Dwellworks 2023 Benefits Guide
MEDICAL / RX – Medical Mutual of Ohio HEALTH | PLAN COMPARISON
Option 1
Option 2
Option 3
HDHP $3,000 Embedded Deductible
PPO $1,500 Embedded Deductible
PPO $750 Embedded Deductible
IN-NETWORK BENEFITS
DEDUCTIBLE Single Deductible
$3,000
$1,500
$750
Two Person/Family Deductible
$6,000
$3,000
$1,500
COINSURANCE (applies after deductible is met) & Out of Pocket Max (includes coinsurance and deductible) Plan Pays 80% 80%
80%
Single Maximum
$5,300
$4,000
$3,000
Two Person/Family Maximum
$10,600
$8,000
$6,000
Health Savings Account
Eligible Plan for HSA
MEMBER COPAYMENT(S) Primary Care (PCP) - Office Visit
80% after deductible
$30 copay
$20 copay
Virtual Visit
80% after deductible
$30 copay
$20 copay
Preventive Services
100%
100%
100%
Specialist - Office Visit
80% after deductible
$30 copay
$20 copay
OP Lab, X-Ray, MRI/Cat Scan
80% after deductible
80% after deductible
80% after deductible
Hospital IP, OP Surgery
80% after deductible
80% after deductible
80% after deductible
Urgent Care Facility
80% after deductible
$75 copay
$75 copay
Emergency Room Visit
80% after deductible
$250 copay
$250 copay
Rx Copays
HDHP $3,000
PPO $1,500
PPO $750
Retail
Mail-Order
Retail
Mail-Order
Retail
Mail-Order
30 Days
90 Days
30 Days
90 Days
30 Days
90 Days
GENERIC
80% after deductible
$10
$25
$10
$25
Preferred Brand
80% after deductible
$30
$75
$30
$75
Non-Preferred Brand
80% after deductible
$50
$125
$50
$125
HDHP $3,000
PPO $1,500
PPO $750
Employee Portion (Per pay)
Employee Portion (Per pay)
Employee Portion (Per pay)
Contributions (24 pays/year) Medical 2023
Dwellworks Portion (Per pay)
Dwellworks Portion (Per pay)
Dwellworks Portion (Per pay)
Employee
$8.00
$208.88 $314.12 $244.79 $444.90
$70.00
$208.78 $393.31 $301.18 $561.42
$90.00
$204.34 $377.54 $287.43 $529.50
Employee + Spouse
$160.00 $120.00 $220.00
$220.00 $170.00 $300.00
$270.00 $210.00 $380.00
Employee + Child(ren)
Family
| BENEFITS GUIDE
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