Medica Encore Gold B – PPO
Network type: PPO
Coverage tier: Gold
Primary care visit: $30 copay
Specialist visit: $70 copay
Urgent care visit: 30% after deductible
Description
Health Care Plan Details
| Network type | PPO |
| Deductible | See brochure See brochure |
| Out-of-pocket max | N/A per person N/A per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $30 copay |
| Specialist visit | $70 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | 30% after deductible |
| Emergency room | 30% after deductible |
| Ambulance | 30% after deductible |
| Hospital stay (facility) | 30% after deductible |
| Hospital stay (physician) | 30% after deductible |
| Outpatient procedure (facility) | 30% after deductible |
| Outpatient procedure (physician) | 30% after deductible |
| Physical rehabilitation | 30% after deductible |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 30% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $10 per script copay |
| Brand | 30% after deductible |
| Non-preferred Brand | 50% after deductible |
| Specialty | 30% after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 30% after deductible |
| Imaging (CT/PET/MRI) | 30% after deductible |
| Blood work | 30% after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $30 copay |
| Psychiatric hospital stay | 30% after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/5ahHcNS5iRPtmUSJPV6Zsohs.pdf |
| Drug and medication plan formulary | https://www.medica.com/MNClosedDrugList-2024 |
