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Elevate by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers)

93078IA0050045
Gold
EPO

Elevate by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers) is a Gold EPO plan by Medica.

IMPORTANT: You are viewing the 2023 version of Elevate by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers) 93078IA0050045. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

Elevate by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers) is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of Elevate by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers) 93078IA0050045.
Insurer: Medica
Network Type: EPO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 93078IA0050045

Cost-Sharing Overview

Elevate by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers) 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 Elevate by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers)?

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

Elevate by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers) 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 Elevate by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers) 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

Elevate by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers) 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
$0.00 100.00%
Specialist Visit
Covered
$80.00 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$0.00 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
30.00% Coinsurance after deductible 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
30.00% Coinsurance after deductible 100.00%
Hospice Services
Covered
30.00% Coinsurance after deductible 100.00% Care (generally in a home setting) for patients who are terminally ill and who have a life expectancy of six months or less. Hospice respite care has a quantity limit of 15 inpatient days and 15 outpatient days per lifetime. Hospice respite care must be used in increments of not more than five days at a time.
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Covered
30.00% Coinsurance after deductible 100.00% Artificial insemination, in vitro fertilization and other limitations and exclusions apply.
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Covered
30.00% Coinsurance after deductible 100.00% Plan refers to home skilled nursing as private duty nursing. Home skilled nursing is intended to provide a safe transition from other levels of care when medically necessary, to provide teaching to caregivers for ongoing care, or to provide short-term treatments that can be safely administered in the home setting.
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$0.00 $0.00
Home Health Care Services
Covered
30.00% Coinsurance after deductible 100.00%
Emergency Room Services
Covered
30.00% Coinsurance after deductible 30.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
30.00% Coinsurance after deductible 30.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
30.00% Coinsurance after deductible 100.00%
Inpatient Physician and Surgical Services
Covered
30.00% Coinsurance after deductible 100.00%
Bariatric Surgery
Covered
30.00% Coinsurance after deductible 100.00%
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
30.00% Coinsurance after deductible 100.00%
Prenatal and Postnatal Care
Covered
30.00% Coinsurance after deductible 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
30.00% Coinsurance after deductible 100.00%
Mental/Behavioral Health Outpatient Services
Covered
$0.00 100.00%
Mental/Behavioral Health Inpatient Services
Covered
30.00% Coinsurance after deductible 100.00%
Substance Abuse Disorder Outpatient Services
Covered
$0.00 100.00%
Substance Abuse Disorder Inpatient Services
Covered
30.00% Coinsurance after deductible 100.00%
Generic Drugs
Covered
$0.00 100.00% Tier 1 preferred generic drugs on Medica’s Drug List are $0 and tier 2 generic drugs are $15. Go to Plan Documents to see the List of Covered Drugs.
Preferred Brand Drugs
Covered
$80.00 100.00% Prescription insulin will not exceed $25 per prescription unit
Non-Preferred Brand Drugs
Covered
50.00% Coinsurance after deductible 100.00%
Specialty Drugs
Covered
$550.00 100.00%
Outpatient Rehabilitation Services
Covered
30.00% Coinsurance after deductible 100.00%
Habilitation Services
Covered
30.00% Coinsurance after deductible 100.00% Treatment for Autism with speech therapy, occupational therapy, or physical therapy is covered.
Chiropractic Care
Covered
$0.00 100.00%
Durable Medical Equipment
Covered
30.00% Coinsurance after deductible 100.00%
Hearing Aids
Not Covered
Imaging (CT/PET Scans, MRIs)
Covered
30.00% Coinsurance after deductible 100.00%
Preventive Care/Screening/Immunization
Covered
No Charge 100.00%
Routine Foot Care
Not Covered
Acupuncture
Not Covered
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
$0.00 100.00%1 Exam(s) per Benefit Period
Eye Glasses for Children
Covered
30.00% Coinsurance after deductible 100.00%1 Item(s) per Benefit Period
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
30.00% Coinsurance after deductible 100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
30.00% Coinsurance after deductible 100.00%
Well Baby Visits and Care
Covered
No Charge 100.00%
Laboratory Outpatient and Professional Services
Covered
30.00% Coinsurance after deductible 100.00%
X-rays and Diagnostic Imaging
Covered
30.00% Coinsurance after deductible 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
Excludes abortions that are elective, except abortions performed when the life of the mother is at risk. Elective, induced abortions are not covered, except as medically necessary to protect the life of the mother.
Transplant
Covered
30.00% Coinsurance after deductible 100.00%
Accidental Dental
Covered
30.00% Coinsurance after deductible 100.00%
Dialysis
Covered
30.00% Coinsurance after deductible 100.00%
Allergy Testing
Covered
30.00% Coinsurance after deductible 100.00%
Chemotherapy
Covered
30.00% Coinsurance after deductible 100.00%
Radiation
Covered
30.00% Coinsurance after deductible 100.00%
Diabetes Education
Covered
30.00% Coinsurance after deductible 100.00%
Prosthetic Devices
Covered
30.00% Coinsurance after deductible 100.00%
Infusion Therapy
Covered
30.00% Coinsurance after deductible 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
30.00% Coinsurance after deductible 100.00%
Nutritional Counseling
Not Covered
Reconstructive Surgery
Covered
30.00% Coinsurance after deductible 100.00%
Gender Affirming Care
Covered
30.00% Coinsurance after deductible 100.00%

Free Preventive Services

There is no copayment or coinsurance for any of the following Elevate by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers) 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 Elevate by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers) 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 Elevate by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers)?

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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