Select by Medica Bronze Premier

53461MO0010051
Expanded Bronze
EPO

Select by Medica Bronze Premier is an Expanded Bronze EPO plan by Medica.

IMPORTANT: You are viewing the 2024 version of Select by Medica Bronze Premier 53461MO0010051. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.

Locations

Select by Medica Bronze Premier is offered in the following counties.

Plan Overview

This is a plan overview for 2024 version of Select by Medica Bronze Premier 53461MO0010051.
Insurer: Medica
Network Type: EPO
Metal Type: Expanded Bronze
HSA Eligible?: No
Plan ID: 53461MO0010051

Cost-Sharing Overview

Select by Medica Bronze Premier offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Select by Medica Bronze Premier?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

Select by Medica Bronze Premier offers the following features and referral requirements.

Wellness Program: No
Disease Program: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy
Notice Pregnancy: No
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what Select by Medica Bronze Premier covers when you are out of the service area or out of the country.

Out of Country Coverage: Yes
Out of Country Coverage Description: Emergency Services
Out of Service Area Coverage: Yes
Out of Service Area Coverage Description: Emergency Services
National Network: No

Additional Benefits and Cost-Sharing

Select by Medica Bronze Premier includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
$0.00 Copay after deductible Not ApplicableNot Applicable 100.00% Virtual visits are unlimited with a $0 copayment when provided by a designated in-network virtual care provider for non-urgent medical symptoms for common illnesses.
Specialist Visit
Covered
$160.00 Copay after deductible Not ApplicableNot Applicable 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$0.00 Copay after deductible Not ApplicableNot Applicable 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Hospice Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Not Covered
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%82.0 Visit(s) per Benefit Period
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$0.00 Copay after deductible Not Applicable$0.00 Copay after deductible Not Applicable
Home Health Care Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%100.0 Visit(s) per Benefit Period To be eligible for benefits, you must essentially be confined to the home, as an alternative to a Hospital stay, and be physically unable to get needed medical services on an outpatient basis.
Emergency Room Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Inpatient Physician and Surgical Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%150.0 Days per Benefit Period
Prenatal and Postnatal Care
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Mental/Behavioral Health Outpatient Services
Covered
$0.00 Copay after deductible Not ApplicableNot Applicable 100.00%
Mental/Behavioral Health Inpatient Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Substance Abuse Disorder Outpatient Services
Covered
$0.00 Copay after deductible Not ApplicableNot Applicable 100.00%
Substance Abuse Disorder Inpatient Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Generic Drugs
Covered
$25.00 Not ApplicableNot Applicable 100.00% Preferred generic drugs on Medica’s Drug List are $25 and generic drugs are $30. Go to Plan Documents to see the List of Covered Drugs.
Preferred Brand Drugs
Covered
$200.00 Not ApplicableNot Applicable 100.00% Prescription insulin will not exceed $25 per prescription unit
Non-Preferred Brand Drugs
Covered
Not Applicable 70.00% Coinsurance after deductibleNot Applicable 100.00%
Specialty Drugs
Covered
$800.00 Not ApplicableNot Applicable 100.00%
Outpatient Rehabilitation Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%20.0 Visit(s) per Benefit Period This visit limit does not apply to services for treatment of autism spectrum disorder.
Habilitation Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%20.0 Visit(s) per Benefit Period This visit limit does not apply to services for mental health conditions or substance use disorder.
Chiropractic Care
Covered
$0.00 Copay after deductible Not ApplicableNot Applicable 100.00%
Durable Medical Equipment
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Hearing Aids
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Benefits include hearing aids provided to a newborn for initial amplification following a newborn hearing screening.
Imaging (CT/PET Scans, MRIs)
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Preventive Care/Screening/Immunization
Covered
Not Applicable No ChargeNot Applicable 100.00%
Routine Foot Care
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Coverage is available if Medically Necessary.
Acupuncture
Not Covered
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
$0.00 Copay after deductible Not ApplicableNot Applicable 100.00%1.0 Exam(s) per Benefit Period
Eye Glasses for Children
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%1.0 Item(s) per Year Covered lenses and frames each available at limit of one per year.
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Unlimited visits for speech therapy.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%20.0 Visit(s) per Benefit Period 20 visit limit each for PT and OT. This visit limit does not apply to services for treatment of autism spectrum disorder.
Well Baby Visits and Care
Covered
Not Applicable No ChargeNot Applicable 100.00%
Laboratory Outpatient and Professional Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
X-rays and Diagnostic Imaging
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Basic Dental Care – Child
Not Covered
Orthodontia – Child
Not Covered
Major Dental Care – Child
Not Covered
Basic Dental Care – Adult
Not Covered
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Not Covered
Abortion for Which Public Funding is Prohibited
Not Covered
Transplant
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Accidental Dental
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Dialysis
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Allergy Testing
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Chemotherapy
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Radiation
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Diabetes Education
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Prosthetic Devices
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Infusion Therapy
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Nutritional Counseling
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Reconstructive Surgery
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Gender Affirming Care
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%

Free Preventive Services

There is no copayment or coinsurance for any of the following Select by Medica Bronze Premier preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for Select by Medica Bronze Premier including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for Select by Medica Bronze Premier?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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