North Memorial Acclaim by Medica Bronze HSA

Health Insurance Plan Details (2025 Plan)

SBC doc

doctor lookup

EPO

HSA

Bronze

Deductible (per individual)	$6,750 /yr
Deductible (per family)	$13,500 /yr
Max Out-of-Pocket (per individual)	$8,300 /yr
Max Out-of-Pocket (per family)	$16,600 /yr
Drug Deductible (per individual)
Drug Deductible (per family)
Drug Max Out-of-Pocket (per individual)
Drug Max Out-of-Pocket (per family)
Plan Type	EPO
Includes Child Dental?	No
Includes Adult Dental?	No

Medical Services
Preventive Care	No Charge
Primary Care Visit	5.00% Coinsurance after deductible
Specialist Visit	5.00% Coinsurance after deductible
Emergency Room	5.00% Coinsurance after deductible
Inpatient Facility	5.00% Coinsurance after deductible
Inpatient Physician	5.00% Coinsurance after deductible

Drug Costs
Generic Drugs	5.00% Coinsurance after deductible
Preferred Brand Drugs	5.00% Coinsurance after deductible
Non-preferred Brand Drugs	5.00% Coinsurance after deductible
Specialty Drugs	5.00% Coinsurance after deductible

Summary of Benefits and Coverage	SBC doc
Provider Directory	Doctor lookup
Drug Formulary List	n/a

* Figures shown are only for in-network medical costs

** Please check with insurance company if Copay and Coinsurance rates are before or after the deductible

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