SummaCare of Ohio PPO Plan Q2501 Plan Information
Plan Overview
Calendar Year Deductible: $2,500/$5,000
Calendar Year Out of Pocket Maximum: $2,500/$5,000
Coinsurance: 100%
Lifetime Benefit Maximum: $3,000,000 Combined
Inpatient Hospital Services
Inpatient Care: 100%
Surgery & Anesthesia: 100%
Physician Services: 100%
Medically Necessary Supplies & Services: 100%
Rehabilitative Services: 100%
X-ray, Laboratory and other Diagnostic Services: 100%
Outpatient Services
Outpatient Surgery: 100%
Maternity Services: Not covered under this plan
Mental Health and Substance Abuse/Alcohol Abuse
Biologically Based Mental Health
Inpatient: 100%
Outpatient: 100%
Non-Biologically Based Mental Health/Substance Abuse/Alcohol Abuse( includes $550 per calendar year of Alcohol Abuse)
Inpatient (21 days per calendar year): 100%
Outpatient (20 visits per calendar year): 100%
Emergency Rooom/Urgent Care Services
Emergency Care: 100%
Urgent Care: 100%
Medical Services
Primary Care Office Visits: 100%
Gynecological Visits: 100%
Specialist Office Visits: 100%
Annual Physical Exam: 100%
Preventive Care: 100%
X-ray, Laboratory: 100%
Mammograms: 100% -NOT subject to deductible
Infertility Diagnosis: 100%
Allergy Tests & Treatment: 100%
Other Services
Vision Exam: 100%
Skilled Nursing Facility: 100%
Home Health Care: 100%
Ambulance Services : 100%
Hospice Services: 100%
Durable Medical Equipment: 100%
Chiropractic Services: 100%
Prescription Drugs: 100%
Other SummaCare of Ohio health insurance plans:
