2022 Arizona Health Plans Portfolio (IFB)

What else you need to know

Eligibility and requirements To qualify for a Medica plan, you must be a resident of Arizona, live within your selected plan's service area, 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 your Medica Individual and Family insurance policy. This can be found by visiting Medica.com/ AZPlans22 or request a paper copy by calling 1 (888) 300-6542 (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/ AZPlans22 or call 1 (888) 300-6542 (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 the 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/AZPlans22.

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 receive 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 the Marketplace, 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. Medica privacy notice Medica takes its responsibility of protecting your personal information seriously. Where possible, Medica de-identifies or encrypts personal information. We 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. Medica’s full Privacy Notice is available upon request by calling 1 (888) 300-6542 (TTY: 711 ) or by going to Medica.com/Privacy .

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