SummaCare of Ohio PPO Plan 5000M Plan Information
Plan Overview
Calendar Year Deductible: $5,000/$10,000
Calendar Year Out of Pocket Maximum: $7,000/$14,000
Coinsurance: 80%
Lifetime Benefit Maximum: $2,500,000
Inpatient Hospital Services
Inpatient Care: 80%
Surgery & Anesthesia: 80%
Physician Services: 80%
Medically Necessary Supplies & Services: 80%
Rehabilitative Services: 80%
X-ray, Laboratory and other Diagnostic Services: 80%
Outpatient Services
Outpatient Surgery: 80%
Maternity Services
Office Visits: $25 Copay
Hospital Services: (48 hours for vaginal delivery; 96 hours for Cesarean delivery) (if discharged early, home care is covered up to 72 hours after discharge) (270-day benefit waiting period) 80%
Prenatal-Postpartum Care: 80%
Mental Health and Substance Abuse/Alcohol Abuse
Biologically Based Mental Health
Inpatient: 80%
Outpatient: Preferred- $25 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): 80%
Outpatient (20 visits per calendar year): 50%
Emergency Rooom/Urgent Care Services
Emergency Care: 80% 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: $25 copay
Gynecological Visits: $25 copay
Specialist Office Visits: $25 copay
Annual Physical Exam: $25 copay
Preventive Care: $25 copay
X-ray, Laboratory:80%
Mammograms: 80% -NOT subject to deductible
Infertility Diagnosis: 50%
Allergy Tests & Treatment: $25 copay per visit (injections only-no copay)
Other Services
Vision Exam: $25 copay per 24 month visit
Skilled Nursing Facility: 80%
Home Health Care: 80%
Ambulance Services : $75 copay (waived if admitted)
Hospice Services: 80%
Durable Medical Equipment: 80%
Chiropractic Services: 70%
Prescription Drugs: $15/$30/$60 or 50% up to a max of $200, whichever is greater
Other SummaCare of Ohio health insurance plans:
