Custome
`Service
`Have some questions?
`Just give us a call.
`Mpls./St. Paul
`metro callers:
`(612) 945-8000
`Non-metro callers:
`1 -300-952-3455
`
`Hearing-impaired
`Mpls./S1. Paul
`metro callers:
`(612) 992-3190 (TDD)
`Hearing-impaired
`non-metro callers:
`1-800-041-6753 [TDD)
`You will be asked to enter
`your group number when you
`call. Your group number is
`found on your Medina Elect
`ID card. If you do not have an
`ID card and don't know your
`gwup m,,nbe,, smmiy my on
`the line afterthe recorded
`message and a representative
`will assist you.
`
`I»!1.
`MEDICA
`HEALTH l’L AN
`ALLINA 111:.-u.n
`TEM
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` 71415’! Mar
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`HIIIHIIJIIHWINI[WillIIINIIHIIIIHIII
`03-05-2000
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`What's Inside
`Medina Elect’:
`Advantages
`I113
`fl.nesiibns:& Answers
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`How tn Enroll
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`

`

`Q Are there any providers I can receive
`care from without a referral from my
`primary care clinic or physician?
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`I1. Will I be covered if my primary
`care physician relers me to a
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`0. Do I have to contact my designated primary
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`Questions & Answers
`(1 What are the advantages of receiving care
`from my designated primary care clinic?
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`(1. Can I select a diflerem primary care clinic
`Ior my spouse and/or children?
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`(1. How often can I change my designated
`primary care clinic’!
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`Merlica Ca||Link:
`Answering Vnur Health
`Questions, Day or Night
`One of Medicas most popular
`features IS Medma Cal|LIr1l<."Tl11s
`Z4»h1:1t1rs—a—day, 385—days LI year
`servIce1s staffed by cxpnrmnced
`reg1stered nurses who are ready
`and w1l|1ng to answer your quesuons
`on a variety ofmedrcal suhlects
`and sltuauons.
`The exper1eru:ed stall atMed1ca
`Calltmk can help you
`0 answer your general hualth—rclatcrl
`quesfuris and offer you ass1star1ce
`in s1tuat10ns wherehrst am or
`home care is appropriate,
`- determine whether you should
`schedule an apporrrtrnentwuh
`your prnnary cure chnic or go to
`an ernergcncy room.
`Nledma Calltink nurses answer
`thousands or calls each yearlrorn
`Medica members. They gwe adwce
`on a wide range of concerns, from
`huwtu hnd a liealllrielaled support
`group to huw to treat a minor hurn
`u. a eh1ld‘s stuffy nose
`W1thMen11ca CallL1nk, you'll find
`thatqul1:k,sour1d rned1ca|adv1ce 15
`only a phone call away.
`Medica Calllink
`Mpls./St Paul metro 1: allers:
`(E51) GM-IIJIIO
`Nurwnetro callers:
`1-Hflfl-962-9497
`Hearing-1rnpa1red callers:
`1~8llfl-55|J-Z257 lTDD)
`
`

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`Working Toward
`Healthier Communities
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`Opium Assistance Services: Metro 8. Non-Metro 1.Bfl0.liZ6.7944 Hearliitrliiiixaireitl1.800.698.5597
`
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`Our Goal is to Help You
`Stay Healthy
`7
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`on-Metro 1.300.552.9497
`
`

