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2021 Harmony by Medica Plans Documents

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

Oklahoma 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)

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

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

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

Document	Care Type
Summary of Benefits and Coverage (SBC)	Bronze Value (PDF)
Policy of Coverage	Bronze Value (PDF)

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