Essentia Choice Care with Medica Silver HSA – EPO
Network type: EPO
Coverage tier: Silver
Primary care visit: 25% after deductible
Specialist visit: 25% after deductible
Urgent care visit: 25% after deductible
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | $3,100 per person $3,100 per person |
| Out-of-pocket max | $7,200 per person $14,400 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | 25% after deductible |
| Specialist visit | 25% after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | 25% after deductible |
| Emergency room | 25% after deductible |
| Ambulance | 25% after deductible |
| Hospital stay (facility) | 25% after deductible |
| Hospital stay (physician) | 25% after deductible |
| Outpatient procedure (facility) | 25% after deductible |
| Outpatient procedure (physician) | 25% after deductible |
| Physical rehabilitation | 25% after deductible |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 25% after deductible |
Pharmacy, Drugs, and Medication
| Generic | 25% after deductible |
| Brand | 25% after deductible |
| Non-preferred Brand | 25% after deductible |
| Specialty | 25% after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 25% after deductible |
| Imaging (CT/PET/MRI) | 25% after deductible |
| Blood work | 25% after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | 25% after deductible |
| Psychiatric hospital stay | 25% after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/TKcpHmq9MuxyWm8Aj5Vr7Kmg.pdf |
| Drug and medication plan formulary | https://www.medica.com/MNClosedDrugList-2024 |
