SummaCare of Ohio PPO Plan 5-70 Plan Information
Plan Overview
Calendar Year Deductible: $5,000/$10,000
Calendar Year Out of Pocket Maximum: $7,000/$14,000
Coinsurance: 70%
Lifetime Benefit Maximum: $2,500,000
Inpatient Hospital Services
Inpatient Care: 70%
Surgery & Anesthesia: 70%
Physician Services: 70%
Medically Necessary Supplies & Services: 70%
Rehabilitative Services: 70%
X-ray, Laboratory and other Diagnostic Services: 70%
Outpatient Services
Outpatient Surgery: 70%
Maternity Services: Not covered under this plan
Mental Health and Substance Abuse/Alcohol Abuse
Biologically Based Mental Health
Inpatient: 70%
Outpatient: Preferred- $40 copay per visit
Non-Biologically Based Mental Health/Substance Abuse/Alcohol Abuse( includes $550 per calendar year of Alcohol Abuse)
Inpatient (21 days per calendar year): 70%
Outpatient (20 visits per calendar year): 50%
Emergency Rooom/Urgent Care Services
Emergency Care: 70% after $100 copay (copay waived if admitted)
Urgent Care: Preferred- 100% after $35 copay at approved urgent care facility
Medical Services
Primary Care Office Visits: $40 copay
Gynecological Visits: $40 copay
Specialist Office Visits: $40 copay
Annual Physical Exam: $40 copay
Preventive Care: $40 copay
X-ray, Laboratory:70%
Mammograms: 70% -NOT subject to deductible
Infertility Diagnosis: 70%
Allergy Tests & Treatment: 70%
Other Services
Vision Exam: $60 copay per 24 month visit
Skilled Nursing Facility: 70%
Home Health Care: 70%
Ambulance Services : $75 copay (waived if admitted)
Hospice Services: 70%
Durable Medical Equipment: 70%
Chiropractic Services: 70%
Prescription Drugs: $10 generic, $30 copay 90-day supply, maximum $500 per person
Other SummaCare of Ohio health insurance plans:
