Medica Individual Choice Bronze HSA – EPO

Description

Health Care Plan Details

Network type	EPO
Deductible	$6,750 per person $6,750 per person
Out-of-pocket max	$8,000 per person $16,000 per family
Metal tier	Expanded Bronze

Visit Copay

Primary care visit	5% coinsurance after deductible
Specialist visit	5% coinsurance after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	5% coinsurance after deductible
Emergency room	5% coinsurance after deductible
Ambulance	5% coinsurance after deductible
Hospital stay (facility)	5% coinsurance after deductible
Hospital stay (physician)	5% coinsurance after deductible
Outpatient procedure (facility)	5% coinsurance after deductible
Outpatient procedure (physician)	5% coinsurance after deductible
Physical rehabilitation	5% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	5% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	5% coinsurance after deductible
Brand	5% coinsurance after deductible
Non-preferred Brand	5% coinsurance after deductible
Specialty	5% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	5% coinsurance after deductible
Imaging (CT/PET/MRI)	5% coinsurance after deductible
Blood work	5% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	5% coinsurance after deductible
Psychiatric hospital stay	5% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://portal.medica.com/visitor/sbcsearch/docdisplay?plancode=2024-IFBICBHWI&uid=FFM.pdf
Drug and medication plan formulary	https://www.Medica.com/WIDrugList-2024
Search doctor list	https://www.Medica.com/SearchIndividualChoiceNetwork-2024