Plan B - Medica Choice Passport: $2,600-20% HSA

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Plan B - Medica Choice Passport: $2,600-20% HSA

National network

Medica Choice Passport® is an easy-to-use plan with a large network. You can visit any doctor, clinic or facility in the network without a referral.

Plan highlights

  • One of the largest networks in the nation
  • No referrals needed when you see network providers 
  • Nationwide network coverage when you travel

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Benefit Summary for Plan B - Medica Choice Passport: $2,600-20% HSA

Network Benefits
Annual Deductible $2,600 per person/ $5,200 per family for in-network services. $4,800 per person/ $9,600 per family for out-of-network services. Deductible does not apply to preventive care, or prenatal care from in-network providers or well child or prenatal care from out-of-network providers.
Out-of-Pocket Maximum $4,000 per person/ $8,000 per family for in-network services. $10,200 per person/ $19,400 per family for out-of-network services.
Primary Care Visit to Treat an Injury or an Illness 20% co-insurance after deductible
Specialist Visit 20% co-insurance after deductible
Other Practitioner Office Visit 20% co-insurance after deductible for chiropractic care. 20% co-insurance after deductible for convenience care.
Preventive Care/Screening/Immunization No charge
Diagnostic Test (X-ray, blood work) 20% co-insurance after deductible
Imaging (CT/PET scans, MRI) 20% co-insurance after deductible
Outpatient Surgery 20% co-insurance after deductible for facility fee; 20% co-insurance after deductible for physician/surgeon fees
Emergency Care 20% co-insurance after deductible for emergency room services; 20% co-insurance after deductible for emergency medical transportation
Urgent Care 20% co-insurance after deductible
Hospital Stay 20% co-insurance after deductible for facility fee; 20% co-insurance after deductible for physician/surgeon fees
Prescription Drugs
Generic 20% co-insurance after deductible.
Preferred Brand 20% co-insurance after deductible.
Non-preferred Brand 20% co-insurance after deductible.
Network Information
Network Type National network
Network Area Nationwide
Special Features Largest network of providers.
Referrals Needed No referrals needed if you see a Medica Choice Passport network provider.

How it works

Choose from any doctor, clinic or facility in the large Medica Choice Passport network. While you don’t need a referral to see a specialist in the network, it’s a good idea to work closely with your primary care doctor to coordinate your health care needs.

» View the Summary of Benefits and Coverage for Plan B - Medica Choice Passport: $2,600-20% HSA.

» Find a physician or facility in Medica Choice Passport.

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