flier

Online Tools Flier

Preventive Care Services Guide

Specialty Drug Solutions Flier

Urgent Care Facts

Where to Find Care

Preventive Care Guideline

QuitLine Member Brochure

Where to Find Care

Case Management

Member Guide FAQ Rx Brochure

MedMutual Find a Provider and Cost Estimate

Nurse Line

Sword MMO Toolkit Flyer

MMO Medical Plans & Resources

CLECare Plan : Health Maintenance Organization

In Network only plan, anchored by MetroHealth
Low deductible to meet, with no cost sharing except for copays after deductible is met
Enjoy the predictability of set copay amounts
Lower payroll contributions in comparison to Traditional PPO Plans offered

Services	In-Network	Out-of-Network
Deductible	$250 / $500	Not Covered
Annual Out-of-Pocket Maximum	$6,600 / $13,200	Not Covered
Coinsurance	0% after Deductible	Not Covered
Primary Care Visits	0% after Deductible	Not Covered
Preventive Care	0% after Deductible	Not Covered
Specialist Visits	0% after Deductible	Not Covered
Inpatient Visit	0% after Deductible	Not Covered
Outpatient Services	0% after Deductible	Not Covered
Emergency Room	$0	Not Covered
Urgent Care	$0	Not Covered
Rx Retail
Generic	$5	Not Covered
Preferred Brand	$10	Not Covered
Non-Preferred Brand	$20	Not Covered
Rx Mail Order
Generic	$0	Not Covered
Preferred Brand	$0	Not Covered
Non-Preferred Brand	$0	Not Covered