Essentia Choice Care with Medica Bronze Copay $0 PCP

Health Insurance Plan Details (2024 Plan)

Monthly Premium

HMO
$ubsidy
Bronze
Deductible
$7,850 /yr
Max Out-of-Pocket
$9,450 /yr

Details

Deductible (per individual) $7,850 /yr
Deductible (per family) $15,700 /yr
Max Out-of-Pocket (per individual) $9,450 /yr
Max Out-of-Pocket (per family) $18,900 /yr
Drug Deductible (per individual) Included in Medical
Drug Deductible (per family) Included in Medical
Drug Max Out-of-Pocket (per individual) Included in Medical
Drug Max Out-of-Pocket (per family) Included in Medical
Plan Type HMO
Includes Child Dental? No
Includes Adult Dental? No
Medical Services
Preventive Care No Charge
Primary Care Visit No Charge
Specialist Visit $150 Copay
Emergency Room 50% Coinsurance after deductible
Inpatient Facility 50% Coinsurance after deductible
Inpatient Physician 50% Coinsurance after deductible
Drug Costs
Generic Drugs $25 Copay
Preferred Brand Drugs $200 Copay
Non-preferred Brand Drugs 70% Coinsurance after deductible
Specialty Drugs $800 Copay

Plan Documents

Summary of Benefits and Coverage SBC doc
Provider Directory Doctor lookup
Drug Formulary List drug list

* 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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