Medica Choice Passport ND 1000-25-20% Rx 15/40/70
īģŋMedica Choice Passport ND 1000-25-20% Rx 15/40/70
Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services
Coverage Period: Beginning on or after 6/1/17
Coverage for: Individual/Family | Plan Type: PPO
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the
cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a
summary. For more information about your coverage, or to get a copy of the complete terms of coverage, go to or by calling 952-945-8000
(Minneapolis/St. Paul Metro area) or 1-800-952-3455. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment,
deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at ebsa/healthreform or iio. or call Medica
at the numbers above to request a copy.
Important Questions
Answers
Why this Matters:
What is the overall
deductible?
$1,000 per person/ $2,000 per family
in-network and $1,500 per person/
$3,000 per family for out-of-network
services.
Yes. Preventive care, copayments,
hospice
or prescription drugs from
Are there services
in-network
providers and the first 5
covered before you meet hours of mental
health or first 5 visits
your deductible?
of substance abuse office visits from
out-of-network providers.
Generally, you must pay all of the costs from providers up to the deductible amount before this plan
begins to pay. If you have other family members on the plan, each family member must meet their own
individual deductible until the total amount of deductible expenses paid by all family members meets the
overall family deductible.
This plan covers some items and services even if you havenĄ¯t yet met the deductible amount. But a
copayment or coinsurance may apply. For example, this plan covers certain preventive services without
cost-sharing and before you meet your deductible. See a list of covered preventive services at
.
Are there other
deductibles for specific No
services?
You donĄ¯t have to meet deductibles for specific services.
balance-billing charges,
What is not included in Premiums,
and
health
care
this plan doesnĄ¯t
the out-of-pocket limit? cover.
Even though you pay these expenses, they donĄ¯t count towards the out-of-pocket limit.
What is the
out-of-pocket limit for
this plan?
$2,500 per person/ $5,000 per family The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family
in-network. $4,500 per person for
members in this plan, they have to meet their own out-of-pocket limits until the overall family
out-of-network services.
out-of-pocket limit has been met.
Yes. See or call
952-945-8000
or 1-800-952-3455 or
Will you pay less if you 711 (TTY users)
for a list of Medica
use a network provider? Choice with UnitedHealthcare
network providers.
This plan uses a provider network. You will pay less if you use a provider in the planĄ¯s network. You will
pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the
difference between the providerĄ¯s charge and what your plan pays (balance billing). Be aware, your
network provider might use an out-of-network provider for some services (such as lab work). Check with
your provider before you get services.
Do you need a referral to No. You donĄ¯t need a referral to see a You can see the specialist you choose without a referral.
see a specialist?
specialist.
COM Agri-Cover Inc-1-00417
(201703011541)
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Medica Choice Passport ND 1000-25-20% Rx 15/40/70
Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services
Coverage Period: Beginning on or after 6/1/17
Coverage for: Individual/Family | Plan Type: PPO
All coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
Common Medical Services You May Need
Event
Primary care visit to treat an
injury or illness
If you visit a
health care
Specialist visit
providerĄ¯s office
or clinic
Preventive care/ screening/
immunization
Diagnostic test (x-ray, blood
work)
If you have a test
Imaging (CT/PET scans,
MRIs)
Generic drugs
If you need
drugs to treat
your illness or
condition
Preferred brand drugs
More information
about prescription Non-preferred brand drugs
drug coverage is
available at
.
Specialty drugs
What You Will Pay
Network Provider
Out-of-network
(You will pay the least)
(You will pay the most)
Primary care: $25 copay/ visit. Deductible
does not apply.
Primary care: 40% coinsurance
Chiropractic: $25 copay/ visit. Deductible Chiropractic:
40% coinsurance
does not apply.
Convenience:
40% coinsurance
Convenience: $15 copay/ visit. Deductible
does not apply.
$25 copay/ visit. Deductible does not
40% coinsurance
apply.
No charge. Deductible does not apply.
40% coinsurance
Lab: 20% coinsurance
X-ray: 20% coinsurance
40% coinsurance
20% coinsurance
Retail: $15/ prescription
Deductible does not apply.
Mail order: $30/ prescription
Deductible does not apply.
Retail: $40/ prescription
Deductible does not apply.
Mail order: $80/ prescription
Deductible does not apply.
Retail: $70/ prescription
Deductible does not apply.
Mail order: $140/ prescription
Deductible does not apply.
Preferred: 20% coinsurance. No more
than $200 copay/ prescription. Deductible
does not apply.
Non-Preferred: 40% coinsurance.
Deductible does not apply.
40% coinsurance
Limitations, Exceptions & Other
Important Information
Limited to 15 visits per member, per
year for out-of-network chiropractic
care.
---none---
You may have to pay for services
that arenĄ¯t preventive. Ask your
provider if the services needed are
preventive. Then check what your
plan will pay for. Routine physicals
and eye exams are not covered
out-of-network.
