Elevate by Medica Silver Enhanced – EPO
87% cost sharing reduction [Popular Plan]
Network type: EPO
Coverage tier: Silver
Primary care visit: $50 copay
Specialist visit: $100 copay
Urgent care visit: $50 copay
Description
This plan has 87% cost sharing reduction [Popular Plan]
Health Care Plan Details
| Network type | EPO |
| Deductible | $0 per person $0 per person |
| Out-of-pocket max | $3,150 per person $6,300 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $50 copay |
| Specialist visit | $100 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $50 copay |
| Emergency room | 30% coinsurance |
| Ambulance | 30% coinsurance |
| Hospital stay (facility) | 30% coinsurance |
| Hospital stay (physician) | 30% coinsurance |
| Outpatient procedure (facility) | 30% coinsurance |
| Outpatient procedure (physician) | 30% coinsurance |
| Physical rehabilitation | 30% coinsurance |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 30% coinsurance |
Pharmacy, Drugs, and Medication
| Generic | $5 copay |
| Brand | $100 copay |
| Non-preferred Brand | 40% coinsurance |
| Specialty | $500 copay |
Lab Tests and Diagnostic Procedures
| X-rays | 30% coinsurance |
| Imaging (CT/PET/MRI) | 30% coinsurance |
| Blood work | 30% coinsurance |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $50 copay |
| Psychiatric hospital stay | 30% coinsurance |
Health Plan Provider Information
| Health Plan Benefits | https://portal.medica.com/visitor/sbcsearch/docdisplay?plancode=2024-IFBEMSENNE87&uid=FFM.pdf |
| Drug and medication plan formulary | https://www.Medica.com/NEDrugList-2024 |
| Search doctor list | https://www.Medica.com/SearchElevateNetwork-2024 |
