Á½ÐÔÉ«ÎçÒ¹

MedFlex is a narrow network medical plan offered through Medical Mutual. A narrow network plan uses a smaller group of doctors, hospitals, and healthcare facilities than a traditional PPO plan. Because the network is more limited, premiums and overall healthcare costs are lower.

MedFlex uses a focused, Ohio-based network of physicians, hospitals, specialists, urgent-care centers, and other healthcare providers. The network includes providers and health systems throughout Ohio. It is designed for members who live in Ohio, work in Ohio, or primarily receive their healthcare in Ohio.

MedFlex is available to:

• Eligible non-bargaining employees
• Eligible AFSCME employees
• MedFlex is not currently available to employees in the KSUFA bargaining unit

MedFlex is primarily an Ohio-based network. Before enrolling, employees should carefully confirm that their preferred doctors, specialists, hospitals, and other providers participate in the MedFlex network.

MedFlex may not be a good fit for employees or covered family members who regularly receive routine or planned healthcare outside Ohio, attend school out of state, live outside Ohio for part of the year, or rely on providers who do not participate in the MedFlex network.

You can continue seeing your current physician if that provider participates in the Medical Mutual MedFlex network.

Participation in another Medical Mutual network does not automatically mean a provider participates in MedFlex. Before enrolling, verify each provider’s participation in MedFlex, including:

• Primary care providers
• Specialists
• Hospitals
• Urgent-care facilities
• Behavioral-health providers
• Physical therapists and other rehabilitation providers
• Laboratories and imaging facilities
• Surgery centers and other outpatient facilities

You should also call the provider’s office and confirm that the provider participates in the Medical Mutual MedFlex network for the upcoming plan year.

Before enrolling, you should:

• Use Medical Mutual's provider search tool.
• Verify your primary care physician is in the MedFlex network.
• Check that any specialists you see are in the MedFlex network.
• Confirm that your preferred hospital and healthcare facilities participate.
• If you have a dependent living away from home (such as a student at college), search for available network providers near their school location.

Do not assume that because a provider accepts Medical Mutual they are automatically part of the MedFlex network.

No. MedFlex is a non-gatekeeper HMO, which means you do not have to select a primary care physician and generally do not need a referral to see an in-network specialist.

However, choosing a primary care physician is encouraged. A primary care physician can help coordinate preventive care, chronic-condition management, prescriptions, follow-up care, and specialist services.

Generally, no. You may see an in-network specialist without a referral from a primary care physician.

Some services may still require prior authorization or medical review. Employees should check plan materials or contact Medical Mutual before receiving services that may require approval, such as certain imaging services, procedures, hospital admissions, specialty medications, or durable medical equipment.

Non-emergency care received outside the MedFlex network is not covered.

If you receive routine, planned, or non-emergency care from a provider or facility that does not participate in MedFlex, you may be responsible for the full cost of the service.

Always confirm that both the provider and the facility participate in MedFlex before receiving non-emergency care.

In an emergency, call 911 or go to the nearest emergency department. Emergency services are covered regardless of whether the provider or hospital participates in MedFlex.

After the emergency is stabilized, contact Medical Mutual as soon as possible for guidance about follow-up care, transfer, admission, or continuing treatment. Whenever possible, ongoing care should be moved to an in-network MedFlex provider or facility.

If you have a medical emergency while traveling, seek emergency care immediately.

For non-emergency care while traveling, contact Medical Mutual before receiving services whenever possible. Because MedFlex is an Ohio-based network and non-emergency out-of-network care is not covered, routine or planned care outside the network may result in full financial responsibility for the service.

No. Prescription-drug coverage under MedFlex is the same as prescription-drug coverage under Á½ÐÔÉ«Îçҹ’s other medical plans.

Employees enrolled in MedFlex will have the same prescription-drug formulary, pharmacy network, and applicable prescription rules as employees enrolled in Á½ÐÔÉ«Îçҹ’s other medical-plan options. This includes applicable requirements for prior authorization, step therapy, quantity limits, specialty medications, and preferred pharmacy use.

Preventive services are covered when received from an in-network MedFlex provider or facility.

To avoid unexpected costs, use MedFlex providers for preventive appointments and confirm that the provider, laboratory, imaging center, and any facility involved in your care participate in the MedFlex network.

Not necessarily. A hospital may participate in MedFlex, but individual professionals involved in your care may have separate network status. This can include surgeons, anesthesiologists, radiologists, pathologists, ambulance providers, and other physician groups.

Before planned care, verify that the hospital or facility and the professionals expected to provide your care participate in MedFlex.

This is an important consideration. MedFlex does not include a national wrap network. Its network is concentrated within Ohio, spanning more than 70 counties, or about 80% of the state. If a covered dependent, such as a college student attending school in another part of Ohio outside the MedFlex service area or out of state, needs routine or non-emergency care, that care generally will not be covered unless it is received from a MedFlex network provider.

True emergencies are always covered regardless of location. However, routine visits, prescriptions, mental health counseling, follow-up care, and other planned or non-emergency services obtained near a dependent's school would likely not be covered under MedFlex. Before enrolling, carefully consider each dependent's location, where they attend school, and whether they would have reasonable access to MedFlex network providers or would instead need to travel home for non-emergency care.

Before choosing MedFlex, employees should:

• Confirm that their doctors, hospitals, specialists, and other frequently used providers participate in MedFlex.
• Consider whether covered family members receive care outside Ohio or outside the MedFlex network.
• Review the medical-plan comparison materials, payroll contributions, deductibles, copays, coinsurance, and out-of-pocket maximums.
• Consider any anticipated healthcare needs, including pregnancy, surgery, chronic-condition care, behavioral-health treatment, specialty medications, or ongoing therapy.
• Remember that prescription coverage is the same under MedFlex and Á½ÐÔÉ«Îçҹ’s other medical plans.
• Understand that non-emergency care outside the MedFlex network is not covered.

MedFlex may be a good option for eligible non-bargaining and AFSCME employees who:

• Primarily receive healthcare in Ohio
• Have confirmed that their preferred providers and facilities participate in MedFlex
• Are comfortable using a focused provider network
• Do not anticipate needing routine or planned care outside the MedFlex network
• Want to compare MedFlex’s payroll cost and cost-sharing structure with other Á½ÐÔÉ«ÎçÒ¹ plan options

Another Á½ÐÔÉ«ÎçÒ¹ medical-plan option may be a better fit for employees or family members who:

• Regularly receive non-emergency care outside Ohio
• Have physicians, specialists, hospitals, or treatment facilities that do not participate in MedFlex
• Have a dependent attending school or living outside Ohio who may need routine care
• Want broader flexibility to receive non-emergency care from out-of-network providers
• Are currently receiving ongoing treatment from providers outside the MedFlex network.