---none-----none---
40% coinsurance. Mail order not covered
Up to a 31-day supply/ retail or
40% coinsurance. Mail order not covered 93-day supply/ mail order
prescription.
40% coinsurance. Mail order not covered
Not covered
Up to a 31-day supply per
prescription received from a
designated specialty pharmacy.
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Medica Choice Passport ND 1000-25-20% Rx 15/40/70
Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services
Common Medical Services You May Need
Event
If you have
outpatient
surgery
Facility fee (e.g., ambulatory
surgery center)
Physician/surgeon fees
Emergency room care
If you need
Emergency medical
immediate
medical attention transportation
Urgent care
If you have a
hospital stay
Facility fee (e.g., hospital
room)
Physician/surgeon fees
If you need
mental health,
Outpatient services
behavioral
health, or
substance abuse
needs
Inpatient services
Office visits
If you are
pregnant
Coverage Period: Beginning on or after 6/1/17
Coverage for: Individual/Family | Plan Type: PPO
What You Will Pay
Network Provider
Out-of-network
(You will pay the least)
(You will pay the most)
20% coinsurance
20% coinsurance
$100 copay/ visit. Deductible does not
apply.
20% coinsurance
Limitations, Exceptions & Other
Important Information
40% coinsurance
---none---
Covered as an in-network benefit.
---none---
40% coinsurance
---none---
Covered as an in-network benefit.
---none---
Covered as an in-network benefit.
---none---
20% coinsurance
40% coinsurance
---none---
$25 copay/ visit. Deductible does not
apply.
40% coinsurance
20% coinsurance
40% coinsurance
No charge. Deductible does not apply.
40% coinsurance
$25 copay/ visit. Deductible does not
apply.
20% coinsurance
Childbirth/delivery professional 20% coinsurance
services
Childbirth/delivery facility
20% coinsurance
services
40% coinsurance
40% coinsurance
40% coinsurance
---none--No charge for the first 5 hours of
mental health or first 5 visits of
substance abuse outpatient
services per year in or
out-of-network. Outpatient
cost-sharing will apply to additional
services.
---none--Maternity care may include tests
and services described elsewhere
in the SBC (i.e. ultrasound.)
---none-----none---
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Medica Choice Passport ND 1000-25-20% Rx 15/40/70
Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services
What You Will Pay
Network Provider
Out-of-network
(You will pay the least)
(You will pay the most)
Common Medical Services You May Need
Event
Home health care
20% coinsurance
40% coinsurance
Rehabilitation services
$25 copay/ visit. Deductible does not
apply.
40% coinsurance
$25 copay/ visit. Deductible does not
apply.
40% coinsurance
Skilled nursing care
20% coinsurance
40% coinsurance
Durable medical equipment
Hospice services
ChildrenĄ¯s eye exam
20% coinsurance
No charge. Deductible does not apply.
No charge. Deductible does not apply.
40% coinsurance
40% coinsurance
Not covered
Not covered
Not covered
If you need help
recovering or
have other
special health
Habilitation services
needs
If your child
needs dental or ChildrenĄ¯s glasses
eye care
ChildrenĄ¯s dental check-up
Coverage Period: Beginning on or after 6/1/17
Coverage for: Individual/Family | Plan Type: PPO
Not covered
Not covered
Limitations, Exceptions & Other
Important Information
120 visits in-network and 60 visits
out-of-network per member per
year.
Physical and occupational therapy
combined limited to 20 visits
out-of-network per member per
year. Out-of-network speech
therapy is limited to 20 visits per
member per year.
Physical and occupational therapy
combined limited to 20 visits
out-of-network per member per
year. Out-of-network speech
therapy is limited to 20 visits per
member per year.
120 day limit combined in and
out-of-network per member per
year.
---none-----none-----none--Glasses are not covered by the
plan.
Dental check-ups are not covered
by the plan.
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Medica Choice Passport ND 1000-25-20% Rx 15/40/70
Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services
Coverage Period: Beginning on or after 6/1/17
Coverage for: Individual/Family | Plan Type: PPO
Excluded Services & Other Covered Services:
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of other excluded services.)
Acupuncture exceeding 15 visits per member
per year for in-network and out-of-network
acupuncture services combined
Chiropractic care exceeding 15 visits per
member per year for out-of-network chiropractic
care.
Cosmetic Surgery
Dental Care (Adult)
Dental check-up
Glasses
Hearing aids except for members 18 years of
age and younger for hearing loss due to
functional congenital malformation of the ears
that is not correctable by other covered
procedures; coverage is limited to one hearing
aid per ear every three years.
Long Term Care
Private-duty nursing
Routine foot care except for specified conditions
Weight Loss programs
Other Covered Services (Limitations may apply to these services. This isnĄ¯t a complete list. Please see your plan document.)
Bariatric Surgery
Infertility treatment
Non-emergency care when traveling outside the
U.S.
Routine eye care (Adult)
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