Medical

Medical Mutual

Coverage period: January 1, 2024 – December 31, 2024

Services	PPO Plan		CleCare HMO Plan
Services	In-Network	Out-of-Network	In-Network	Out-of-Network
Deductible (Individual/Family)	$1,000 / $2,000	$2,000 / $4,000	$1,000 / $2,000	N/A
Co-Insurance (Individual/Family)	$3,500 / $7,000	$7,000 / $14,000	$2,500 / $5,000	N/A
Out of Pocket Max (Individual/Family) Includes deductibles, copays & coinsurance	$6,600 / $13,200	Unlimited	$6,600 / $13,200	N/A
Primary Care Physician Office Visit	$25 copay	40% coinsurance	$25 copay	Not Covered
Specialist Office Visit	$50 copay	40% coinsurance	$50 copay	Not Covered
Independent Lab / X-Ray	100% (at Physician)	40% coinsurance 60% after deductible	100%	Not Covered
Inpatient Hospitalization	20% coinsurance	40% coinsurance	20% coinsurance	Not Covered
Outpatient Services	20% coinsurance	40% coinsurance	20% coinsurance	Not Covered
Preventative Care	100%	40% coinsurance	100%	Not Covered
Emergency ER Use	$250 copay, (copay is waived if admitted)	$250 copay, (copay is waived if admitted)	$250 copay (copay is waived if admitted)	$250 copay (copay is waived if admitted)
Urgent Care	$60 copay	40% coinsurance	$60 copay, then 100% MetroExpress Locations Only	Not Covered
Prescription Drugs Retail (30 Days)
	Administered by CVS		MetroHealth Pharmacies	MMO Pharmacies
Generic	$8	N/A	$8*	$16**
Preferred	$30	N/A	$30*	$60**
Non-Preferred	$50	N/A	$50*	$100**
Specialty	50% up to $150 Maximum	N/A	50% up to $150 Maximum*	N/A
Mail Order (90 Days)
Generic	$16	N/A	$16*	N/A
Preferred	$60	N/A	$60*	N/A
Non-Preferred	$100	N/A	$100*	N/A

Under the PPO plan, you will be required to fill 90 day supplies of maintenance medications through mail order or a CVS retail pharmacy. For more information on the Pharmacy Plan click here.

*MetroHealth Pharmacy Only
** All Other Pharmacies