Balance by Medica Gold Copay ($0 Virtual Care on our platforms + $5 Generic Drugs + Online Wellness) - 21333OK0060001 Health Insurance Plan
Medica Insurance Company health insurance plan with the Plan ID 21333OK0060001. The plan is called Balance by Medica Gold Copay ($0 Virtual Care on our platforms + $5 Generic Drugs + Online Wellness).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 79.75% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 20.25% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.
| Health Insurance Plan ID | 21333OK0060001 | ||||||||||||||||||
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| Health Insurance Plan Year | 2022 | ||||||||||||||||||
| State | Oklahoma | ||||||||||||||||||
| Health Insurance Issuer | Medica Insurance Company | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 21333OK0060001-00 | ||||||||||||||||||
| Provider Network(s) | ['OKN006'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 30 Apr 2024 06:06 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 21333OK0060001-00 Standard On Exchange Plan - 21333OK0060001-01 |
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| Last Plan Update Date | Sat, 26 Feb 2022 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 30 Apr 2024 06:06 GMT |
Balance by Medica Gold Copay ($0 Virtual Care on our platforms + $5 Generic Drugs + Online Wellness) Health Insurance Plan Variant 21333OK0060001-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.797502647 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2022 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Gold Off Exchange Plan |
| Dental Only Plan | No |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy |
| EHB Percent of Total Premium | 1 |
| First Tier Utilization | 100% |
| Formulary ID | OKF001 |
| Formulary URL | URL |
| HIOS Product ID | 21333OK006 |
| Import Date | 2/26/2022 4:03 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 21333 |
| Issuer Marketplace Marketing Name | Medica |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | OKN006 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency Services |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergency Services and Out of Network services received in the state of Oklahoma |
| Plan Brochure | URL |
| Plan Effective Date | 1/1/2022 |
| Plan Expiration Date | 12/31/2022 |
| Plan ID (Standard Component ID with Variant) | 21333OK0060001-00 |
| Plan Marketing Name | Balance by Medica Gold Copay ($0 Virtual Care on our platforms + $5 Generic Drugs + Online Wellness) |
| Plan Type | PPO |
| Plan Variant Marketing Name | Balance by Medica Gold Copay ($0 Virtual Care on our platforms + $5 Generic Drugs + Online Wellness) |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $3,000 |
| SBC Scenario, Having a Baby, Copayment | $10 |
| SBC Scenario, Having a Baby, Deductible | $1,200 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $700 |
| SBC Scenario, Having Diabetes, Deductible | $1,100 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $400 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $100 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,200 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | OKS006 |
| Source Name | HIOS |
| Plan ID | 21333OK0060001 |
| State Code | OK |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 30.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $3600 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $1200 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,200 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $29700 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $9900 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $9,900 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $16200 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8100 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,100 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of Balance by Medica Gold Copay ($0 Virtual Care on our platforms + $5 Generic Drugs + Online Wellness) Health Insurance Plan, 21333OK0060001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Balance by Medica Gold Copay ($0 Virtual Care on our platforms + $5 Generic Drugs + Online Wellness), 21333OK0060001 Health Insurance Plan, 21333OK0060001
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Does Balance by Medica Gold Copay ($0 Virtual Care on our platforms + $5 Generic Drugs + Online Wellness) Health Insurance Plan, 21333OK0060001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (21333OK0060001) Health Insurance Plan, Variant (21333OK0060001-00) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy
Does (21333OK0060001) Health Insurance Plan, Variant (21333OK0060001-00) have Out Of Country Coverage?
Yes. Details: Emergency Services
Does (21333OK0060001) Health Insurance Plan, Variant (21333OK0060001-00) have Out of Service Area Coverage?
Yes. Details: Emergency Services and Out of Network services received in the state of Oklahoma
Does (21333OK0060001) Health Insurance Plan, Variant (21333OK0060001-00) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy
Does Balance by Medica Gold Copay ($0 Virtual Care on our platforms + $5 Generic Drugs + Online Wellness) Health Insurance Plan, Variant (21333OK0060001-00) offer Disease Management Programs for Asthma?
Yes, the Balance by Medica Gold Copay ($0 Virtual Care on our platforms + $5 Generic Drugs + Online Wellness) Health Insurance Plan Variant
21333OK0060001-00 offers Disease
Management Program for Asthma.
Does Balance by Medica Gold Copay ($0 Virtual Care on our platforms + $5 Generic Drugs + Online Wellness) Health Insurance Plan, Variant (21333OK0060001-00) offer Disease Management Programs for Heart disease?
Yes, the Balance by Medica Gold Copay ($0 Virtual Care on our platforms + $5 Generic Drugs + Online Wellness) Health Insurance Plan Variant
21333OK0060001-00 offers Disease
Management Program for Heart disease.
Does Balance by Medica Gold Copay ($0 Virtual Care on our platforms + $5 Generic Drugs + Online Wellness) Health Insurance Plan, Variant (21333OK0060001-00) offer Disease Management Programs for Depression?
Yes, the Balance by Medica Gold Copay ($0 Virtual Care on our platforms + $5 Generic Drugs + Online Wellness) Health Insurance Plan Variant
21333OK0060001-00 offers Disease
Management Program for Depression.
Does Balance by Medica Gold Copay ($0 Virtual Care on our platforms + $5 Generic Drugs + Online Wellness) Health Insurance Plan, Variant (21333OK0060001-00) offer Disease Management Programs for Diabetes?
Yes, the Balance by Medica Gold Copay ($0 Virtual Care on our platforms + $5 Generic Drugs + Online Wellness) Health Insurance Plan Variant
21333OK0060001-00 offers Disease
Management Program for Diabetes.
Does Balance by Medica Gold Copay ($0 Virtual Care on our platforms + $5 Generic Drugs + Online Wellness) Health Insurance Plan, Variant (21333OK0060001-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Yes, the Balance by Medica Gold Copay ($0 Virtual Care on our platforms + $5 Generic Drugs + Online Wellness) Health Insurance Plan Variant
21333OK0060001-00 offers Disease
Management Program for High blood pressure & high cholesterol.
Does Balance by Medica Gold Copay ($0 Virtual Care on our platforms + $5 Generic Drugs + Online Wellness) Health Insurance Plan, Variant (21333OK0060001-00) offer Disease Management Programs for Low back pain?
Yes, the Balance by Medica Gold Copay ($0 Virtual Care on our platforms + $5 Generic Drugs + Online Wellness) Health Insurance Plan Variant
21333OK0060001-00 offers Disease
Management Program for Low back pain.
Does Balance by Medica Gold Copay ($0 Virtual Care on our platforms + $5 Generic Drugs + Online Wellness) Health Insurance Plan, Variant (21333OK0060001-00) offer Disease Management Programs for Pregnancy?
Yes, the Balance by Medica Gold Copay ($0 Virtual Care on our platforms + $5 Generic Drugs + Online Wellness) Health Insurance Plan Variant
21333OK0060001-00 offers Disease
Management Program for Pregnancy.
Disclaimer: This is based on the import(Date: Tue, 30 Apr 2024 06:06 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API