Welcome to Medica | 2023 Arizona Plans

Discrimination is Against the Law

Medica complies with applicable Federal civil rights laws and will not discriminate against any person on the basis of race, color, national origin, age, disability or sex. Medica:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as: TTY communication and written information in other formats (large print, audio, other formats). • Provides free language services to people whose primary language is not English, such as: Qualified interpreters and information written in other languages.

What else you need to know

If you need these services, call the number included in this document or on the back of your Medica ID card. If you believe that Medica has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with: Civil Rights Coordinator, Mail Route CP250, PO Box 9310, Minneapolis, MN 55443-9310, 952-992-3422 (phone/fax), TTY 711, civilrightscoordinator@medica.com. You can file a grievance in person or by mail, fax, or email. You may also contact the Civil Rights Coordinator if you need assistance with filing a complaint. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue, SW Room 509F, HHH Building, Washington, D.C. 20201, 800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Eligibility and requirements To qualify for a Medica plan, you must be a resident of Arizona, and not eligible for or enrolled in Medicare. You also must live within your selected network’s service area to enroll in and remain in the plan. Understanding benefits and coverage details This brochure is a brief overview of the plans. For complete benefit details, limitations, and exclusions please see a Medica Individual and Family insurance policy. You can find that at Medica.com/ ShopAZPlans-23 , or you can get a paper copy by calling 1 (866) 298-3090 (TTY: 711 ). Prior approvals and excluded services Some services and procedures require prior approval from Medica before they are covered. Services not covered include, but are not limited to, custodial care, adult eyewear, most dental services, cosmetic services, refractive eye surgery, those received while on military duty and services that are investigational or not medically necessary. For a complete list, see a Medica Individual and Family insurance policy available on Medica.com/ ShopAZPlans-23 or call 1 (866) 298-3090 (TTY: 711 ). Pediatric dental is not covered These policies do not include pediatric dental services. Pediatric dental is an essential health benefit that can be purchased as a standalone product through Healthcare. gov. For more information visit Healthcare.gov. Member Complex Case Management We have services and programs designed to help members with certain health conditions manage their overall care and treatment. Find more information about the programs and services available by visiting Medica. com/ShopAZPlans-23.

Health Savings Account The Bronze HSA plan can be paired with a health savings account (HSA) — which is a special savings account for IRS-approved medical expenses. Generally, CSR plans cannot be paired with an HSA. Learn more about the benefits of an HSA or how to open an account by visiting Medica.com/HSA. Deductible and out-of-pocket maximum details The deductible and out-of-pocket maximum are subject to a “cost of living” increase on a yearly basis. This increase is tied to the Consumer Price Index and/or may result from adjustments needed to keep plans within the range for a given metal level; metal levels (e.g., Gold, Silver, Bronze) must always be in compliance with the Affordable Care Act (ACA) for Qualified Health Plans (QHPs). Cost Share Reduction plans You may be able to get help paying your health insurance premium or qualify for plans with reduced deductibles and copays. Plans with reduced deductibles and copays are called Cost Share Reduction (CSR) plans. You can get this assistance if you get health insurance through Healthcare.gov, your income is below a certain level, and you choose a health plan from the Silver plan category. Reduced cost sharing is not available with a Catastrophic plan. If you’re a member of a federally recognized tribe, you may qualify for additional cost-sharing benefits. To see if you’re eligible, please visit Healthcare.gov. Receiving care outside your network Unless it's an emergency, air ambulance service, or certain out-of-network care at an in-network facility or pre-approved by Medica, there is no coverage if you visit a provider that is not in your plan's network. This means that your provider may require you to be responsible for the full cost of any care or supplies. Learn more at Medica.com/BalanceBill.

If you want free help translating this information, call the number included in this document or on the back of your Medica ID card.

