Medica Insurance Company

Select by Medica Gold Copay ($0 Virtual Care)

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $850 Family: $2,550 Per Person: $850
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,100 Family: $16,200 Per Person: $8,100

Office Visit

Primary Doctor	CoPay: $15.00 CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: $90.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $80.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Prescription insulin will not exceed $25 per prescription unit
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered
Generic Drugs	CoPay: $5.00 CoInsurance: Not Applicable Covered: Covered
Specialty Drugs	CoPay: $550.00 CoInsurance: Not Applicable Covered: Covered

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 30.00% Coinsurance after deductible Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: 30.00% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: Not Applicable CoInsurance: 30.00% Coinsurance after deductible Covered: Covered
Urgent Care Facility	CoPay: $15.00 CoInsurance: Not Applicable Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 30.00% Coinsurance after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: 30.00% Coinsurance after deductible Covered: Covered

Vision

Routine Eye Exams For Children

CoPay: $15.00
CoInsurance: Not Applicable
Covered: Covered

Major Dental Care

Routine Dental Checkups for Children	Covered: Not Covered
Routine Dental Checkups for Adults	Covered: Not Covered
Basic Dental Care - Adult	Covered: Not Covered
Basic Dental Care - Child	Covered: Not Covered
Major Dental Care - Adult	Covered: Not Covered
Major Dental Care - Child	Covered: Not Covered

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