Medica Insurance Company

Medica with CHI Health Silver $0 Copay PCP Visits

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

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Plan Overview

Combined Medical and Drug Deductible	Individual: $3,500.00 Family: $7000 Per Person: $3500
Combined Medical and Drug Out of Pocket Maximum	Individual: $9,000.00 Family: $18000 Per Person: $9000

Office Visit

Primary Doctor	CoPay: $0.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: 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	CoPay: $80.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $125.00 CoInsurance: Not Applicable Covered: Covered
Non Preferred Brand Drugs	CoPay: $225.00 CoInsurance: Not Applicable Covered: Covered
Generic Drugs	CoPay: $25.00 CoInsurance: Not Applicable Covered: Covered
Specialty Drugs	CoPay: $700.00 CoInsurance: Not Applicable Covered: Covered

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered
Urgent Care Facility	CoPay: $0.00 CoInsurance: Not Applicable Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered

Vision

Routine Eye Exams for Children

CoPay: $0.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per Year

Major Dental Care

Routine Dental Checkups for Children	Covered: Not Covered
Routine Dental Checkups for Adults	Covered: Not Covered

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