Elevate by Medica Gold Share – EPO

Description

Health Care Plan Details

Network type	EPO
Deductible	$800 per person $800 per person
Out-of-pocket max	$8,500 per person $17,000 per family
Metal tier	Gold

Visit Copay

Primary care visit	30% coinsurance after deductible
Specialist visit	30% coinsurance after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	30% coinsurance after deductible
Emergency room	30% coinsurance after deductible
Ambulance	30% coinsurance after deductible
Hospital stay (facility)	30% coinsurance after deductible
Hospital stay (physician)	30% coinsurance after deductible
Outpatient procedure (facility)	30% coinsurance after deductible
Outpatient procedure (physician)	30% coinsurance after deductible
Physical rehabilitation	30% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	30% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	No charge
Brand	$80 copay
Non-preferred Brand	50% coinsurance after deductible
Specialty	$550 copay

Lab Tests and Diagnostic Procedures

X-rays	30% coinsurance after deductible
Imaging (CT/PET/MRI)	30% coinsurance after deductible
Blood work	30% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	30% coinsurance after deductible
Psychiatric hospital stay	30% coinsurance after deductible

Health Plan Provider Information

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