IFB 2021 Oklahoma Health Plans Portfolio

OTHER IMPORTANT INFORMATION Eligibility and Requirements

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 the Health Insurance Marketplace. 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/Plans4OK . 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, Cost Share Reduction (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 .

To qualify for a Medica plan, you must be a resident of Oklahoma, 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. This can be found by visiting Medica.com/ Plans4OK or request a paper copy by calling (855) 347-5009 (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/ Plans4OK or call (855) 347-5009 (TTY: 711 ).


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