Medical Comparison Chart

This summary of benefits is designed to provide a high-level overview of Cleveland State University’s Medical and Prescription Drug benefits.

Should there be a conflict between this summary and the actual terms and provisions of the plan documents, the terms of the plan documents and contracts will govern in all cases. You will not gain any new benefits because of a misstatement or an omission in this overview.

Benefit Period January 1–December 31*

	MetroHealth Select		Medical Mutual Value Plan		Medical Mutual Traditional Plan
	CSU Health and Wellness Services are provided at no cost to Faculty and Staff Covers 100% of preventive care services provided in-network (according to age and gender) Primarily utilizes MetroHealth Select Healthcare Professionals Requires you to Pay 100% for most Non-Network services Option to participate in Health Care Flexible Spending Account		CSU Health and Wellness Services are provided at no cost to Faculty and Staff Covers 100% of preventive care services provided in-network (according to age and gender) In-Network coverage through Medical Mutual SuperMed Network Option to participate in Health Care Flexible Spending Account		CSU Health and Wellness Services are provided at no cost to Faculty and Staff Covers 100% of preventive care services provided in-network (according to age and gender) In-Network coverage through Medical Mutual SuperMed Network Option to participate in Health Care Flexible Spending Account
	In-Network	Non-Network	In-Network	Non-Network	In-Network	Non-Network
Deductible
Individual	$350	Not covered	$1,100	$2,200	$600	$1,200
Family	$700	Not covered	$2,200	$4,400	$1,200	$2,400
Coinsurance After Deductible	10%, after ded.	Not covered	20% after ded.	40% after ded.	10% after ded.	30% after ded.
Coinsurance Limit—Medical Only—Excludes Deductibles and Copayments
Individual	$1,000	N/A	$3,250	$6,500	$1,750	$3,500
Family	$2,000	N/A	$6,500	$13,000	$3,500	$7,000
Inpatient Facility Services	10%, after ded.	Not covered	20% after ded.	40% after ded.	10% after ded.	30% after ded.
Outpatient Facility & X-Ray/ Lab Services	10%, after ded.	Not covered	20% after ded.	Not covered	10% after ded.	30% after ded.
Preventive Care Office Visit	$0 copay, no ded.	Not covered	$0 copay, no ded.	40% after ded.	$0 copay, no ded.	30% after ded.
Office Visit—Primary Care Physician	$20 copay	Not covered	$35 copay	40% after ded.	$25 copay	30% after ded.
Office Visit—Specialist	$30 copay	Not covered	$45 copay	40% after ded.	$35 copay	30% after ded.
Urgent Care Visit	$40 copay	Not covered	$65 copay	40% after ded.	$50 copay	30% after ded.
Emergency Room Visit (copay waived if admitted)	100% after $250 copay	100% after $250 copay	$350 copay +20% after ded.	$350 copay +20% after ded.	$300 copay +10% after ded.	$300 copay +10% after ded.
Emergency Room Visit—Non- Emergency	$250 copay + 10% after ded.	Not covered	$350 copay +20% after ded.	$350 copay +40% after ded.	$300 copay +30% after ded.	$300 copay +30% after ded.

* The benefit period is based on a calendar year and it is the period of time during which covered services are rendered and benefit maximums, deductibles, and out-of-pocket maximums are accumulated.