Plan C - Medica Choice Passport: $1,000-$35-25%

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Plan C - Medica Choice Passport: $1,000-$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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Benefit Summary for Plan C - Medica Choice Passport: $1,000-$35-25%

Network Benefits
Annual Deductible $1,000 per person/ $2,750 per family for in-network services. $2,500 per person/ $7,000 per family for out-of-network services. Deductible does not apply to preventive care, co-pay services, hospice, lab, or prescription drugs from in-network providers or well child or prenatal care from out-of-network providers.
Out-of-Pocket Maximum $3,500 per person/ $7,000 per family for in-network services. $6,000 per person/ $12,000 per family for out-of-network services.
Primary Care Visit to Treat an Injury or an Illness $35 co-pay/ visit
Specialist Visit $35 co-pay/ visit
Other Practitioner Office Visit $35 co-pay/ visit for chiropractic care. $15 co-pay/ visit for convenience care.
Preventive Care/Screening/Immunization No charge
Diagnostic Test (X-ray, blood work) No charge for lab services. 25% co-insurance after deductible for x-ray services.
Imaging (CT/PET scans, MRI) 25% co-insurance after deductible
Outpatient Surgery 25% co-insurance after deductible for facility fee; 25% co-insurance after deductible for physician/surgeon fees
Emergency Care $75 co-pay/ visit for emergency room services; 25% co-insurance after deductible for emergency medical transportation
Urgent Care $35 co-pay/ visit
Hospital Stay 25% co-insurance after deductible for facility fee; 25% co-insurance after deductible for physician/surgeon fee
Prescription Drugs
Generic $11/ prescription
Preferred Brand $45/ prescription
Non-preferred Brand $60/ prescription
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: $1,000-$35-20%

» Find a physician or facility in Medica Choice Passport.

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