Balance by Medica Silver Standard - 21333OK0060057 Health Insurance Plan
Medica Insurance Company health insurance plan with the Plan ID 21333OK0060057. The plan is called Balance by Medica Silver Standard.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 87.33% (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 12.67% 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 | 21333OK0060057 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Oklahoma | ||||||||||||||||||
| Health Insurance Issuer | Medica Insurance Company | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 21333OK0060057-05 | ||||||||||||||||||
| Provider Network(s) | PREFERRED PREFERREDTIER STANDARDTIER | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 04 Nov 2025 05:30 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 21333OK0060057-00 Standard On Exchange Plan - 21333OK0060057-01 Open to Indians below 300% FPL - 21333OK0060057-02 Open to Indians above 300% FPL - 21333OK0060057-03 73% AV Silver Plan - 21333OK0060057-04 |
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| Last Plan Update Date | Fri, 03 Jan 2025 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 04 Nov 2025 05:30 GMT |
Benefits of Balance by Medica Silver Standard Health Insurance Plan, 21333OK0060057-05
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
Exclusions: nan nan |
NO | ||
| Accidental Dental
Exclusions: nan nan |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Acupuncture
Exclusions: nan nan |
NO | ||
| Allergy Testing
Exclusions: nan nan |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Bariatric Surgery
Exclusions: nan nan |
NO | ||
| Basic Dental Care - Adult
Exclusions: nan nan |
NO | ||
| Basic Dental Care - Child
Exclusions: nan nan |
NO | ||
| Chemotherapy
Exclusions: nan nan |
YES | $40.00 |
50.00% Coinsurance after deductible |
| Chiropractic Care
Exclusions: nan nan |
YES | $20.00 |
50.00% Coinsurance after deductible |
| Cosmetic Surgery
Exclusions: nan nan |
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Exclusions: nan nan |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Dental Check-Up for Children
Exclusions: nan nan |
NO | ||
| Diabetes Education
Exclusions: nan nan |
YES | No Charge |
50.00% Coinsurance after deductible |
| Dialysis
Exclusions: nan nan |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Durable Medical Equipment
Exclusions: nan nan |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Emergency Room Services
Exclusions: nan nan |
YES | 30.00% Coinsurance after deductible |
30.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
Exclusions: nan nan |
YES | 30.00% Coinsurance after deductible |
30.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year Exclusions: nan nan |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Gender Affirming Care
Exclusions: nan nan |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Generic Drugs
Exclusions: nan nan |
YES | $10.00 |
100.00% |
| Habilitation Services
Limit: 30.0 Visit(s) per Benefit Period Exclusions: nan See policy or plan document for additional benefit explanation. |
YES | $20.00 |
50.00% Coinsurance after deductible |
| Hearing Aids
Exclusions: nan See policy or plan document for additional benefit explanation. |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Home Health Care Services
Limit: 30.0 Visit(s) per Benefit Period Exclusions: nan nan |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Hospice Services
Exclusions: nan nan |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Exclusions: nan nan |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Infertility Treatment
Exclusions: nan nan |
NO | ||
| Infusion Therapy
Limit: 25.0 Visit(s) per Benefit Period Exclusions: nan See policy or plan document for additional benefit explanation. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
Exclusions: nan nan |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services
Exclusions: nan nan |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services
Exclusions: nan nan |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Long-Term/Custodial Nursing Home Care
Exclusions: nan nan |
NO | ||
| Major Dental Care - Adult
Exclusions: nan nan |
NO | ||
| Major Dental Care - Child
Exclusions: nan nan |
NO | ||
| Mental/Behavioral Health Inpatient Services
Exclusions: nan nan |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Mental/Behavioral Health Outpatient Services
Exclusions: nan nan |
YES | $20.00 |
50.00% Coinsurance after deductible |
| Non-Preferred Brand Drugs
Exclusions: nan nan |
YES | $60.00 Copay after deductible |
100.00% |
| Nutritional Counseling
Exclusions: nan See policy or plan document for additional benefit explanation. |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Orthodontia - Adult
Exclusions: nan nan |
NO | ||
| Orthodontia - Child
Exclusions: nan nan |
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
Exclusions: nan nan |
YES | $20.00 |
50.00% Coinsurance after deductible |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Exclusions: nan nan |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Outpatient Rehabilitation Services
Limit: 30.0 Days per Benefit Period Exclusions: nan See policy or plan document for additional benefit explanation. |
YES | $20.00 |
50.00% Coinsurance after deductible |
| Outpatient Surgery Physician/Surgical Services
Exclusions: nan nan |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Preferred Brand Drugs
Exclusions: nan nan |
YES | $20.00 |
100.00% |
| Prenatal and Postnatal Care
Exclusions: nan nan |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Preventive Care/Screening/Immunization
Exclusions: nan nan |
YES | 0.00% |
50.00% Coinsurance after deductible |
| Primary Care Visit to Treat an Injury or Illness
Exclusions: nan Virtual visits are unlimited with a $0 copayment when provided by an in-network virtual care provider for non-urgent medical symptoms for common illnesses. |
YES | $20.00 |
50.00% Coinsurance after deductible |
| Private-Duty Nursing
