MEDICA CHOICE PASSPORT SD CERTIFICATE OF COVERAGE
MEDICA CHOICE PASSPORT SD
CERTIFICATE OF COVERAGE
POET, LLC
MEDICA CHOICE PASSPORT SD 1500-35-50-20% BPL #91657 DOC #37147
MEDICA CUSTOMER SERVICE
1-800-952-3455
TTY Users: National Relay Center: 711 then ask them to dial Medica at 1-800-952-3455
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? 2016 Medica. Medica? is a registered service mark of Medica Health Plans. "Medica" refers to the family of health plan businesses that includes Medica Health Plans, Medica Health Plans of Wisconsin, Medica Insurance Company, Medica Self-Insured and Medica Health Management, LLC.
Welcome!
We're glad you're a Medica member. Health insurance can be complicated. The information found in the pages of this Certificate of Coverage can help you better understand your coverage and how it works.
You may need to reference multiple sections to get a complete picture of your coverage and what you will pay when you receive care. If you have more than one service during a visit, you may pay a separate copayment or coinsurance for each service. The most specific section of this certificate will apply. Use the Where to Find It section to learn about related benefits when you access common services.
Some terms used have specific meanings.
In this certificate, the words "you," "your" and "yourself" refer to you, the member. The word "sponsor" refers to the organization through which the coverage is made available. The word "employer" refers to the business entity that employs you and because of which you are eligible for coverage. See the Definitions section at the end of this document for more terms with specific meanings.
Where to Find It
Note: This is a quick guide to some common benefits. For a complete understanding of your coverage, be sure to read any other related sections in this certificate.
Do you need...
Immediate medical attention?
Ambulance Emergency room Urgent care
Quick access to care?
Convenience care Virtual care
To visit a provider or clinic?
Chiropractic care Office visit
Preventive care?
Immunizations Physicals Women's preventive services
Prescription drugs or supplies?
Diabetic equipment and supplies Outpatient medications Preventive medications and products Specialty medications
A medical test?
Examples: blood work, ultrasounds
Genetic testing and counseling Lab and pathology services X-rays, imaging, MRI, CT and PET CT scans
Outpatient surgery?
Anesthesia services Outpatient/ambulatory surgical center services
(facility charge) Physician services (doctor charge)
Read section(s):
Ambulance Emergency Room Care Physician/Professional Services Physician/Professional Services
Physician/Professional Services
Preventive Health Care
Prescription Drugs
Prescription Specialty Drugs
Genetic Testing and Counseling Lab and Pathology X-Rays and Other Imaging Anesthesia Hospital Services Physician/Professional Services
MIC PP SD LG (1/17)
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POET, LLC 1500-35-50-20%
BPL 91657 DOC 37147
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