Medica Symphony for HSA Bronze G Plan Details for 2021- HealthPocket

Medica Symphony for HSA Bronze G

$315.43/mo

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Zip Code55106
Applicant11/28/1986 Male
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameMedica Symphony for HSA Bronze G
Plan IDhhs-31616MN0200017
Plan Year2021
Insurance ProviderMedica
Metal LevelExpanded Bronze
Plan TypePPO
Deductible$6,600
Out-of-Pocket Maximum$7,000
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness20.00% Coinsurance after deductible
Specialist Visit20.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services20.00% Coinsurance after deductible
X-rays and Diagnostic Imaging20.00% Coinsurance after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans20.00% Coinsurance after deductible
Deductible - Family$13200 per group
Out-of-Pocket Maximum - Family$14000 per group

Prescription drug coverage

Generic Drugs20.00% Coinsurance after deductible
Preferred Brand Drugs20.00% Coinsurance after deductible
Non-Preferred Brand Drugs20.00% Coinsurance after deductible
Specialty Drugs20.00% Coinsurance after deductible

Access to doctors and hospitals

Provider directory URLhttp://www.medica.com/FindADoctor/IndividualandFamilyPlanMembers/default.aspx
Does this plan have access to a national provider network?No
Is a referral required to see a Specialist?Not Covered
Does this plan cover services outside plan service area?Yes - Out of Network Benefits
Does this plan cover services outside the country?Yes - Emergency Services

Hospital services

Emergency Room Services20.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)20.00% Coinsurance after deductible
Inpatient Physician and Surgical Services20.00% Coinsurance after deductible
Emergency Transportation or Ambulance Service20.00% Coinsurance after deductible

Maternity

Prenatal and Postnatal Care20.00% Coinsurance after deductible
Delivery and all inpatient services for maternity care20.00% Coinsurance after deductible

Mental Health

Mental/Behavioral Health Outpatient Services20.00% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services20.00% Coinsurance after deductible
Substance use disorder outpatient services20.00% Coinsurance after deductible
Substance use disorder inpatient services20.00% Coinsurance after deductible

Medical Management Programs

Does this plan offer disease managment programs?Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs
Does this plan offer a wellness program?Not Covered

Vision Coverage

Routine Eye Exam for ChildrenIncluded
Eye Glasses for ChildrenIncluded
Routine Eye Exam for AdultsIncluded

Child Dental Coverage

Child Dental Coverage - Routine Dental CareNot Covered
Child Dental Coverage - Basic Dental CareNot Covered
Child Dental Coverage - OrthodontiaNot Covered
Child Dental Coverage - Major Dental CareNot Covered

Adult Dental Coverage

Adult Dental Coverage - Routine Dental CareNot Covered
Adult Dental Coverage - Basic Dental CareNot Covered
Adult Dental Coverage - OrthodontiaNot Covered
Adult Dental Coverage - Major Dental CareNot Covered

Exclusions and Limitations

More Included BenefitsOther Practitioner Office Visit (Nurse, Physician Assistant)
Preventive Care/Screening/Immunization
Imaging (CT/PET Scans, MRIs)
Outpatient Surgery Physician/Surgical Services
Urgent Care Centers or Facilities
Inpatient Physician and Surgical Services
Outpatient Rehabilitation Services
Habilitation Services
Durable Medical Equipment
Hospice Services
Chiropractic Care
Accidental Dental
Allergy Testing
Chemotherapy
Diabetes Education
Dialysis
Infusion Therapy
Laboratory Outpatient and Professional Services
Nutritional Counseling
Prosthetic Devices
Radiation
Reconstructive Surgery
Rehabilitative Occupational and Rehabilitative Physical Therapy
Rehabilitative Speech Therapy
Transplant
Treatment for Temporomandibular Joint Disorders
Well Baby Visits and Care
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
More Limited BenefitsSkilled Nursing Facility
Hearing Aids
Home Health Care Services
More Excluded BenefitsAcupuncture
Bariatric Surgery
Cosmetic Surgery
Infertility Treatment
Private-Duty Nursing
Weight Loss Programs
Dental Check-Up for Children
Routine Foot Care
Abortion for Which Public Funding is Prohibited
Long-Term/Custodial Nursing Home Care
PremiumPlan NameDeductible
from $262North Memorial Acclaim Bronze H S A$6,700.00Select
from $264Bold by M Health Fairview and Medica Bronze H S A$6,700.00Select
from $271Ridgeview Distinct by Medica Bronze H S A$6,700.00Select
from $302Altru Prime by Medica Bronze H S A$6,700.00Select
from $305Medica Applause Bronze H S A$6,700.00Select
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  • Phone Number
    (651) 793-3100
  • Office Locations
    651 Arcade St
    Saint Paul, MN 55106
651 Arcade St Saint Paul MN, 55106

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HealthPocket.com is a free information source. 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. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan. While on our site, if you click on a plan or link, you may be directed to one of our partners who offers health insurance products. HealthPocket, Inc. is part of the Benefytt Technologies, Inc. family of companies.