Todays Date: Effective Date:
Group Name: Zip Code:
City: SIC/Business:
Broker Co.: Broker Name:
Email/Fax #: Current Carrier:
MEDICAL MUTUAL OF OHIO
Tier Rate: Deductible Deductible
Office Visit Coinsurance OOP In-Ntwk
In-Ntwk Non-Ntwk OOP Non-Ntwk Single/Family
Copay In/Out Single/Family
Single/Family Single/Family
COSE - Standard $15k life - 10-99 Lives
All OOP Maximums exclude deductible amount
Please check desired plans: P
Supermed Plus Options- Hospital and Professional Provider Network PPO
1000 / 3000 $20 $1000 / $3000 $2000 / $6000 100% / 80% N/A $4000 / $12000
2000 / 6000 $20 $2000 / $6000 $4000 / $12000 100% / 80% N/A $8000 / $24000
3000 / 9000 $20 $3000 / $9000 $6000 / $18000 100% / 80% N/A $12000 / $36000
2080-250 $20 $250 / $500 $500 / $1000 80% / 60% $2000 / $4000 $4000 / $8000
2080-500 $20 $500 / $1000 $1000 / $2000 80% / 60% $2500 / $5000 $5000 / $10000
2080-750 $20 $750 / $1500 $1500 / $3000 80% / 60% $2500 / $5000 $5000 / $10000
2080-1000 $20 $1000 / $2000 $2000 / $4000 80% / 60% $2500 / $5000 $5000 / $10000
250 / 500 $15 $250 / $500 $250 / $500 80% / 64% $1250 / $2500 $2500 / $5000
500 / 1000 $15 $500 / $1000 $500 / $1000 80% / 64% $1250 / $2500 $2500 / $5000
750 / 1500 $20 $750 / $1500 $750 / $1500 80% / 64% $1500 / $3000 $2500 / $5000
1000 / 2000 $20 $1000 / $2000 $1000 / $2000 80% / 64% $1500 / $3000 $2500 / $5000
Supermed Multiple Option Products- Hospital and Professional Provider Network PPO
MOP 80 $20 $100 / $200 $250 / $500 80% / 60% $1250 / $2500 $3000 / $6000
MOP 90 $20 None $250 / $500 90% / 70% $1250 / $2500 $3000 / $6000
MOP 100 $15 None $250 / $500 100% / 70% None $1500 / $3000
HMO Health Ohio Products - PCP required
HMO Ohio $15 None None None
Please return completed quote requests by
4200 Rockside Road, Suite, 300 visiting our website at www.expresslinkga.com
Cleveland, Ohio 44131-2530 and clicking on request a quote.
www.expresslinkga.com