|
2009 Medica Prime Solution Plan Options |
Monthly
Premium* |
Annual
Premium |
|
Value - Includes some copayments
for services
|
Summary of Benefits
Application
Evidence of Coverage |
$35.00 |
$420.00 |
|
Basic - Includes some copayments
for services |
Summary of Benefits (MN only)
Summary of Benefits (ND / SD)
Summary of Benefits (WI)
Application
Evidence of Coverage |
$69.00 |
$828.00 |
|
Enhanced - No copayments for doctor
office visits, routine exams, and many
other preventive services |
Summary of Benefits (MN only)
Summary of Benefits (ND / SD)
Summary of Benefits (WI)
Application
Evidence of Coverage |
$110.00 |
$1,320.00 |
|
2009 Medica Prime Solution Optional Riders |
Monthly
Premium |
Annual
Premium |
|
Modified Standard RX - Value Only |
Application
Evidence of Coverage |
$25.70 |
$308.40 |
| Modified Standard RX - Basic or Enhanced Only |
Application
Evidence of Coverage |
$28.30 |
$339.60 |
|
Enhanced RX - Basic or Enhanced Only |
Application
Evidence of Coverage |
$49.80 |
$597.60 |
|
Wisconsin Rider (WI only) |
Application
Evidence of Coverage |
$22.00 |
$264.00 |
|
SeniorDental Rider (MN only) |
Summary of Benefits
Application
Evidence of Coverage |
$38.00 |
$456.00 |