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MedMutual Advantage Classic (HMO) - H6723-001-002

4.5 out of 5 stars* for plan year 2024

$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: H6723-001-002

* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.

$0.00

Monthly Premium

Ohio Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.

Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.

Learn more about Ohio Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.

Basic Costs and Coverage

CoverageDetails
Monthly plan premium$0.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$95.00
Out-of-pocket maximum$5,150.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$8,000.00
Primary care doctor visitIn-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $5.00
Specialty doctor visitIn-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $35.00
Prior Authorization Required for Doctor Specialty Visit
Inpatient hospital careIn-Network:

Acute Hospital Services:
$295.00 per day for days 1 to 6
$0.00 per day for days 7 to 90
Prior Authorization Required for Acute Hospital Services
Urgent care
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
Emergency Care:
Copayment for Emergency Care $100.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $100.00
Maximum Plan Benefit of $50,000
Ambulance transportationIn-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $275.00

Air Ambulance:
Coinsurance for Air Ambulance Services 50%

Non-emergency ambulance may require authorization. Please contact Plan for details.
Please see Evidence of Coverage for Prior Authorization rules

Health Care Services and Medical Supplies

MedMutual Advantage Classic (HMO) covers a range of additional benefits. Learn more about MedMutual Advantage Classic (HMO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

CoverageDetails
Chiropractic servicesIn-Network:

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $20.00
Diabetes supplies, training, nutrition therapy and monitoringIn-Network:

Diabetic Supplies and Services:
Coinsurance for Medicare-covered Diabetic Supplies 0% to 20%
Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20%
Durable medical equipment (DME)In-Network:

Durable Medical Equipment:
Coinsurance for Medicare-covered Durable Medical Equipment 20%
Prior Authorization Required for Durable Medical Equipment
Diagnostic tests, lab and radiology services, and X-raysIn-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
Home health careIn-Network:

Home Health Services:
Copayment for Medicare-covered Home Health Services $0.00
Prior Authorization Required for Home Health Services
Mental health inpatient careIn-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
Mental health outpatient careIn-Network:

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $35.00
Copayment for Medicare-covered Group Sessions $35.00
Outpatient services/surgeryIn-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $435.00
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
Outpatient substance abuse careIn-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $40.00
Copayment for Medicare-covered Group Sessions $40.00
Over-the-counter itemsIn-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 servicesIn-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $35.00
Prior Authorization Required for Podiatry Services
Skilled Nursing Facility (SNF) careIn-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$203.00 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services

Dental Benefits

The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Dental careIn-Network:

Comprehensive Dental:
Copayment for Medicare-covered Benefits $45.00

Vision Benefits

The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage

CoverageDetails
Vision careIn-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0.00
Copayment for Routine Eye Exams $0.00
  • Maximum 1 Routine Eye Exam every year

Eyewear:
Coinsurance for Medicare-Covered Benefits 20%

Hearing Benefits

The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Hearing careIn-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $0.00
Copayment for Routine Hearing Exams $0.00
  • Maximum 1 visit every year

Hearing Aids:
Copayment for Hearing Aids $499.00 to $999.00
  • Maximum 2 Hearing Aids every year
We offer three tiers of hearing aids. A $499 copay applies to a standard hearing aid. A $699 copay applies to an advanced hearing aid. A $999 copay applies to a premium hearing aid. Hearing aids are limited to one per ear per benefit period. You must see a contracted provider to use this benefit.

Preventive Services and Health/Wellness Education Programs

The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Preventive services and health/wellness education programsIn-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:
  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
  • Tobacco use cessation
    Yearly "Wellness" visit

    Prescription Drug Costs and Coverage

    The MedMutual Advantage Classic (HMO) offers prescription drug coverage, with an annual drug deductible of $95.00 (excludes Tiers 1 and 2)

    Coverage & Cost
    Coverage
    Cost
    Annual drug deductible$95.00 (excludes Tiers 1 and 2)
    Tier 1
    • Preferred retail $0.00
    • Standard retail $8.00
    • Preferred mail order $0.00
    • Standard mail order $7.00
    Tier 2
    • Preferred retail $5.00
    • Standard retail $12.00
    • Preferred mail order $0.00
    • Standard mail order $11.00
    Annual drug deductible$95.00 (excludes Tiers 1 and 2)
    Tier 1
    • Preferred retail $0.00
    • Standard retail $16.00
    • Preferred mail order $0.00
    • Standard mail order $14.00
    Tier 2
    • Preferred retail $10.00
    • Standard retail $24.00
    • Preferred mail order $0.00
    • Standard mail order $22.00
    Annual drug deductible$95.00 (excludes Tiers 1 and 2)
    Tier 1
    • Preferred retail $0.00
    • Standard retail $16.00
    • Preferred mail order $0.00
    • Standard mail order $14.00
    Tier 2
    • Preferred retail $13.00
    • Standard retail $30.00
    • Preferred mail order $0.00
    • Standard mail order $28.00

    When reviewing Ohio Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.

    You may be able to find plans in your part of Ohio that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.

    Plan Documents

    Links to plan documents

    Ohio Counties Served

    We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.

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