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2018 Select by Medica

Select by MedicaSM

Plan Highlights

Select by Medica plans include:

  • Access to a localized network of doctors, clinics and hospitals    
  • 100% coverage of routine preventive exams
  • Gold, silver and bronze metal level plan options
  • Copay, copay plus, health savings account compatible or catastrophic plan options
  • Access to Mayo Clinic through the Centers of Excellence Program

2018 Plan Options at a Glance


Plans that are right for you

Copay Plus and Copay – For individuals and families

Network Benefits Gold Copay Plus Gold Copay
Deductible Individual: $1,000
Family: $3,000 shared family*
Individual: $750
Family: $2,250 shared family*
Out-of-pocket maximum Individual: $5,000
Family: $5,000 per family member or $10,000 for the entire family*
Individual: $6,000
Family: $6,000 per family member or $12,000 for the entire family*
Office visits Primary care: $30 copay
Urgent care: $30 copay
Specialty care: $30 copay
Primary care: $30 copay
Urgent care: $30 copay
Specialty care: $60 copay
Prescription drugs (Medica Drug List)

Preferred generic: $5 copay
Generic: $5 copay
Preferred brand: $35 copay
Non-preferred brand:$150 copay

Look up covered drugs

Preferred generic: $5 copay
Generic: $10 copay
Preferred brand: 30% coinsurance after deductible
Non-preferred brand: 50% coinsurance after deductible

Look up covered drugs

Other eligible health care services 30% coinsurance after deductible 30% coinsurance after deductible
Summary of Benefits and Coverage (SBC) View Kansas SBC (PDF) View Kansas SBC (PDF)

*Cost Sharing Details:
Family plans have a non-embedded deductible and an embedded out-of-pocket maximum. 

Learn the difference between embedded and non-embedded in this tip sheet (PDF)

Network Benefits Silver Copay
Deductible Individual: $3,500
Family: $10,500 shared family*
Out-of-pocket maximum Individual: $7,000
Family: $7,000 per family member or $14,000 for the entire family*
Office Visit Copay Primary care: $30 copay
Urgent care: $30 copay
Specialty care: $60 copay
Prescription drugs (Medica Drug List)

Preferred generic: $5 copay
Generic: $10 copay
Preferred brand: 40% coinsurance after deductible
Non-preferred brand: 60% coinsurance after deductible

Look up covered drugs

Other eligible health care services 40% coinsurance after deductible
Summary of Benefits and Coverage (SBC) View Kansas SBC (PDF)

*Cost Sharing Details:
Family plans have a non-embedded deductible and an embedded out-of-pocket maximum. 

Learn the difference between embedded and non-embedded in this tip sheet (PDF)

Network Benefits Bronze Copay
Deductible Individual: $6,850
Family: $13,700 shared family*
Out-of-pocket maximum Individual: $7,350
Family: $7,350 per family member or $14,700 for the entire family*
Office visits Primary care: $80 copay
Urgent care: $80 copay
Specialty care: $150 copay
Prescription drugs (Medica Drug List)

Preferred generic: $10 copay
Generic: $20 copay
Preferred brand: 50% coinsurance after deductible
Non-preferred brand: 70% coinsurance after deductible

Look up covered drugs

Other eligible health care services 50% coinsurance after deductible
Summary of Benefits and Coverage (SBC)

View Kansas SBC (PDF)

*Cost Sharing Details:
Family plans have a non-embedded deductible and an embedded out-of-pocket maximum. 

Learn the difference between embedded and non-embedded in this tip sheet (PDF)

Health Savings Account (HSA) Compatible – For individuals and families

Network Benefits Bronze HSA Plus   Bronze HSA
Deductible Individual: $2,600
Family: $5,200 shared family*
Individual: $6,000
Family: $12,000 shared family*
Out-of-pocket maximum Individual: $6,650
Family: $6,650 per family member or $13,300 for the entire family*
Individual: $6,650
Family: $6,650 per family member or $13,300 for the entire family*
Office visits Primary, urgent, and specialty care: 40% coinsurance after deductible Primary, urgent, and specialty care: 20% coinsurance after deductible
Prescription drugs (Medica Drug List)

Preferred generic, generic, preferred brand, non-preferred brand: 40% coinsurance after deductible

Look up covered drugs

Preferred generic, generic, preferred brand, non-preferred brand: 20% coinsurance after deductible

Look up covered drugs

Other eligible health care services 40% coinsurance after deductible 20% coinsurance after deductible
Summary of Benefits and Coverage (SBC) View Kansas SBC (PDF) View Kansas SBC (PDF)

*Cost Sharing Details:
Family plans have a non-embedded deductible and an embedded out-of-pocket maximum.

