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2021 Elevate by Medica 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?

Iowa Plans

Document Care Type
Summary of Benefits and Coverage (SBC) Silver Copay (PDF) Bronze Copay (PDF)
Policy of Coverage
 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 Copay (94% AV Level) – (PDF) Silver Copay (87% AV Level) – (PDF) Silver Copay (73% AV Level) – (PDF)
Policy of Coverage
 Silver Copay (94% AV Level) – (PDF) Silver Copay (87% AV Level) – (PDF) Silver Copay (73% AV Level) – (PDF)
Catastrophic
Summary of Benefits and Coverage (PDF)
Policy of Coverage (PDF)
Document Care Type          
Summary of Benefits and Coverage (SBC) Gold Share Limited (PDF) Silver Copay Limited (PDF) Bronze Copay Limited (PDF) Bronze HSA Limited (PDF) Bronze Share Limited (PDF) Bronze Share Plus Limited (PDF)
Policy of Coverage
 Gold Share Limited (PDF) Silver Copay Limited (PDF) Bronze Copay Limited (PDF) Bronze HSA Limited (PDF) Bronze Share Limited (PDF) Bronze Share Plus Limited (PDF)
Document Care Type          
Summary of Benefits and Coverage (SBC) Gold Share Zero (PDF) Silver Copay Zero (PDF) Bronze Copay Zero (PDF) Bronze HSA Zero (PDF) Bronze Share Zero (PDF) Bronze Share Plus Zero (PDF)
Policy of Coverage
 Gold Share Zero (PDF) Silver Copay Zero (PDF) Bronze Copay Zero (PDF) Bronze HSA Zero (PDF) Bronze Share Zero (PDF) Bronze Share Plus Zero (PDF)
Document Care Type
Summary of Benefits and Coverage (SBC) Gold Share (PDF) Bronze Share (PDF) Bronze Share Plus (PDF)
Policy of Coverage Gold Share (PDF) Bronze Share (PDF) Bronze Share Plus (PDF)

Nebraska Plans

Document Care Type
Summary of Benefits and Coverage (SBC) Silver Copay (PDF) Bronze Copay (PDF)
Policy of Coverage
 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 Copay (94% AV Level) – (PDF) Silver Copay (87% AV Level) – (PDF) Silver Copay (73% AV Level) – (PDF)
Policy of Coverage
 Silver Copay (94% AV Level) – (PDF) Silver Copay (87% AV Level) – (PDF) Silver Copay (73% AV Level) – (PDF)
Catastrophic
Summary of Benefits and Coverage (PDF)
Policy of Coverage (PDF)
Document Care Type          
Summary of Benefits and Coverage (SBC) Gold Share Limited (PDF) Silver Copay Limited (PDF) Bronze Copay Limited (PDF) Bronze HSA Limited (PDF) Bronze Share Limited (PDF) Bronze Share Plus Limited (PDF)
Policy of Coverage
 Gold Share Limited (PDF) Silver Copay Limited (PDF) Bronze Copay Limited (PDF) Bronze HSA Limited (PDF) Bronze Share Limited (PDF) Bronze Share Plus Limited (PDF)
Document Care Type          
Summary of Benefits and Coverage (SBC) Gold Share Zero (PDF) Silver Copay Zero (PDF) Bronze Copay Zero (PDF) Bronze HSA Zero (PDF) Bronze Share Zero (PDF) Bronze Share Plus Zero (PDF)
Policy of Coverage
 Gold Share Zero (PDF) Silver Copay Zero (PDF) Bronze Copay Zero (PDF) Bronze HSA Zero (PDF) Bronze Share Zero (PDF) Bronze Share Plus Zero (PDF)
Document Care Type
Summary of Benefits and Coverage (SBC) Gold Share (PDF) Silver Share (PDF) Bronze Share (PDF) Bronze Share Plus (PDF)
Policy of Coverage Gold Share (PDF) Silver Share (PDF) Bronze Share (PDF) Bronze Share Plus (PDF)

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