SummaCare of Ohio PPO Plan Q2501-80 Plan Information
Plan Overview
Calendar Year Deductible: $2,500/$5,000
Calendar Year Out of Pocket Maximum: $5,000/$10,000
Coinsurance: 80%
Lifetime Benefit Maximum: $3,000,000 Combined
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: Not covered under this plan
Mental Health and Substance Abuse/Alcohol Abuse
Biologically Based Mental Health
Inpatient: 80%
Outpatient: 80%
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): 80%
Emergency Rooom/Urgent Care Services
Emergency Care: 80%
Urgent Care: 80%
Medical Services
Primary Care Office Visits:80%
Gynecological Visits: 80%
Specialist Office Visits: 80%
Annual Physical Exam: 80%
Preventive Care: 80%
X-ray, Laboratory: 80%
Mammograms: 80% -NOT subject to deductible
Infertility Diagnosis: 80%
Allergy Tests & Treatment: 80%
Other Services
Vision Exam: 80%
Skilled Nursing Facility: 80%
Home Health Care: 80%
Ambulance Services : 80%
Hospice Services: 80%
Durable Medical Equipment: 80%
Chiropractic Services: 80%
Prescription Drugs: 80%
Other SummaCare of Ohio health insurance plans:
