Select by Medica Gold Copay $0 PCP – EPO
Network type: EPO
Coverage tier: Gold
Primary care visit: No charge
Specialist visit: $85 copay
Urgent care visit: No charge
Description
Health Care Plan Details
Network type | EPO |
Deductible | $1,750 per person $1,750 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 | $85 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 | $80 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-IFBSMGCPCKS&uid=FFM.pdf |
Drug and medication plan formulary | https://www.Medica.com/KSDrugList-2024 |
Search doctor list | https://www.Medica.com/SearchSelectNetwork-2024 |