Medica with CHI Health Bronze Copay Plan Details for 2020- HealthPocket

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Zip Code68104
Applicant12/9/1984 Male
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameMedica with CHI Health Bronze Copay
Plan IDqhp-20305NE0050005
Plan Year2020
Insurance ProviderMedica
Metal LevelExpanded Bronze
Plan TypeEPO
Deductible$7,200
Out-of-Pocket Maximum$8,150
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness$80 Copay
Specialist Visit$150 Copay
Laboratory Outpatient and Professional Services50.00% Coinsurance after deductible
X-rays and Diagnostic Imaging50.00% Coinsurance after deductible
Deductible - Family$14400
Out-of-Pocket Maximum - Family$16300

Prescription drug coverage

Generic Drugs$30 Copay
Preferred Brand Drugs$160 Copay
Non-Preferred Brand Drugs70% Coinsurance after deductible
Specialty Drugs$600 Copay

Access to doctors and hospitals

Provider directory URLhttps://www.medica.com/uninet

Hospital services

Emergency Room Services50% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)50% Coinsurance after deductible
Inpatient Physician and Surgical Services50% Coinsurance after deductible

Maternity

Prenatal and Postnatal Care50.00% Coinsurance after deductible

Mental Health

Mental/Behavioral Health Outpatient ServicesNot Applicable
Mental/Behavioral Health Inpatient Services50.00% Coinsurance after deductible

Vision Coverage

Routine Eye Exam for ChildrenNot Applicable
Eye Glasses for Children50.00% Coinsurance after deductible

Exclusions and Limitations

More Included BenefitsOutpatient Rehabilitation Services
Habilitation Services
Chiropractic Care
Durable Medical Equipment
Hearing Aids
Imaging (CT/PET Scans, MRIs)
Preventive Care/Screening/Immunization
Rehabilitative Speech Therapy
Rehabilitative Occupational and Rehabilitative Physical Therapy
Well Baby Visits and Care
Transplant
Accidental Dental
Dialysis
Allergy Testing
Chemotherapy
Radiation
Diabetes Education
Prosthetic Devices
Infusion Therapy
Treatment for Temporomandibular Joint Disorders
Nutritional Counseling
Reconstructive Surgery
Other Practitioner Office Visit (Nurse, Physician Assistant)
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Outpatient Surgery Physician/Surgical Services
Hospice Services
Urgent Care Centers or Facilities
Home Health Care Services
Inpatient Physician and Surgical Services
Skilled Nursing Facility
More Excluded BenefitsRoutine Foot Care
Acupuncture
Weight Loss Programs
Dental Check-Up for Children
Abortion for Which Public Funding is Prohibited
Infertility Treatment
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Bariatric Surgery
Cosmetic Surgery
PremiumPlan NameDeductible
from $349
Elevate by Medica Bronze Copay
$7,200.00Select
from $362
Medica with CHI Health Bronze Copay
$7,200.00Select
from $403
Medica Insure Bronze Copay
$7,200.00Select
from $427
Elevate by Medica Bronze Copay
$7,200.00Select
from $538
Medica Insure Bronze Copay
$7,200.00Select
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  • Phone Number
    (402) 558-8100
  • Office Locations
    6069 Maple St
    Omaha, NE 68104
6069 Maple St Omaha NE, 68104

HealthPocket is a free information source designed to help consumers find medical coverage. Whether you are looking for Medicare, or an individual and family health insurance plan, we will help you find the right healthcare option and save on your out of pocket healthcare costs. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. If you select a plan presented on our site, you will be directed (via a click or a call) to one of our partners who can help you with your application. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan. HealthPocket, Inc. is part of the Health Insurance Innovations, Inc. family of companies (NASDAQ: HIIQ).

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HealthPocket is a free information source designed to help consumers find medical coverage. Whether you are looking for Medicare, or an individual and family health insurance plan, we will help you find the right healthcare option and save on your out of pocket healthcare costs. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. If you select a plan presented on our site, you will be directed (via a click or a call) to one of our partners who can help you with your application. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan. HealthPocket, Inc. is part of the Health Insurance Innovations, Inc. family of companies (NASDAQ: HIIQ).