SuperMed Plus Low Plan

Benefits Network Non-Network
Benefit Period January 1st through December 31st
Dependent Age Limit 19-Dependent  24-Student
Removal upon end of calendar year
Blood Pint Deductible 0 Pints
Pre-Existing Condition Waiting Period Initial Group Waiver, All Others: 6-12
Lifetime Maximum $5,000,000
Benefit Period Deductible - Single/Family¹ $1000/$2,000 $2,000/$4,000
Coinsurance 80% 60%
Coinsurance Out-of-Pocket Maximum
(Excluding Deductible) - Single/Family		 $3,000/$6,000 $6,000/$12,000

Physician/Office Services

    
Office Visit (Illness/Injury)² $20 co-pay, then 100% 60% after deductible
Urgent Care Office Visit² $20 co-pay, then 100% 60% after deductible
Voluntary Second Surgical Opinion $20 co-pay, then 100% 60% after deductible
Surgical Services in Physicians Office $20 co-pay, then 100% 60% after deductible
All Immunizations 100% 60% after deductible
Allergy Testing 80% 60% after deductible
Allergy Treatments 100% 60% after deductible

Preventative Services

    
Routine Physical Exams² $20 co-pay, then 100% 60% after deductible
Well Child Care Services including Exam and
Immunizations (to age 9)²		 $20 co-pay, then 100% 60% after deductible
Well Child Care Laboratory Tests (to age 9) 100% 60% after deductible
Routine Vision Exams (includes Refraction)² $20 co-pay, then 100% 60% after deductible
Routine Hearing Exams² $20 co-pay, then 100% 60% after deductible
Routine Mammogram (One, limited to an
$85 maximum per benefit period)		 100% 60% after deductible
Routine Pap Test (One per benefit period) 100% 60% after deductible
Routine Laboratory, X-ray and Medical Tests
(Age 9 and older)		 100% 60% after deductible
Routine Endoscopic Services (Age 9 and older) 100% 60% after deductible

Outpatient Services

    
Surgical Services (other than a physician's office) 80% after deductible 60% after deductible
Diagnostic Services 80% after deductible 60% after deductible
Physical Therapy - Professional and Facility
(30 visits per benefit period)³		 $20 co-pay, then 100% 60% after deductible
Occupational Therapy - Professional and Facility
(30 visits per benefit period)³		 $20 co-pay, then 100% 60% after deductible
Chiropractic Therapy - Professional Only
(12 visits per benefit period)³		 $20 co-pay, then 100% 60% after deductible
Speech Therapy - Facility and Professional
(20 visits per benefit period)³		 $20 co-pay, then 100% 60% after deductible
Cardiac Rehabilitation 80% after deductible 60% after deductible
Emergency use of an Emergency Room³* $75 co-pay, then 100%
Non-Emergency use of an Emergency Room ³* ** $75 co-pay, then 80% $75 co-pay, then 60%

Inpatient Facility

    
Semi-Private Room and Board 80% after deductible 60% after deductible
Diagnostic Services 80% after deductible 60% after deductible
Professional Services 80% after deductible 60% after deductible
Maternity 80% after deductible 60% after deductible
Physical Medicine
(Limited to 60 days in a rehab facility)		 80% after deductible 60% after deductible
Skilled Nursing Facility
(Limited to 180 days per benefit period)		 80% after deductible 60% after deductible

Additional Services

    
Diabetic Education and Training 80% after deductible 60% after deductible
Wigs (Limited to one per lifetime) 80% after deductible 60% after deductible
Ambulance 80% after deductible
Durable Medical Equipment including Prosthetic
Appliances and Orthotic Devices		 80% after deductible 60% after deductible
Home Healthcare 80% after deductible 60% after deductible
(30 visits per benefit period)
Hospice 80% after deductible
Organ Transplants ($1,000,000 lifetime
maximum for all except kidney and cornea)		 100% 50% after deductible
Weight Loss Surgical Services including
complications from Weight Loss Surgery		 Not Covered Not Covered
Private Duty Nursing 80% after deductible 60% after deductible

Mental Health and Substance Abuse

    
Inpatient Mental Health and Substance Abuse
Services (30 days per benefit period; Substance
Abuse limited to two admissions per lifetime)		 80% after deductible 60% after deductible
Outpatient Mental Health and Substance Abuse
Services (30 visits per benefit period)³		 $20 co-pay, then 100% 60% after deductible
Note: Services requiring a copayment are not subject to the single/family deductible.
  Non-Contracting and Facility Other Providers will pay the same as Non-Network.
  Deductible and Coinsurance expenses incurred for services by a network provider will only apply to the network coinsurance out-of-pocket limits. Deductible and Coinsurance expenses incurred for services by a non-network provider will only apply to the non-network coinsurance out-of-pocket limits.
  Benefits will be determined based on Medical Mutual's medical and administrative policies and procedures.
  This is only a partial listing of benefits. The contract of certificate will contain the complete listing of covered services.
  In certain instances, Medical Mutual's payment may not equal the percentage listed above. However, the covered person's coinsurance will always be based on the lesser of the provider's billed charges or Medical Mutual's negotiated rate with the provider.

¹ Maximum family deductible. Member deductible is the same as single deductible. 3-month carryover applies
² The office visit co-pay applies to the cost of the office visit only
³ The co-pay applies to the Coinsurance Out-of-Pocket Maximum and stops being taken when the maximum is met
* Co-pay waived if admitted
** The co-pay applies to room charges only. All other covered charges are subject to deductible and coinsurance

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