Medica with CHI Health Bronze Premier + Adult Eye Exam

Health Insurance Plan Details (2025 Plan)

SBC doc

doctor lookup

drug list

EPO

Bronze

Deductible (per individual)	$2,000 /yr
Deductible (per family)	$4,000 /yr
Max Out-of-Pocket (per individual)	$9,200 /yr
Max Out-of-Pocket (per family)	$18,400 /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	EPO
Includes Child Dental?	No
Includes Adult Dental?	No

Medical Services
Preventive Care	No Charge
Primary Care Visit	No Charge after Deductible
Specialist Visit	$160 Copay after deductible
Emergency Room	50% Coinsurance after deductible
Inpatient Facility	50% Coinsurance after deductible
Inpatient Physician	50% Coinsurance after deductible

Drug Costs
Generic Drugs	$35 Copay
Preferred Brand Drugs	$200 Copay
Non-preferred Brand Drugs	70% Coinsurance after deductible
Specialty Drugs	$750 Copay

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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