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2021 Medica Individual Choice 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?

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

Wisconsin 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)

Copay Plans

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)

Share Plans

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

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