`

`

`

`Medica Elect — Minnesota
`
`
`
`Uut-of-Network
`ln~Network
`Benefits
`Benefits
`These benefits apply
`These benefits apply
`when you directly
`when services are
`access a provider
`provided by or
`other than your
`arranged through your
`Primary Care Clinic or Primary Care Clinic
`Care System. You may without a referral
`directly access services
`from your Primary
`from a preferred net— Care Clinic.
`work Ob/Gyn, or pre-
`ferred network mental
`health/substance
`abuse provider who
`is affiliated with your
`Primary Care Clinic
`or Care System. Also,
`you may directly
`access services from
`a preferred network
`Chiropractor, or a
`network Urgent Care
`Center.
`Unlimited.
`
`$1,000,000 per
`member, per lifetime.
`$3000 per calendar year.
`
`$1,000,000 per
`member, per lifetime.
`$3000 per calendar year.
`
`Partial Listing of
`Covered Services
`
`Lifetime Maximum Benefit
`
`Out-ol—Pocket
`Maximum
`
`Deduwme
`
`Member
`
`Family
`
`Member
`
`$5000 per calendar
`year.
`Not applicable.
`
`Family
`
`Not applicable.
`
`when you receive
`covered services,
`Medica PAYS:
`
`PREVENTIVE CARE RECEIVED
`IN THE PHYSlC|AN‘S OFFICE
`UFI HOSPITAL
`- Routine physical exams
`- Immunizations
`~ Well child care
`~ Mammograms
`- Pap smears
`- Routine eye exams
`- Allergy shots
`SERVICES RECEIVED IN THE
`uuvv:IriAM‘Q n|'.I:It‘I:
`
`100%.
`100%.
`100%.
`100%.
`100%,
`100%.
`100%.
`
`
`in-Network
`Dut»ol-Network
`In-Network
`0ut—of—Network
`In-Network
`0ut—of»Network
`Benefits
`Benefits
`Benefits
`Benefits
`Benefits
`Benefits
`These benefits apply
`These benefits apply
`These benefits apply
`These benefits apply
`These benefits apply
`These benefits apply
`when services are
`when you directly
`when services are
`when you directly
`when services are
`when you directly
`provided by or
`access a provider
`provided by or
`access a provider
`provided by or
`access a provider
`arranged through your other than your
`arranged through your
`other than your
`arranged through your
`other than your
`Primary Care Clinic or Primary Care Clinic.
`Primary Care Clinic or Primary Care Clinic.
`Primary Care Clinic or Primary Care Clinic.
`Care System. You may without a referral
`Care System. You may without a referral
`Care System. You may without a referral
`directly access services
`from your Prlmany
`directly access services
`from your Primary
`directly access services
`from your Primary
`from a preferred net- Care Clinic.
`from a preferred net»
`Care Clinic.
`from a preferred net— Care Clinic.
`work Ob/Gyn, or pre-
`work Ob/Gyn, or pre-
`work Ob/Gyn, or pre-
`ferred network mental
`ferred network mental
`ferred network mental
`health/substance
`health/substance
`health/substance
`abuse provider who
`abuse provider who
`abuse provider who
`is affiliated with your
`is affiliated with your
`is affiliated with your
`Primary Care Clinic
`Primary Care Clinic
`Primary Care Clinic
`or Care System. Also,
`or Care System. Also,
`or Care System. Also,
`you may directly
`you may directly
`you may directly
`access services from
`access services from
`access services from
`a preferred network
`a preferred network
`a preferred network
`Chiropractor, or a
`Chiropractor, or a
`Chiropractor, or a
`network Urgent Care
`network Urgent Care
`network Urgent Care
`Center
`Center.
`Center.
`Unlimited.
`Unlimited.
`Unlimited.
`
`$1,000,000 per
`member, per lifetime.
`$3000 per calendar year.
`7
`Not applicable.
`
`.
`
`$1,000,000 per
`member, per lifetime.
`$2250 per calendar
`Veal
`Not applicable.
`‘
`$300 per calendar
`year,
`7
`8900 per calendar
`year.
`When you receive
`covered services
`alter deductible
`has been satisfied,
`Medica Insurance
`Company PAYS:
`
`$750 per calendar
`V330
`$5000 per calendar
`year,
`Not applicable.
`
`Not applicable.
`
`When you receive
`covered services,
`Medica PAYS:
`
`$5000 per calendar
`year.
`Not applicable.
`
`Not applicable.
`
`when you receive
`covered services,
`Medica PAYS:
`
`Not applicable.
`
`$300 per calendar
`year.
`$900 per calendar
`year.
`When you receive
`covered services
`after deductible
`has been satisfied,
`Medica Insurance
`Company PAYS:
`
`Not applicable.
`
`$300 per calendar
`year.
`$900 per calendar
`year.
`When you receive
`covered services
`alter deductible
`has been satisfied,
`Medica Insurance
`Company PAYS:
`
`$5000 per calendar
`year
`Not applicable.
`
`Not applicable.
`
`when you receive
`covered services,
`Medica PAYS:
`
`$300 per calendar
`year.
`$900 per calendar
`year.
`When you receive
`covered services
`after deductible
`has been satisfied,
`Medica Insurance
`Company PAYS:
`
`No coverage,
`80%?
`80%?
`80%?
`80%‘.
`No coverage.
`80%?
`
`100%.
`100%.
`100%,
`100%.
`100%.
`100%.
`100%.
`
`No coverage.
`80%?
`80%?
`80%?
`80%?
`No coverage.
`80%?
`
`100%.
`100%.
`100%.
`100%.
`100%.
`100%.
`100%.
`
`No coverage.
`80%?
`80%?
`80%?
`80%?
`No coverage.
`80%‘,
`
`100%.
`100%.
`100%.
`100%,
`100%.
`100%.
`100%.
`
`No coverage.
`80%?
`80%?
`80%?
`80%
`No coverage
`80%?
`
`

