MedMutual Advantage Classic (HMO)
MedMutual Advantage Classic (HMO) H6723-001 Plan Details
MedMutual Advantage Classic (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by MEDICAL MUTUAL OF OHIO.
Plan ID: H6723-001.
$0.00
Monthly Premium
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
Adams
Allen
Ashland
Auglaize
Brown
Butler
Carroll
Champaign
Clark
Clermont
Clinton
Columbiana
Coshocton
Crawford
Cuyahoga
Darke
Defiance
Delaware
Erie
Fairfield
Fayette
Franklin
Fulton
Gallia
Geauga
Greene
Guernsey
Hamilton
Hancock
Hardin
Harrison
Henry
Highland
Hocking
Holmes
Huron
Jackson
Knox
Lake
Licking
Logan
Lorain
Lucas
Madison
Mahoning
Marion
Medina
Mercer
Miami
Monroe
Montgomery
Morgan
Morrow
Muskingum
Noble
Ottawa
Paulding
Perry
Pickaway
Pike
Portage
Preble
Putnam
Richland
Ross
Sandusky
Scioto
Seneca
Shelby
Stark
Summit
Trumbull
Tuscarawas
Union
Van Wert
Vinton
Warren
Washington
Wayne
Williams
Wood
Wyandot
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 |
|
