MedMutual Advantage Classic (HMO)
MedMutual Advantage Classic (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by MEDICAL MUTUAL OF OHIO.
Plan ID: H6723-001.
MedMutual Advantage Classic (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by MEDICAL MUTUAL OF OHIO.
Plan ID: H6723-001.
Ohio Counties Served
Basic Costs and Coverage
Coverage | Cost |
---|---|
Monthly Deductible | $95 |
Out of Pocket Max |
In-Network: $5850 Out-of-Network: N/A |
Initial Coverage Limit | $4430 |
Catastrophic Coverage Limit | $7,050 |
Primary Care Doctor Visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $5.00 |
Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $45.00 Prior Authorization Required for Doctor Specialty Visit Prior authorization required |
Inpatient Hospital Care | In-Network: Acute Hospital Services: $335.00 per day for days 1 to 6 $0.00 per day for days 7 to 90 Prior Authorization Required for Acute Hospital Services Prior authorization required |
Urgent Care | Copayment for Urgent Care $45.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $45.00 Maximum Plan Benefit of $50,000 |
Emergency Room Visit | Copayment for Emergency Care $90.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $90.00 Maximum Plan Benefit of $50,000 |
Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $275.00 Air Ambulance: Coinsurance for Air Ambulance Services 50% Non-emergency air ambulance may require authorization. Please contact Plan for details. Please see Evidence of Coverage for Prior Authorization rules Prior authorization required |
Health Care Services and Medical Supplies
MedMutual Advantage Classic (HMO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).
Coverage | Cost |
---|---|
Chiropractic Services | In-Network: Copayment for Medicare-covered Chiropractic Services $10.00 |
Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Coinsurance for Medicare-covered Diabetic Supplies 0% to 20% Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20% |
Durable Medical Eqipment (DME) | In-Network: Coinsurance for Medicare-covered Durable Medical Equipment 20% Prior Authorization Required for Durable Medical Equipment Prior authorization required |
Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00 to $10.00 Copayment for Medicare-covered Lab Services $0.00 to $10.00 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $150.00 to $225.00 Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $50.00 Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services Prior authorization required |
Home Health Care | In-Network: Copayment for Medicare-covered Home Health Services $0.00 Prior Authorization Required for Home Health Services Prior authorization required |
Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $370.00 per day for days 1 to 5 $0.00 per day for days 6 to 90 Prior Authorization Required for Psychiatric Hospital Services Prior authorization required |
Mental Health Outpatient Care | In-Network: Copayment for Medicare-covered Individual Sessions $40.00 Copayment for Medicare-covered Group Sessions $40.00 |
Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $450.00 Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Coinsurance for Medicare Covered Observation Services 20% Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $350.00 Prior Authorization Required for Ambulatory Surgical Center Services Prior authorization required |
Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $40.00 Copayment for Medicare-covered Group Sessions $40.00 |
Over-the-counter (OTC) Items | In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0.00 Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit |
Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $45.00 Prior Authorization Required for Podiatry Services Prior authorization required |
Skilled Nursing Facility Care | In-Network: Skilled Nursing Facility Services: $0.00 per day for days 1 to 20 $188.00 per day for days 21 to 100 Prior Authorization Required for Skilled Nursing Facility Services Prior authorization required |
Dental Benefits
The following dental services are covered from in-network providers.
Coverage | Cost |
---|---|
Dental Care | In-Network: Preventive Dental: Copayment for Oral Exams $0.00
Comprehensive Dental: Copayment for Medicare-covered Benefits $45.00 |
Vision Benefits
The following vision services are covered from in-network providers.
Coverage | Cost |
---|---|
Vision Benefits | In-Network: Eye Exams: Copayment for Medicare Covered Benefits $0.00 Copayment for Routine Eye Exams $0.00
Eyewear: Coinsurance for Medicare-Covered Benefits 20% Copayment for Contact Lenses $0.00
|
Hearing Benefits
The following hearing services are covered from in-network providers.
Coverage | Cost |
---|---|
Hearing Benefits | In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $0.00 Copayment for Routine Hearing Exams $0.00
Hearing Aids: Copayment for Hearing Aids $699.00 to $999.00
|
Preventive Services and Health/Wellness Education Programs
The following services are covered from in-network providers.
Coverage | Cost |
---|---|
Preventive Services and Health/Wellness Education Programs | In-Network: $0.00 copay for Medicare Covered Preventive Services: Abdominal aortic aneurysm screening Alcohol misuse screenings & counseling Bone mass measurements (bone density) Cardiovascular disease screenings Cardiovascular disease (behavioral therapy) Cervical & vaginal cancer screening Colorectal cancer screenings Depression screenings Diabetes screenings Diabetes self-management training Glaucoma tests Hepatitis B (HBV) infection screening Hepatitis C screening test HIV screening Lung cancer screening Mammograms (screening) Nutrition therapy services Obesity screenings & counseling One-time Welcome to Medicare preventive visit Prostate cancer screenings(PSA) Sexually transmitted infections screening & counseling Shots:
Yearly "Wellness" visit |
Prescription Drug Costs and Coverage
The MedMutual Advantage Classic (HMO) plan offers the following prescription drug coverage, with an annual drug deductible of $95 (excludes Tiers 1 and 2) per year.
Coverage |
Cost
|
---|---|
Coverage & Cost
|
|
Annual Drug Deductible | $95 (excludes Tiers 1 and 2) |
Preferred Generic |
|
Generic |
|
Annual Drug Deductible | $95 (excludes Tiers 1 and 2) |
Preferred Generic |
|
Generic |
|
Annual Drug Deductible | $95 (excludes Tiers 1 and 2) |
Preferred Generic |
|
Generic |
|