Plan C - Medica Choice Passport: $1,250-$35-25%

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Plan C - Medica Choice Passport: $1,250-$35-25%

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 C - Medica Choice Passport: $1,250-$35-25%

Network Benefits
Overall deductible $1,250 per person/ $3,500 per family for in-network services. $2,500 per person/ $7,000 per family for out-of-network services.
Out-of-pocket limit $4,000 per person/ $8,000 per family for in-network services. $7,000 per person/ $14,000 per family for out-of-network services
If you visit a health care provider's office or clinic
Primary care visit $35 copay/visit. Deductible does not apply.
Chiropractic visit $35 copay/visit. Deductible does not apply.
Convenience care visit $15 copay/visit. Deductible does not apply.
Specialist visit $35 copay/visit. Deductible does not apply.
Preventive care/screening/immunization No charge. Deductible does not apply.
If you have a test
Diagnostic test - lab No charge. Deductible does not apply.
Diagnostic test - x-ray 25% co-insurance
Imaging (CT/PET scans, MRI) 25% co-insurance
If you need drugs to treat your illness or condition
Generic drugs Retail: $11/prescription. Deductible does not apply. Mail order: $22/prescription. Deductible does not apply.
Preferred brand drugs Retail: $45/prescription. Deductible does not apply. Mail order: $90/prescription. Deductible does not apply.
Non-preferred brand drugs Retail: $60/prescription. Deductible does not apply. Mail order: $120/prescription. Deductible does not apply.
Specialty drugs Preferred: 20% coinsurance. No more than $200 copay/ prescription. Deductible does not apply. Non-preferred: 40% coinsurance. Deductible does not apply.
If you have outpatient surgery
Facility fee (e.g., ambulatory surgery center) 25% coinsurance
Physician/surgeon fees 25% coinsurance
If you need immediate medical attention
Emergency room care $75 copay/visit. Deductible does not apply.
Emergency medical transportation 25% coinsurance
Urgent care $35 copay/visit. Deductible does not apply.
If you have a hospital stay
Facility fee (e.g., hospital room) 25% coinsurance
Physician/surgeon fees 25% 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 C - Medica Choice Passport: $1,250-$35-25%

» Find a physician or facility in Medica Choice Passport.

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