Medica with CHI Health Gold Copay $0 PCP Office Visits – EPO
Network type: EPO
Coverage tier: Gold
Primary care visit: No charge
Specialist visit: $90 copay
Urgent care visit: No charge
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | $1,500 per person $1,500 per person |
| Out-of-pocket max | $8,700 per person $17,400 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | No charge |
| Specialist visit | $90 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | No charge |
| 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 | $100 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 | No charge |
| Psychiatric hospital stay | 30% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://portal.medica.com/visitor/sbcsearch/docdisplay?plancode=2024-IFBCHGCPCNE&uid=FFM.pdf |
| Drug and medication plan formulary | https://www.Medica.com/NEDrugList-2024 |
| Search doctor list | https://www.Medica.com/SearchCHINetwork-2024 |
