Please contact Medica at (952) 945-8000 or 1-800-952-3455 with questions regarding coverage and plan designs.

Under 65, or those who live Out of the Area and without Medicare Parts A & B

MEDICA

Plan Provision

In – Network

Out-of- Network

Calendar Year Deductible

$1,000 / person

$2,000 / family

$1,500 / person

$3,000 / family

Out-of-Pocket Maximum

$2,000 / person

$4,000 / family

$3,000 / person

$6,000 / family

Lifetime Max

Unlimited

$2 million

Preventive Care

100% coverage; deductible does not apply

Office Visits

Hospital Services

Lab,, Pathology, X-Ray, Other Imaging

Member pays 20% after annual deductible

Member pays 40% after annual deductible

Emergency

Urgent Care or

Hospital ER

Member pays 20% after annual deductible

Covered as in-network benefit

Prescription Drug Co-Pays

(retail up to a 34-day supply)

$10 preferred generic

$25 preferred brand

$50 non-preferred

Deductible, then member/patient pays greater of 40% or $50

Prescription Drug Co-Pays

(mail order up to a 93-day supply)

$20 preferred generic

$50 preferred brand

$100 non-preferred

No coverage

Three Network Options

Medica Network Options and Group Numbers

Elect

Essential

Choice

Major Care Systems Included

A care system is a group of providers, including primary care physicians, that coordinates delivery of health services including referrals for specialty care.

Allina*

Aspen Medical Group

Integrity Health Network (Duluth) formerly known as CareNorth

Children’s Physician

Hennepin Faculty Assoc.

Lakeview Health Care

Minnesota Healthcare Network

Park Nicollet/Methodist

Riverway/North Suburban Clinics

St. Luke’s (Duluth)

This network was previously in Plans 1 & 2

Altru Health System (ND)

Integrity Health Network (Duluth) formerly known as CareNorth

Innovis (ND)

Fairview Physicians

HealthEast

St. Luke’s (Duluth)

This network was previously in Plans 1 & 2

The Choice network includes more than 17,000 primary care and specialty care providers including those in the Elect and Essential care systems.

This network was previously in Plan 4

Referral Requirements

The primary care clinic you choose determines your care system. You can see any provider within that care system without a referral. In order to receive care from a provider outside your care system, you must receive a referral from your primary care clinic.

* Allina requires referrals outside of its primary care clinic, even if seeking care within their care system.

Choice is an open access network. Open access means that you can go to any provider who is part of the network and be covered for eligible services.

Monthly Premium

Single: $447.60

Family: $1,432.31

Single: $476.17

Family: $1,552.73

This health care plan may not cover all of your health care expenses; read your Certificate of Coverage carefully to determine which expenses are covered. This is a benefit summary and does not outline all of your benefits. If there is a discrepancy between information in this summary and your Certificate of Coverage, the Certificate of Coverage will take precedence in determining your benefits.

A summary of City of Minneapolis Medical Plan benefits is shown on the reverse. When you enroll in the medical plan you must select the Elect, Essential or Choice network. Below are some things to consider when deciding which network to select.

· You are currently in Plan 4, but your doctor/doctors are in the Elect or Essential networks

· You and/or your family members live within the Elect or Essential service area (generally, Minnesota, western Wisconsin and eastern North Dakota)

· You are willing to spend more in premiums for an open access network, including access to specialists without referrals

· You and/or your family members live outside the Elect or Essential service area

Here are answers to commonly asked questions that can help you make your decision:

How do I find out if my provider is in the Elect or Essential network?	There are two easy ways to find out: 1) Visit the member section of www.medica.com. Click on Find a Doctor, then Member Through Work and select Medica Elect or Medical Essential or 2) Call Medica Customer Service at 952-945-8000 or 1-800-952-3455
Can I select a different network for my spouse and/or children?	No, all family members must use the same network.
Can I select a different primary care clinic for my spouse and/or children?	Elect and Essential: Yes, you may select a different primary care clinic for each family member. You will need to choose a primary care clinic from the list of participating clinics within the network you choose. Choice: Choice is an option access network; a primary care clinic selection is not required.
Can I change my primary clinic selection within my network?	You may change your primary care clinic once per month. You must notify Medica Customer Service at least 10 days before the first of the month you want the change to become effective. All changes are effective on the first of the month.
Can I make a mid-year change to my network election?	No, you may not change between the Elect, Essential and Choice networks during the year. You may only make these changes once a year at open enrollment for coverage effective the next January 1^st.
If I choose Elect or Essential, when will I need a referral in order to receive the highest level of benefits?	*Providers within your care system:* With the exception of Allina in the Elect network, you can see any provider in that care system without a referral. Allina requires referrals for visits outside your primary care clinic even when seeing an Allina provider. *Providers outside your care system:* To receive care from a network provider that is outside your care system, you must receive a referral from your primary care clinic. *Urgent care:* You may receive care at a network urgent care center without contacting the clinic beforehand and still receive the highest level of coverage. *Out-of-network:* Referrals to a provider who is not in Elect or Essential network requires prior authorization by Medica. Your physician must contact Medica to obtain the prior authorization.
Do I have coverage if I travel?	If you travel out of Medica’s service area, you can get care with in network level benefits from any provider in UnitedHealthcare’s Options PPO Network. There are more than 500,000 physicians and 5,000 hospitals included in the Network.
Can I choose Elect or Essential, if I live outside the Medica service area?	If there isn’t a care system within 30 miles of your home address, then you will need to enroll in the Choice network.
What happens if I don’t obtain necessary referrals and/or receive medical services outside of the network?	You will have to pay a larger share of the cost for such care (see the reverse for information on out-of-network benefits). These costs do not apply to the network deductible and out-of-pocket maximum. You will also lose the savings of the discount Medica negotiates with providers on your behalf.