이전화정번보호를나번역하는데무료로도움을받고싶으시면,이문서에포함된 Medica ID 카드 뒷면의 전화번호로 전화하십시오. Si vous voulez une assistance gratuite pour traduire ces informations, appelez le numéro indiqué dans ce document ou au dos de votre carte d’identification Medica. er>h t.J ’;d w>us;d xpH XRuvMD >eRw>*>h w>usRd tRH vXtuvMD .<u;d vwD pJ ed .D *>H vXty. Cmk vXvmH wvD mH rtD yRl tRH rwh r>h zeJ Meid c avmH t.k o;c;uth v>D cwH uyRtzcD .d M.wu>h I Kung nais mo ng libreng tulong sa pagsasalin ng impormasyong ito, tawagan ang numero na kasama sa dokumentong ito o sa likod ng iyong Kard ng Medica ID. ይህን መረጃ ለመተርጎም ነጻ እርዳታ የሚፈልጉ ከሆነ በዝ ህ ሰነድ ዉስጥ ያለውን ቁጥር ወይም Medica መታወቅያ ካርድዎ በስተጀርባ ያለውን ይደውሉ። Ako želite besplatnu pomoć za prijevod ovih informacija, nazovite broj naveden u ovom dokumentu ili na poleđini svoje ID kartice Medica. D77 t’11 j77k’e sh1 ata’ hodoonih n7n7zingo 47 ninaaltsoos Medica bee n47ho’d7lzin7g7 bine’d44’ n1mboo bik1’7g78j8’ b44sh bee hod7ilnih. Wenn Sie bei der Übersetzung dieser Informationen kostenlose Hilfe in Anspruch nehmen möchten, rufen Sie bitte die in diesem Dokument oder auf der Rückseite Ihrer Medica-ID-Karte angegebene Nummer an. COMIFB-0119-I How we pay agents + brokers With the Consolidated Appropriations Act of 2021 (CAA), health insurance companies offering individual health insurance coverage must tell you how much they pay brokers for helping someone enroll in a health insurance plan. You can review this information on our website before you finalize your enrollment or renew your plan. To learn more about this disclosure or to see how much your broker earned with your enrollment, go to Medica.com/AgentPayment.

Si desea asistencia gratuita para traducir esta información, llame al número que figura en este documento o en la parte posterior de su tarjeta de identificación de Medica. Yog koj xav tau kev pab dawb kom txhais daim ntawv no, hu rau tus xov tooj nyob hauv daim ntawv no los yog nyob nraum qab ntawm koj daim npav Medica ID. 如果您需要免費翻譯此資訊,請致電本文檔中或者在您的 Medica ID 卡背面包含的號碼。 Nếu quý vị muốn trợ giúp dịch thông tin này miễn phí, hãy gọi vào số có trong tài liệu này hoặc ở mặt sau thẻ ID Medica của quý vị. Odeeffannoo kana gargaarsa tolaan akka isinii hiikamu yoo barbaaddan, lakkoobsa barruu kana keessatti argamu ykn ka dugda kaardii Waraqaa Eenyummaa Medica irra jiruun bilbila’a. إذاكنتتريدمساعدةمجانيةفيترجمةهذهالمعلومات،فاتصلعلى الرقمالواردفيهذهالوثيقةأوعلىظهربطاقةتعريفميديكاالخاصةبك. Если Вы хотите получить бесплатную помощь в переводе этой информации , позвоните по номеру телефона , указанному в данном документе и на обратной стороне Вашей индентификационной карты Medica. ຖ້າທ່ານຕ້ອງການຄວາມຊ່ວຍເຫຼືອໃນການແປຂໍ້ມູນນີ້ຟຣີ , ໃຫ້ໂທຫາເລກໝາຍ ທີ່ມີຢູ່ໃນເອກະສານນີ້ ຫຼື ຢູ່ດ້ານຫຼັງຂອງບັດ Medica ຂອງທ່ານ. Medica privacy notice We take our responsibility of protecting your personal information seriously. Where possible, we de-identify or encrypt personal information. We also use and disclose personal information only to the extent necessary to conduct treatment, payment, and health care operations, or to comply with legal, regulatory, or accreditation requirements. You can get our full Privacy Notice by calling 1 (866) 298-3090 (TTY: 711 ) or by going to Medica.com/Privacy .

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