Plan B - Medica Choice Passport: $2,700-20% HSA

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Plan B - Medica Choice Passport: $2,700-20% 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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You can compare this plan side-by-side with up to two other plans to see the differences between their benefits.

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Benefit Summary for Plan B - Medica Choice Passport: $2,700-20% HSA

Network Benefits
Overall deductible $2,700 per person/ $5,400 per family for in-network services. $4,800 per person/ $9,600 per family for out-of-network services.
Out-of-pocket limit $4,500 per person/ $9,000 per family for in-network services. $10,200 per person/ $19,400 per family for out-of-network services.
If you visit a health care provider's office or clinic
Primary care visit 20% coinsurance
Chiropractic visit 20% coinsurance
Convenience care visit 20% coinsurance
Specialist visit 20% coinsurance
Preventive care/screening/immunization No charge. Deductible does not apply.
If you have a test
Diagnostic test - lab 20% coinsurance
Diagnostic test - x-ray 20% coinsurance
Imaging (CT/PET scans, MRI) 20% coinsurance
If you need drugs to treat your illness or condition
Generic drugs Retail: 20% coinsurance Mail order: 20% coinsurance
Preferred brand drugs Retail: 20% coinsurance Mail order: 20% coinsurance
Non-preferred brand drugs Retail: 20% coinsurance Mail order: 20% coinsurance
Specialty drugs Preferred: 20% coinsurance. Non-preferred: 20% coinsurance.
If you have outpatient surgery
Facility fee (e.g., ambulatory surgery center) 20% coinsurance
Physician/surgeon fees 20% coinsurance
If you need immediate medical attention
Emergency room care 20% coinsurance
Emergency medical transportation 20% coinsurance
Urgent care 20% coinsurance
If you have a hospital stay
Facility fee (e.g., hospital room) 20% coinsurance
Physician/surgeon fees 20% coinsurance
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: $2,700-20% HSA.

» Find a physician or facility in Medica Choice Passport.

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