Elevate by Medica Bronze Copay $0 PCP – EPO
Network type: EPO
Coverage tier: Expanded Bronze
Primary care visit: No charge
Specialist visit: $150 copay
Urgent care visit: No charge
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | $7,500 per person $7,500 per person |
| Out-of-pocket max | $9,450 per person $18,900 per family |
| Metal tier | Expanded Bronze |
Visit Copay
| Primary care visit | No charge |
| Specialist visit | $150 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | No charge |
| Emergency room | 50% coinsurance after deductible |
| Ambulance | 50% coinsurance after deductible |
| Hospital stay (facility) | 50% coinsurance after deductible |
| Hospital stay (physician) | 50% coinsurance after deductible |
| Outpatient procedure (facility) | 50% coinsurance after deductible |
| Outpatient procedure (physician) | 50% coinsurance after deductible |
| Physical rehabilitation | 50% coinsurance after deductible |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 50% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $25 copay |
| Brand | $200 copay |
| Non-preferred Brand | 70% coinsurance after deductible |
| Specialty | $750 copay |
Lab Tests and Diagnostic Procedures
| X-rays | 50% coinsurance after deductible |
| Imaging (CT/PET/MRI) | 50% coinsurance after deductible |
| Blood work | 50% coinsurance after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | No charge |
| Psychiatric hospital stay | 50% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://portal.medica.com/visitor/sbcsearch/docdisplay?plancode=2024-IFBEMBCPCIA&uid=FFM.pdf |
| Drug and medication plan formulary | https://www.Medica.com/IADrugList-2024 |
| Search doctor list | https://www.Medica.com/SearchElevateNetwork-2024 |