Learn the difference between embedded and non-embedded in this tip sheet (PDF)

Cost Sharing Reduction (CSR) – For individuals and families who meet certain income requirements

Network Benefits Silver Copay 94% CSR Silver Copay 87% CSR Silver Copay 73% CSR
Deductible Individual: $100
Family: $300 shared family*
Individual: $500
Family: $1,500 shared family*
Individual: $2,500
Family: $7,500 shared family*
Out-of-pocket maximum Individual: $1,000
Family: $1,000 per family member or $2,000 for the entire family*
Individual: $2,000
Family: $2,000 per family member or $4,000 for the entire family*
Individual: $5,850
Family: $5,850 per family member or $11,700 for the entire family*
Office visits Primary care: $30 copay 
Urgent care: $30 copay
Specialty care: $60 copay
Primary care: $30 copay 
Urgent care: $30 copay
Specialty care: $60 copay
Primary care: $30 copay
Urgent care: $30 copay
Specialty care: $60 copay
Prescription drugs (Medica Drug List)

Preferred generic: $5 copay
Generic: $10 copay
Preferred brand: 5% coinsurance after deductible
Non-preferred brand: 25% coinsurance after deductible

Look up covered drugs

Preferred generic: $5 copay
Generic: $10 copay
Preferred brand: 20% coinsurance after deductible
Non-preferred brand: 40% coinsurance after deductible

Look up covered drugs

Preferred generic: $5 copay
Generic: $10 copay
Preferred brand: 30% coinsurance after deductible
Non-preferred brand: 50% coinsurance after deductible

Look up covered drugs

Other eligible health care services 5% coinsurance after deductible 20% coinsurance after deductible 30% coinsurance after deductible
Summary of Benefits and Coverage (SBC) View Kansas SBC (PDF) View Kansas SBC (PDF)
View Kansas SBC (PDF)

*Cost Sharing Details:
Family plans have a non-embedded deductible and an embedded out-of-pocket maximum.

Learn the difference between embedded and non-embedded in this tip sheet (PDF)

Catastrophic – For individuals and families under age 30 or those with an eligible exemption

Network Benefits Catastrophic
Deductible Individual: $7,350
Family: $7,350 per family member or $14,700 for the entire family*
Out-of-pocket maximum Individual: $7,350
Family: $7,350 per family member or $14,700 for the entire family*
Office visits Primary care: $30 copay for the first 3 visits per person per calendar year. After 3rd, 0% coinsurance after deductible
Urgent care: 0% coinsurance
Specialty care: 0% coinsurance
Prescription drugs (Medica Drug List)

Preferred generic, generic, preferred brand, non-preferred brand : 0% coinsurance after deductible

Look up covered drugs

Other eligible health care services 0% coinsurance after deductible
Summary of Benefits and Coverage (SBC) View Kansas SBC (PDF)

*Cost Sharing Details:
Family plans have an embedded deductible and out-of-pocket maximum.

Learn the difference between embedded and non-embedded in this tip sheet (PDF)

Note: Pediatric Dental is Not Covered
These policies do not include pediatric dental services. Pediatric dental is an essential health benefit that can be purchased as a stand-alone product through Delta Dental. For information visit deltadentalks.com


2018 Network Information


Who and Where Your Care Comes From

 

Find a Physician or Facility

The Select network is a large care system-based network that provides access to Saint Luke’s Health System doctors plus others in the Kansas City region. The network includes:
800+ Primary and specialty care doctors
12+ Online and convenience care clinics
10+ Hospitals

Pioneering health care innovation, Saint Luke's offers:
- Adult heart transplant program with one of the nation's top 35 cardiology and heart surgery programs
- Recognized liver and kidney transplant programs
- One of the nation's leading stroke reversal program dedicated to preventing and treating stroke
- A nationally recognized children's behavioral health center

It’s important to note that unless it’s an emergency, there is no coverage if you visit a provider who is not in the Select network. This means you will be responsible for the full cost of any care.

Search for a physician, clinic or hospital 

Need help with your search?

If you're looking for something specific, try these keywords to help narrow your search:

- Clinical/Medical Social Worker
- Mh/Cd Outpatient Facility
- Multispecialty
- Other Mental Health
- Psychology
- Psychiatry

 

Find a Network Pharmacy

Our pharmacy network includes more than 64,000 pharmacies nationwide including most major chains and thousands of Independent pharmacies.

Search for a network pharmacy

 

 

Centers of Excellence Program featuring Mayo Clinic

This program allows members to receive care for certain transplants, rare cancers and other complex medical conditions at Mayo Clinic. An allowance for transportation, lodging and living expenses for the patient and one travel companion is included.

 

Get care anytime, anywhere with Saint Luke's 24/7 App

Visit with a physician or nurse practitioner by phone or secure video. It's health care where you need it most.




Medica is a Qualified Health Plan issuer in the Health Insurance Marketplace.


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Plan Documents

Date: 12/14/2018 11:32:11 PM Version: 4.0.30319.42000 Machine Name: PWIVE-CMSWEB01