Elevate by Medica Bronze Share Plus – EPO

Description

Health Care Plan Details

Network type	EPO
Deductible	$3,000 per person $3,000 per person
Out-of-pocket max	$9,450 per person $18,900 per family
Metal tier	Expanded Bronze

Visit Copay

Primary care visit	50% coinsurance after deductible
Specialist visit	50% coinsurance after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	50% coinsurance after deductible
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	50% coinsurance after deductible
Psychiatric hospital stay	50% coinsurance after deductible

Health Plan Provider Information

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