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2021 Empower by Medica Plan Documents

To see your summary of benefits and coverage (SBC) and policy of coverage documents, select your state and plan below.

Iowa Plans

Document	Care Type
Summary of Benefits and Coverage (SBC)	Gold Copay (PDF)	Silver Copay (PDF)	Bronze Copay (PDF)
Policy of Coverage	Gold Copay (PDF)	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 Copay 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 Copay 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 Copay 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 Copay 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)	Bronze Share (PDF)	Bronze Share Plus (PDF)
Policy of Coverage	Bronze Share (PDF)	Bronze Share Plus (PDF)

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