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Medica Individual Choice Gold Copay $0 PCP

73751ND0130045
Gold
HMO

Medica Individual Choice Gold Copay $0 PCP is a Gold HMO plan by Medica.

IMPORTANT: You are viewing the 2024 version of Medica Individual Choice Gold Copay $0 PCP 73751ND0130045. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.

Locations

Medica Individual Choice Gold Copay $0 PCP is offered in the following counties.

Plan Overview

This is a plan overview for 2024 version of Medica Individual Choice Gold Copay $0 PCP 73751ND0130045.
Insurer: Medica
Network Type: HMO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 73751ND0130045

Cost-Sharing Overview

Medica Individual Choice Gold Copay $0 PCP 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 Medica Individual Choice Gold Copay $0 PCP?

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

Medica Individual Choice Gold Copay $0 PCP 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 Medica Individual Choice Gold Copay $0 PCP 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

Medica Individual Choice Gold Copay $0 PCP 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 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
$85.00 Not ApplicableNot Applicable 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$0.00 Not ApplicableNot Applicable 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Hospice Services
Covered
Not Applicable 30.00% 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
Not Covered
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$0.00 Not Applicable$0.00 Not Applicable
Home Health Care Services
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%40.0 Visit(s) per Benefit Period
Emergency Room Services
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 30.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 30.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Inpatient Physician and Surgical Services
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Bariatric Surgery
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%1.0 Procedure(s) per Lifetime
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%30.0 Days per Benefit Period
Prenatal and Postnatal Care
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Mental/Behavioral Health Outpatient Services
Covered
$0.00 Not ApplicableNot Applicable 100.00%
Mental/Behavioral Health Inpatient Services
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Substance Abuse Disorder Outpatient Services
Covered
$0.00 Not ApplicableNot Applicable 100.00%
Substance Abuse Disorder Inpatient Services
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Generic Drugs
Covered
$0.00 Not ApplicableNot Applicable 100.00% Preferred generic drugs on Medica’s Drug List are $0 and generic drugs are $15. Go to Plan Documents to see the List of Covered Drugs.
Preferred Brand Drugs
Covered
$80.00 Not ApplicableNot Applicable 100.00% Prescription insulin will not exceed $25 per prescription unit
Non-Preferred Brand Drugs
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Specialty Drugs
Covered
$550.00 Not ApplicableNot Applicable 100.00%
Outpatient Rehabilitation Services
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%30.0 Visit(s) per Benefit Period This visit limit does not apply to services for treatment of autism spectrum disorder.
Habilitation Services
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%30.0 Visit(s) per Benefit Period This visit limit does not apply to services for treatment of autism spectrum disorder.
Chiropractic Care
Covered
$0.00 Not ApplicableNot Applicable 100.00%20.0 Visit(s) per Benefit Period
Durable Medical Equipment
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Hearing Aids
Not Covered
Imaging (CT/PET Scans, MRIs)
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Preventive Care/Screening/Immunization
Covered
Not Applicable No ChargeNot Applicable 100.00%
Routine Foot Care
Not Covered
Acupuncture
Not Covered
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
$0.00 Not ApplicableNot Applicable 100.00%1.0 Exam(s) per Benefit Period
Eye Glasses for Children
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%1.0 Item(s) per Benefit Period Frames are limited to one every other benefit period. Lenses are limited to one pair per benefit period.
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%30.0 Visit(s) per Year This visit limit does not apply to services for treatment of autism spectrum disorder.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%30.0 Visit(s) per Year 30-visit limit is for each of 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 30.00% Coinsurance after deductibleNot Applicable 100.00%
X-rays and Diagnostic Imaging
Covered
Not Applicable 30.00% 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 30.00% Coinsurance after deductibleNot Applicable 100.00%1.0 Exam(s) per Transplant One evaluation is allowed per transplant procedure. Services must be performed at a qualified transplant center.
Accidental Dental
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Dialysis
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Allergy Testing
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Chemotherapy
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Radiation
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Diabetes Education
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Prosthetic Devices
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Infusion Therapy
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%2.0 Treatment(s) per Lifetime Benefits are subject to a Lifetime Maximum of 2 surgical procedures per Member and a Maximum Benefit Allowance of 1 splint per Member per Benefit Period.
Nutritional Counseling
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%4.0 Visit(s) per Benefit Period
Reconstructive Surgery
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Gender Affirming Care
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%

Free Preventive Services

There is no copayment or coinsurance for any of the following Medica Individual Choice Gold Copay $0 PCP 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 Medica Individual Choice Gold Copay $0 PCP 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 Medica Individual Choice Gold Copay $0 PCP?

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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