Medica Individual Choice Silver Share – EPO

Description

Health Care Plan Details

Network type	EPO
Deductible	$2,200 per person $2,200 per person
Out-of-pocket max	$8,700 per person $17,400 per family
Metal tier	Silver

Visit Copay

Primary care visit	40% coinsurance after deductible
Specialist visit	40% coinsurance after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	40% coinsurance after deductible
Emergency room	40% coinsurance after deductible
Ambulance	40% coinsurance after deductible
Hospital stay (facility)	40% coinsurance after deductible
Hospital stay (physician)	40% coinsurance after deductible
Outpatient procedure (facility)	40% coinsurance after deductible
Outpatient procedure (physician)	40% coinsurance after deductible
Physical rehabilitation	40% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	40% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$5 copay
Brand	$125 copay
Non-preferred Brand	60% coinsurance after deductible
Specialty	$750 copay

Lab Tests and Diagnostic Procedures

X-rays	40% coinsurance after deductible
Imaging (CT/PET/MRI)	40% coinsurance after deductible
Blood work	40% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	40% coinsurance after deductible
Psychiatric hospital stay	40% coinsurance after deductible

Health Plan Provider Information

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