Limit: 85.0 Visit(s) per Benefit Period Exclusions: nan nan |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Prosthetic Devices
Exclusions: nan nan |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Radiation
Exclusions: nan nan |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Reconstructive Surgery
Exclusions: nan nan |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 25.0 Visit(s) per Benefit Period Exclusions: nan See policy or plan document for additional benefit explanation. |
YES | $20.00 |
50.00% Coinsurance after deductible |
| Rehabilitative Speech Therapy
Limit: 25.0 Visit(s) per Benefit Period Exclusions: nan See policy or plan document for additional benefit explanation. |
YES | $20.00 |
50.00% Coinsurance after deductible |
| Routine Dental Services (Adult)
Exclusions: nan nan |
NO | ||
| Routine Eye Exam (Adult)
Exclusions: nan nan |
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year Exclusions: nan nan |
YES | $20.00 |
50.00% Coinsurance after deductible |
| Routine Foot Care
Exclusions: nan nan |
NO | ||
| Skilled Nursing Facility
Limit: 30.0 Days per Benefit Period Exclusions: nan nan |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Specialist Visit
Exclusions: nan nan |
YES | $40.00 |
50.00% Coinsurance after deductible |
| Specialty Drugs
Exclusions: nan nan |
YES | $250.00 Copay after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
Exclusions: nan nan |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services
Exclusions: nan nan |
YES | $20.00 |
50.00% Coinsurance after deductible |
| Transplant
Exclusions: nan nan |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Treatment for Temporomandibular Joint Disorders
Exclusions: nan nan |
NO | ||
| Urgent Care Centers or Facilities
Exclusions: nan nan |
YES | $30.00 |
$30.00 |
| Weight Loss Programs
Exclusions: nan nan |
NO | ||
| Well Baby Visits and Care
Exclusions: nan nan |
YES | No Charge |
50.00% Coinsurance after deductible |
| X-rays and Diagnostic Imaging
Exclusions: nan nan |
YES | 30.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Balance by Medica Silver Standard Health Insurance Plan Variant 21333OK0060057-05 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.873341380348537 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2025 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | 87% AV Level Silver Plan |
| Dental Only Plan | No |
| Design Type | Design 1 |
| Disease Management Programs Offered | Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | OKF002 |
| Formulary URL | URL |
| HIOS Product ID | 21333OK006 |
| Import Date | 2025-01-03 00:01:49 |
| 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 | Silver |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | OKN006 |
| Out of Country Coverage | No |
| 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 | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 21333OK0060057-05 |
| Plan Marketing Name | Balance by Medica Silver Standard |
| Plan Type | PPO |
| Plan Variant Marketing Name | Balance by Medica Silver Standard |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,500 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $500 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $200 |
| SBC Scenario, Having Diabetes, Copayment | $700 |
| SBC Scenario, Having Diabetes, Deductible | $500 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $600 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $90 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $500 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | OKS006 |
| Source Name | HIOS |
| Plan ID | 21333OK0060057 |
| 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 | $1000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $500 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $500 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $23100 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $11550 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $11,550 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $6000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $3000 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $3,000 |
| 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 Silver Standard Health Insurance Plan, 21333OK0060057
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Balance by Medica Silver Standard, 21333OK0060057 Health Insurance Plan, 21333OK0060057
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Does Balance by Medica Silver Standard Health Insurance Plan, 21333OK0060057 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (21333OK0060057) Health Insurance Plan, Variant (21333OK0060057-05) offer Disease Management Programs?
Does (21333OK0060057) Health Insurance Plan, Variant (21333OK0060057-05) have Out Of Country Coverage?
Does (21333OK0060057) Health Insurance Plan, Variant (21333OK0060057-05) have Out of Service Area Coverage?
Does (21333OK0060057) Health Insurance Plan, Variant (21333OK0060057-05) offer Disease Management Programs?
Does Balance by Medica Silver Standard Health Insurance Plan, Variant (21333OK0060057-05) offer Disease Management Programs for Asthma?
Does Balance by Medica Silver Standard Health Insurance Plan, Variant (21333OK0060057-05) offer Disease Management Programs for Heart disease?
Does Balance by Medica Silver Standard Health Insurance Plan, Variant (21333OK0060057-05) offer Disease Management Programs for Depression?
Does Balance by Medica Silver Standard Health Insurance Plan, Variant (21333OK0060057-05) offer Disease Management Programs for Diabetes?
Does Balance by Medica Silver Standard Health Insurance Plan, Variant (21333OK0060057-05) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Balance by Medica Silver Standard Health Insurance Plan, Variant (21333OK0060057-05) offer Disease Management Programs for Low back pain?
Does Balance by Medica Silver Standard Health Insurance Plan, Variant (21333OK0060057-05) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 04 Nov 2025 05:30 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