Members

2021 Medica Insure 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)

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 HSA Limited (PDF)	Bronze Share Limited (PDF)	Bronze Share Plus Limited (PDF)	Silver Share 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)	Silver Share 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 HSA Zero (PDF)	Bronze Share Zero (PDF)	Bronze Share Plus Zero (PDF)
Policy of Coverage	Gold Copay Zero (PDF)	Silver Copay Zero (PDF)	Silver Share 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)	Silver Share	Bronze Share	Bronze Share Plus (PDF)
Policy of Coverage	Silver Share	Bronze Share	Bronze Share Plus (PDF)

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)	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 Copay Limited (PDF)	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 Copay Zero (PDF)	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 Copay Zero (PDF)	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)

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