`

`
`' Lou and IK'|ay
`IUU‘/u.
`UU“/a.
`IUU‘/o.
`dU“/of
`'|UU"/o.
`6U“/of
`100°/o.
`BO“/a'.‘
`- Surgical services
`100%.
`80%?
`100% after $10
`80%?
`100% after $10
`'
`80%?
`80%.
`80%?
`copayment per visit.
`copayment per visit.
`
`
`
`.
`
`100%
`
`100%.
`
`100%.
`
`100%
`
`100%.
`100%.
`
`80%? Coverage is
`limited to a combined
`total of 120 days per
`member, per calendar
`year for all non—network
`inpatient services.
`80%?
`
`100%
`
`100%.
`
`80%? Coverage is
`limited to a combined
`total of 120 days per
`member, per calendar
`year for all non—network
`inpatient services.
`80%?
`
`80%?
`
`80%?
`
`80%?
`80%?
`
`100% after $10
`copayment per visit.
`100% after $10
`copayment per visit.
`
`100%.
`100%.
`
`80%?
`
`80%?
`
`80%?
`80%?
`
`80%. Maximum
`$500 copayment
`per inpatient stay.
`
`100%.
`
`100% after $10
`copayment per visit.
`100% after $10
`copayment per visit.
`
`100%.
`100%.
`
`80%? Coverage is
`limited to a combined
`total of 120 days per
`member. per calendar
`year lor all non—nelworl<
`inpatient services.
`80%?
`
`80%?
`
`80%?
`
`80%?
`80%?
`
`80%.
`
`80%.
`
`80%.
`
`80%.
`
`100%.
`100%.
`
`80%? Coverage is
`limited to a combined
`total of 120 days per
`member, per calendar
`year for all non—network
`inpatient services.
`80%?
`
`80%?
`
`80%‘.
`.
`
`80%‘.
`80%?
`
`100% after $10
`copayment per visit.
`100% after $60
`copayment per visit.
`80%.
`
`See below.
`
`See below.
`See below.
`
`100% after $10
`copayment per visit.
`100% after $60
`copayment per visit.
`80%.
`
`See below.
`
`See below.
`See below.
`
`100% after $10
`copayment per visit.
`100% after $50
`copayment per visit.
`80%.
`
`See below.
`
`See below.
`See below.
`
`100% after $10
`copayment per visit.
`80%.
`80%.
`
`See below.
`
`See below.
`See below.
`
`80%. A deductible does not apply—to
`emergency services. Member pays a
`maximum of $500 per calendar year.
`
`80%. A deductible does not apply to
`emergency services. Member pays a
`maximum 01 $500 per calendar year.
`
`80%. A deductible does not apply to
`emergency services. Member pays a
`maximum of $500 per calendar year.
`
`80%. A deductible does not apply to
`emergency services. Member pays a
`maximum of $750 per calendar year.
`
`SERVICES RECEIVED IN A
`HOSPITAL 0R SURGICENTER
`- Inpatient hospital
`Facility
`
