Page 5 - PRO_2023 Client Benefits Guide

Medical (Cont’d)
Following is a high-level overview of the coverage available through Medica. For complete coverage details, please refer to the Summary Plan Description (SPD).
Key Medical Benefits
Plan 1 - MN 500-20-20% - PPO
Plan 2 - MN 1000-30-50-20% - PPO
Plan 3 - MN 1500-30-50-30% - PPO
In-Network
Out-of-Network1
In-Network
Out-of-Network1
In-Network
Out-of-Network1
Deductible (per Calendar year)
Individual / Family
$500 / $1,500
$1,200 / $2,400
$1,000 / $3,000
$3,000 / $,9000
$1,500 / $4,500
$3,000 / $9,000
Out-of-Pocket Maximum (per Calendar year)
Individual / Family
$2,500 / $5,000
$4,500 / $9,000
$3,500 / $7,000
$10,500 / $21,000
$6,500 / $9,000
$13,500 / $27,000
Covered Services
Office Visits
(physician/specialist)
$20 / $20 copay
30%* / 30%*
$30 copay / $50 copay
50%* / 50% *
$30 copay / $50 copay
50%*/ 50% *
Virtual Visits
$5 copay
30%*
$15 copay
50%*
$20 copay
50%*
Routine Preventive Care
No charge
Well Child Care: 0% / Other Services: 30%*
No charge
Well Child Care: 0% / Other Services: 50%*
No charge
Well Child Care: 0% / Other Services: 50%*
Outpatient Diagnostic
(lab/X-ray)
No charge / 20%*
30%*
No charge / 20%*
50%*
No charge / 30%*
50%*
Complex Imaging
20%*
30%*
20%*
50%*
30%*
50%*
Chiropractic
$20 copay
30%*
$30 copay
50%*
$30 copay
50%*
Ambulance
20%*
20%*
20%*
30%*
Emergency Room
20%*
20%*
20%*
30%*
Urgent Care Facility
$20 copay
$30 copay
$30 copay
Inpatient Hospital Stay
20%*
30%*
20%*
50%*
30%*
50%*
Outpatient Surgery
20%*
30%*
20%*
50%*
30%*
50%*
Prescription Drugs (Generic / Preferred Brand / Non-Preferred Brand / Specialty Preferred / Specialty Non-Preferred)
Retail Pharmacy
(30-day supply)
$10 / $25 / $40 / 20% to maximum of $200 / 40%
30%*
$10 / $50 / $150 / 20% to no more than $200 / 40%
50%*
$10 / $50 / $150 / 30% to no more than $200 / 45%
50%*
Mail Order
(90-day supply)
$20 / $50 / $80
Not covered
$20 / $100 / $300
Not covered
$20 / $100 / $300
Not covered
Coinsurance percentages and copay amounts shown in the above chart represent what the member is responsible for paying.
*Benefits with an asterisk ( * ) require that the deductible be met before the Plan begins to pay.
To be eligible for the HSA, you cannot be covered through Medicare Part A or Part B or TRICARE programs. See the plan documents for full details. 1. If you use an out-of-network provider, you will be responsible for any charges above the maximum allowed amount.
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