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Individual + family plan FAQs

Get answers to common questions about health insurance plans for individuals and families. Find out about benefits, coverage, financial information, and more.


Plan overview

A health plan is insurance that protects you against the potentially high costs of medical care and prescription drugs. With health insurance, you'll have a limit on your health care costs for covered services and supplies. Plus, you'll get discounted fees from doctors, clinics, and hospitals.

Sign in for your plan details

Get personalized information and help

  • View all your benefits
  • Find providers in your network
  • Download your ID card
  • Get quick answers to your questions and more


When it comes to individual and family health plans, there's a lot to consider. We've pulled together all our resources in one place to help you figure out:

  • How insurance works
  • Coverage and benefits
  • Plan Types
  • Enrollment periods
  • Subsidies
  • Helpful terms

Explore resources

Getting care

Is my doctor covered by my plan?

You can search for the doctors, specialists, and other providers covered by your specific plan.

Find providers by plan

What care options do I have?

Check out the programs and services covered by your specific plan.

See your options

Should I go to urgent care or the emergency room?

You’ll have to decide based on how you’re feeling. We can make that choice a little easier.

Get more info 

Is my prescription medication covered?

Medication coverage varies by plans. Sign in to review the list of drugs covered by your plan.

Sign in

Why do I need to stay in network?

Every health plan has a network of providers, clinics, pharmacies, and hospitals. When you pick a plan, you’re choosing your network. Your coverage depends on your provider being in your network.

Out of Network Care Costs (PDF)

Out of Network Care Costs – Plans with No Benefits (PDF)

Note: If you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you’re protected from surprise or balance billing. 
Read your rights.

How do tiered networks work?

Some of our individual and family plans have three tiers of network providers. You’ll receive different levels of coverage based on your provider’s tier. 

Tiered Networks and Benefits (PDF)

What type of wellness programs are offered by Medica?

Sign in to see which wellness programs are offered for your specific plan. Or view our general wellness offerings. 

See what we offer 

What is the Important Information Guide? Why should I use it?

This booklet includes important information to help you decide how to best use your health insurance benefits and how to file a complaint or appeal, if you need to. 

How to Get the Care You Need Guide (PDF)

Benefits + coverage

How can I find my benefits?

Sign in to see your specific plan benefits.

What's an Explanation of Benefits (EOB)?

It's a document that explains who, when, and how much you may need to pay for health care services. It's not a bill, but it does include a summary of services you received and how your plan covers them.

What Is an Explanation of Benefits (PDF)

What's my Summary of Benefits and Coverage (SBC) document?

It provides an overview of important information about your plan's benefits and coverage.

Summary of Benefits and Coverage (PDF)


What’s the difference between a deductible, copay, and coinsurance?

Your deductible is the amount you pay each year before your insurance starts to pay. A copay is flat fee you pay for some services and prescriptions. Copays apply to your out-of-pocket maximum, not the deductible. Coinsurance is a percentage of the charges for a health care service that you pay.

Deductibles (PDF)

How do I read the invoice for my premium?

We’ve broken down all the parts of your invoice to make it easy.

Breaking Down Your Invoice (PDF)

How do I make a premium payment?

You can make payments online.

Make a payment

How do I file a claim?

The process can vary depending on your provider’s networks status and the type of claim you’re filing. You typically won’t have to file a claim — providers usually do it. But if you ever need to file one, we’ve made it easy to figure out how to do it.

How to submit a claim (PDF)

Can I get financial assistance to help pay for my insurance?

Many people who buy individual insurance can get a subsidy to help pay premiums and out-of-pocket costs. To get a subsidy, you have to buy your plan through your state's health insurance marketplace. 

About Advance Premium Tax Credits

Additional plan details

How does my Member ID card work?

Here's how to understand all the parts of your ID card.

Member ID Card (PDF)

How do I get forms related to my plan?

We've pulled all our forms together to help you find what you need.

Find your form

Who can I contact with questions?

We're here to answer any questions you might have. Just give us a call.

What is an Arizona state appeals packet?

Every state has unique rules about how you can file a health insurance claim appeal. If you live in Arizona, this packet explains everything you'll need to know such as, who can file an appeal, how to send it in, and how long a health insurance company has to make a decision.

Where can I see my pharmacy claims?

In your member portal, you'll find a summary in "Claims Overview" under "Claims" in the navigation. To view details of a specific claim, click on the claim number. If your claim information isn't immediately available, keep in mind it takes time for a claim to arrive from your provider, be processed, and show up in your member website.

What does the status of my pharmacy claim in my member portal mean?

As you're reviewing your "Claims Overview," keep in mind current status will be shown. Claim history is not shown. You can find more detailed claim information at Express Scripts®.

General contact

8 a.m. – 5 p.m. CT, Monday – Thursday
10 a.m. – 5 p.m. CT, Friday
Information to help you
We get it. There’s a lot to think about when it comes to health insurance plans. We’ll help you figure it all out.

Health plan info guides

What you need to know about coverage at key points in your life.

First-time coverage

Shopping for health care coverage for the first time doesn’t have to be scary. We can help you navigate 

Starting a new family

Make sure to protect your loved ones with a health care plan.


We can take the mystery out of buying insurance, so you can get back to running your business.

Early retirement

You’re ready to exit the workforce and step into retirement. Find a plan that helps you stay healthy for years to come.