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2021 Medica Individual Choice Plan Documents

To see your summary of benefits and coverage (SBC) and policy of coverage documents, select your state and plan below.

Looking for the 2020 documents?

North Dakota Plans

Document Care Type    
Summary of Benefits and Coverage (SBC) Gold Copay (PDF)
Silver Copay (PDF)
Bronze Copay (PDF)
Policy of Coverage
Gold Copay (PDF)
Silver Copay (PDF)
Bronze Copay (PDF)
Document Care Type
Summary of Benefits and Coverage (SBC) Bronze HSA (PDF) 
Policy of Coverage
Bronze HSA (PDF)
Document Care Type
Summary of Benefits and Coverage (SBC) Silver Share (PDF) Bronze Share Plus (PDF)
Policy of Coverage Silver Share (PDF) Bronze Share Plus (PDF)
Document Care Type
Summary of Benefits and Coverage (SBC) Bronze Value (PDF)
Policy of Coverage Bronze Value (PDF)

Wisconsin Plans

Document Care Type    
Summary of Benefits and Coverage (SBC) Gold Copay (PDF)
Silver Copay (PDF)
Bronze Copay (PDF)
Policy of Coverage
Gold Copay (PDF)
Silver Copay (PDF)
Bronze Copay (PDF)
Document Care Type
Summary of Benefits and Coverage (SBC) Bronze HSA (PDF) 
Policy of Coverage
Bronze HSA (PDF)
Document Care Type
Summary of Benefits and Coverage (SBC) Silver Share (PDF) Bronze Share Plus (PDF)
Policy of Coverage Silver Share (PDF) Bronze Share Plus (PDF)
Date: 7/31/2021 10:04:35 AM Version: 4.0.30319.42000 Machine Name: PWIVE-CDWEB01