`Physician
`- Outpatient hospital
`Facility
`
`Physician
`~ Outpatient Lab and x-ray
`Facility
`Physician
`URGENT 0R EMERGENCY CARE
`~ Urgent care center
`
`- Hospital emergency room
`- Emergency ambulance
`services
`EMERGENCY SERVICES FROM
`NON-NETWORK PROVIDERS
`
`MATERNITY CARE RECEIVED IN
`THE PHYSICIANS OFFICE 0R
`HOSPITAL
`- Prenatal services
`- Delivery services
`Physician
`Hospital
`
`- Postnatal services
`PRESCRIPTION MEDICATIONS
`RECEIVED AT A PHRRMACY
`
`100%.
`
`100%.
`100%.
`
`100%.
`
`100%.
`100%.
`
`80%?
`
`80%?
`80%? Coverage is
`limited to a combined
`total 01 120 days per
`member, per calendar
`year for all non—
`network inpatient
`services.
`80%?
`Up it) a 34-day mpply
`for incilicziririm iecziiiert
`at tl nori~ncrwrrrk
`]ii\l|T7I\UL’_\‘.
`60%.’ Member pays
`the greater of 40%
`or a $26 copayment.
`
`80%‘.
`
`100%.
`
`80%‘.
`
`100%.
`80%. Maximum
`$500 copayment
`per inpatient stay.
`
`80%?
`80%? Coverage is
`limited to a combined
`total of 120 days per
`member, per calendar
`year for all non—
`network inpatient
`services.
`80%?
`Up In a 34—clzI_y supply
`frrr I'm’[[ICflfll0IS fl,’('L’l1’|’Ll
`at a nini—nt-ziiiirii
`l)illl1TIlAlL\'.
`60%? Member pays
`the greater of 40%
`or a $26 copayment.
`
`80%?
`80%? Coverage is
`limited to a combined
`total of 120 days per
`member, per calendar
`year tor all non—
`network inpatient
`services.
`80%‘.
`Up to a 54-day supply
`fur nicrlicririirm TL'CL‘II'('Kl
`(I! ll iiinimeriurirlr
`plvimiiim.
`60%? Member pays
`the greater of 40%
`or a $26 copayment.
`
`100%.
`
`100%.
`00%.
`
`80%?
`
`80%?
`80%? Coverage is’
`limited to a combined
`total of 120 days per
`member, per calendar
`year tor all non—
`network inpatient
`services.
`80%?
`I Iii lit a i4-tiny my-lily
`flrr iiieiliptiiiinit mt-iml
`or [I iiini—iicrimil.-
`yiluiriiinxy.
`60%.‘ Member pays
`the greater 01 40%
`or a $26 copayment.
`
`100%.
`100%.
`100%.
`100%.
`Up (04154-clay mpply
`Up ID a 34~Ll(1j( supply
`Up (u u 34«zlay mpply
`Up to II 34~£LIy supply
`for iiiediczitium reccivetl
`fur meJir:rin'on5 -rcceiu-ii
`fur nu-dimrirm rm-iwd
`for meclicarioris receivert
`[III a nciuurk
`at (1 iieiiuork
`or a network
`at in network
`liliumuim.
`piuimiuty.
`[!II[IV'nI1lC)'.
`i>hwmai:y.
`100% after $11
`100% after $11
`100% after 811
`100% after $11