Type of Service	HealthPartners Freedom Plan 3B	UCare for Seniors
Calendar Year Deductible	None	None
Calendar Year Out-of-Pocket Maximum	$3,000 medical only	$3,400 medical only
Preventive (physicals, cancer screenings, eye exams, immunizations, etc.)	100% Coverage	100% Coverage
Office Visits (non-preventive care including mental health, chemical health, chiropractic)	$15 Co-Pay	$15 Co-Pay
Inpatient Hospital (illness or injury, mental and chemical health)	100% Coverage	100% Coverage
Outpatient Care (scheduled outpatient surgeries and procedures, MRI and CT)	100% Coverage	$100 Co-Pay for outpatient surgery $25 Co-Pay for non-surgical outpatient
Urgent Care	$15 Co-Pay	$20 Co-Pay
Emergency Care at Hospital Emergency Room	$50 Co-Pay	$50 Co-Pay
Emergency Ambulance	100% Coverage	100% Coverage
Prescription Drugs (Medicare Part D) Retail pharmacy Mail order	Generic / Brand Name /Specialty Co-Pays $12 / $30 / $30 (30-day supply) $24 / $60 / $60 (90-day supply)	Generic / Brand Name Co-Pays $10 / $30 (34-day supply) $20 / $60 (three month supply)
Diabetic Equipment & Supplies (under Medicare Part B)	90% Coverage	100% Coverage
Durable Medical Equipment & Prosthetic Devices	90% Coverage	80% Coverage
Preventive Dental Services	$15 Co-Pay	100% Coverage
Out of Area Travel Benefit Non-Emergency Services	The Extended Absence Benefit provides plan level coverage for up to 9 months while you are away from the service area. Call Member Services to activate.	80% Coverage; no limit
Out-of-Network Services	Medicare Benefits Only	Point of Service Benefit 80%; no limit
Prescription Drug Threshold	2010 Medicare Prescription Drug Part D threshold is $4,550; once this threshold is met you pay a $2.50 to $6.30 co-pay per prescription or 5% co-insurance, whichever is greater	2010 Medicare Prescription Drug Part D threshold is $4,550; once this threshold is met you pay a $2.50 to $6.30 co-pay per prescription or 5% co-insurance, whichever is greater
Monthly Rates: Single/Couple	$247.00 / $494.00	$242.00 / 484.00
Telephone Numbers	952-883-5601 or 952-883-7430/Jennifer Bradford	612-676-6900 (1-877-598-6574 toll-free)

Type of Service	Medica Option 1 Group Prime Solution with Part D		Medica Option 2 Group Prime Solution without Part D		Medica Option 3 Group Prime Solution modified standard Part D
Calendar Year Deductible	None
Out-of-Pocket Maximum	$2,000 includes all medical and prescription drug copayments and coinsurance	$2,000 includes all medical copayments				$2,000 includes all medical copayments
Preventive (physicals, cancer screenings, eye exams, immunizations, etc.)	100% Coverage
Office Visits (includes mental health, substance abuse, chiropractic)	$15 Co-Pay
Inpatient Hospital	$100 Co-Pay
Outpatient Services	$50 Co-pay
Urgent Care	$15 Co-Pay in network; $50 Co-Pay out-of-network
Emergency (In or Out-of-Network)	$75 Co-Pay (waived if admitted within 24 hrs)
Emergency Ambulance	$75 Co-Pay
Prescription Drugs Medicare Part D, 31-day supply	Up to: $10 Generic Co-Pay $25 Preferred Brand Co-Pay $50 Non-preferred Brand Co-Pay $75 Specialty Co-Pay Includes coverage for Medicare excluded drugs, NO coverage gap			No Coverage	Up to: $10 Generic Co-Pay $34 Preferred Brand Co-Pay $74 Non-preferred Brand Co-Pay 25% Specialty Coinsurance Includes coverage for Medicare excluded drugs
Mail Order Prescription Program	2 Copayments for 93-day supply			Not applicable	2 Copayments for 93-day supply
Medicare Part B Drugs	90% Coverage
Durable Medical & Prosthetics	90% Coverage
Preventive Dental Services	No Coverage
Out of Area Travel Benefit Non-Emergency Services	Extended Absence benefits include routine, non-emergency coverage outside the service area but within the United States. Coverage for up to 9 consecutive months. Member must call Medica to activate this option.
Out-of-Network Services	Medicare benefits only unless Extended Absence Option is activated
Prescription Drug Threshold	N/A. Rx copayments accumulate toward the $2,000 Out-of-Pocket Maximum.			N/A	Level 1: See above for annual prescription drug costs up to $2,840. Level 2: After your total drug costs for 2011 reach $2,840, you receive a discount on brand name drugs, and you pay 93% of the plan’s costs for generic drugs until your total drug cost reaches $4,550. Level 3: After your out-of-pocket drug payments equal $4,550, you pay the greater of a $2.50 copay for generics and $6.30 for other drugs or 5% coinsurance.
Monthly Rates: Single/Couple	$240.00 / $480.00			$95.00 / $190.00	$135.00 / $270.00
Telephone Numbers	Customer Service Number 952-992-2330 or 1-800-575-2330

CITY OF MINNEAPOLIS

2012 Medica Health Plan Design Options and Rates

MEDICA