MEDICA PLAN DETAILS

Monthly Premium
$154

• Primary care delivered on-site by the Genevive Primary Care Team
• Maximum medical out of pocket limit of $5,000 (in network)
• $0 deductible in network care
• $0 copay for primary care visits and 20% coinsurance for specialist visits
• Mental Health Services: $0 copay for outpatient group or individual therapy delivered in living setting, 20% coinsurance outside living setting
• Podiatry Services: $0 copay in living setting, 20% coinsurance outside living setting
• Office Visits with Other Health Care Professionals: $0 copay in living setting, 20% coinsurance outside living setting
• 0 day hospital stay required prior to skilled nursing facility admission:
  • $0 copay days 1-20
  • $170 copay days 21-100
• Inpatient Hospital Stays:
  • $0 copay for days 1-6
  • $500 copay for days 7-10
• 5 tier formulary with more than 3,600 drugs
• Includes $5 copays for Tier 1 drug and $12 copays for Tier 2 drugs
• $435 Part D deductible

Monthly Premium
$68.40

• Primary care delivered on-site by the Genvive Primary Care Team
• Maximum medical out of pocket limit of $5,000 (in network)
• $0 deductible in network care
• $0 copay for primary care visits and 20% coinsurance for specialist visits
• Mental Health Services: $0 copay for outpatient group or individual therapy delivered in living setting, 20% coinsurance outside living setting
• Podiatry Services: $0 copay in living setting, 20% coinsurance outside living setting
• Office Visits with Other Health Care Professionals:
  • $0 copay in living setting, 20% coinsurance outside living setting
• 0 day hospital stay required prior to skilled nursing facility admission:
  • $0 copay days 1-20
  • $170 copay days 21-100
• Inpatient Hospital Stays:
  • $0 copay for days 1-6
  • $500 copay for days 7-10
• 5 tier formulary with more than 3,600 drugs
• Includes $5 copays for Tier 1 drug and $13 copays for Tier 2 drugs
• $435 Part D deductible

Monthly Premium
$66

• Primary care delivered on-site by the Genevive Primary Care Team
• Maximum medical out of pocket limit of $3,500
• $0 deductible
• $0 copay for on-site primary care visits and $25 coinsurance for specialist visits
• Mental Health Services: $0 copay for outpatient group or individual therapy delivered in living setting, 20% coinsurance outside living setting
• Podiatry Services: $0 copay in living setting, 20% coinsurance outside living setting
• 0 day hospital stay required prior to skilled nursing facility admission:
  • $0 copay days 1-20
  • $184 copay days 21-100
• Inpatient Hospital Stays:
  • $300 copay for days 1-6
  • $0 copay for days 7-90
• 5 tier formulary with more than 3,600 drugs
• Includes $5 copays for Tier 1 drug and $12 copays for Tier 2 drugs
• $140 Part D deductible
• Additional gap coverage for select insulins
  • This program limits cost share for insulins to $35 copay for 30-day supply

Monthly Premium
$16

• Primary care delivered on-site by the Genevive Primary Care Team
• Maximum medical out of pocket limit of $7,550
• $0 deductible
• $0 copay for on-site primary care visits and $50 copayment for specialist visits
• Mental Health Services: $0 copay for outpatient group or individual therapy delivered in living setting, $40 copay outside living setting
• Podiatry Services: $0 copay in living setting, 20% coinsurance outside living setting
• 0 day hospital stay required prior to skilled nursing facility admission:
  • $0 copay days 1-20
  • $184 copay days 21-100
• Inpatient Hospital Stays:
  • $325 copay for days 1-6
  • $0 copay for days 7-90
• 5 tier formulary with more than 3,600 drugs
• Includes $5 copays for Tier 1 drug and $12 copays for Tier 2 drugs
• $140 Part D deductible