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

20305NE0030055
Gold
EPO

Elevate by Medica Gold Standard ($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 Standard ($0 Virtual Care with Designated Providers) 20305NE0030055. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

Elevate by Medica Gold Standard ($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 Standard ($0 Virtual Care with Designated Providers) 20305NE0030055.
Insurer: Medica
Network Type: EPO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 20305NE0030055

Cost-Sharing Overview

Elevate by Medica Gold Standard ($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 Standard ($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 Standard ($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 Standard ($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 Standard ($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
$30.00 100.00% Virtual visits are unlimited with a $0 copayment when provided by designated providers for non-urgent medical symptoms.
Specialist Visit
Covered
$60.00 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$30.00 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
25.00% Coinsurance after deductible 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
25.00% Coinsurance after deductible 100.00%
Hospice Services
Covered
25.00% Coinsurance after deductible 100.00%
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Not Covered
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Not Covered
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$45.00 $45.00
Home Health Care Services
Covered
25.00% Coinsurance after deductible 100.00%60 Days per Year
Emergency Room Services
Covered
25.00% Coinsurance after deductible 25.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
25.00% Coinsurance after deductible 25.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
25.00% Coinsurance after deductible 100.00%
Inpatient Physician and Surgical Services
Covered
25.00% Coinsurance after deductible 100.00%
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
25.00% Coinsurance after deductible 100.00%60 Days per Year
Prenatal and Postnatal Care
Covered
25.00% Coinsurance after deductible 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
25.00% Coinsurance after deductible 100.00%
Mental/Behavioral Health Outpatient Services
Covered
$30.00 100.00%
Mental/Behavioral Health Inpatient Services
Covered
25.00% Coinsurance after deductible 100.00%
Substance Abuse Disorder Outpatient Services
Covered
$30.00 100.00%
Substance Abuse Disorder Inpatient Services
Covered
25.00% Coinsurance after deductible 100.00%
Generic Drugs
Covered
$15.00 100.00%
Preferred Brand Drugs
Covered
$30.00 100.00% Prescription insulin will not exceed $25 per prescription unit
Non-Preferred Brand Drugs
Covered
$60.00 100.00%
Specialty Drugs
Covered
$250.00 100.00%
Outpatient Rehabilitation Services
Covered
25.00% Coinsurance after deductible 100.00%45 Treatment(s) per Year
Habilitation Services
Covered
25.00% Coinsurance after deductible 100.00%45 Treatment(s) per Year
Chiropractic Care
Covered
$30.00 100.00%20 Visit(s) per Year
Durable Medical Equipment
Covered
25.00% Coinsurance after deductible 100.00%
Hearing Aids
Covered
25.00% Coinsurance after deductible 100.00% Limited to $3000 every 48 months age 18 and under.
Imaging (CT/PET Scans, MRIs)
Covered
25.00% 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
$30.00 100.00%1 Exam(s) per Year
Eye Glasses for Children
Covered
25.00% Coinsurance after deductible 100.00%1 Item(s) per Year
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
$30.00 100.00%45 Visit(s) per Year
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$30.00 100.00%45 Visit(s) per Year
Well Baby Visits and Care
Covered
No Charge 100.00%
Laboratory Outpatient and Professional Services
Covered
25.00% Coinsurance after deductible 100.00%
X-rays and Diagnostic Imaging
Covered
25.00% 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
Transplant
Covered
25.00% Coinsurance after deductible 100.00%
Accidental Dental
Covered
25.00% Coinsurance after deductible 100.00%
Dialysis
Covered
25.00% Coinsurance after deductible 100.00%
Allergy Testing
Covered
25.00% Coinsurance after deductible 100.00%
Chemotherapy
Covered
25.00% Coinsurance after deductible 100.00%
Radiation
Covered
25.00% Coinsurance after deductible 100.00%
Diabetes Education
Covered
25.00% Coinsurance after deductible 100.00%
Prosthetic Devices
Covered
25.00% Coinsurance after deductible 100.00%
Infusion Therapy
Covered
25.00% Coinsurance after deductible 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
25.00% Coinsurance after deductible 100.00%
Nutritional Counseling
Covered
25.00% Coinsurance after deductible 100.00% Only for diabetes management as provided by the plan.
Reconstructive Surgery
Covered
25.00% Coinsurance after deductible 100.00% Available only post-mastectomy or when required to restore, reconstruct or correct any bodily function that was lost, impaired or damaged as a result of Injury or Illness.
Gender Affirming Care
Covered
25.00% Coinsurance after deductible 100.00%

Free Preventive Services

There is no copayment or coinsurance for any of the following Elevate by Medica Gold Standard ($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 Standard ($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 Standard ($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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