Engage by Medica Gold Standard - 57845WI0050055 Health Insurance Plan
Medica Community Health Plan health insurance plan with the Plan ID 57845WI0050055. The plan is called Engage by Medica Gold Standard.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 100.00% (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 0.00% 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 | 57845WI0050055 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Wisconsin | ||||||||||||||||||
| Health Insurance Issuer | Medica Community Health Plan | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 57845WI0050055-02 | ||||||||||||||||||
| 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 - 57845WI0050055-00 Standard On Exchange Plan - 57845WI0050055-01 |
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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 Engage by Medica Gold Standard Health Insurance Plan, 57845WI0050055-02
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
Exclusions: nan nan |
NO | ||
| Accidental Dental
Exclusions: See policy or plan document for additional benefit exclusions. See policy or plan document for additional benefit explanation. |
YES | $0.00, 0.00% |
100.00% |
| Acupuncture
Exclusions: nan nan |
NO | ||
| Allergy Testing
Exclusions: See policy or plan document for additional benefit exclusions. nan |
YES | $0.00, 0.00% |
100.00% |
| 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 See policy or plan document for additional benefit explanation. |
YES | $0.00, 0.00% |
100.00% |
| Chiropractic Care
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Cosmetic Surgery
Exclusions: nan nan |
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Dental Check-Up for Children
Exclusions: nan nan |
NO | ||
| Diabetes Education
Exclusions: See policy or plan document for additional benefit exclusions. See policy or plan document for additional benefit explanation. |
YES | $0.00, 0.00% |
100.00% |
| Dialysis
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Durable Medical Equipment
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Emergency Room Services
Exclusions: nan nan |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Emergency Transportation/Ambulance
Exclusions: nan nan |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year Exclusions: See policy or plan document for additional benefit exclusions. See policy or plan document for additional benefit explanation. |
YES | $0.00, 0.00% |
100.00% |
| Gender Affirming Care
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Generic Drugs
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Habilitation Services
Limit: 60.0 Visit(s) per Year Exclusions: See policy or plan document for additional benefit exclusions. See policy or plan document for additional benefit explanation. |
YES | $0.00, 0.00% |
100.00% |
| Hearing Aids
Limit: 2.0 Item(s) per 3 Years Exclusions: See policy or plan document for additional benefit exclusions. See policy or plan document for additional benefit explanation. |
YES | $0.00, 0.00% |
100.00% |
| Home Health Care Services
Limit: 60.0 Visit(s) per Year Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Hospice Services
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Infertility Treatment
Exclusions: nan nan |
NO | ||
| Infusion Therapy
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Inpatient Physician and Surgical Services
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Laboratory Outpatient and Professional Services
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| 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 | $0.00, 0.00% |
100.00% |
| Mental/Behavioral Health Outpatient Services
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Non-Preferred Brand Drugs
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Nutritional Counseling
Exclusions: nan See policy or plan document for additional benefit explanation. |
YES | $0.00, 0.00% |
100.00% |
| Orthodontia - Adult
Exclusions: nan nan |
NO | ||
| Orthodontia - Child
Exclusions: nan nan |
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Outpatient Rehabilitation Services
Limit: 60.0 Visit(s) per Year Exclusions: See policy or plan document for additional benefit exclusions. See policy or plan document for additional benefit explanation. |
YES | $0.00, 0.00% |
100.00% |
| Outpatient Surgery Physician/Surgical Services
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Preferred Brand Drugs
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Prenatal and Postnatal Care
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Preventive Care/Screening/Immunization
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Exclusions: nan Virtual visits are unlimited with a $0 copayment when provided by a designated in-network virtual care provider for non-urgent medical symptoms for common illnesses. |
YES | $0.00, 0.00% |
100.00% |
| Private-Duty Nursing
Exclusions: nan nan |
NO | ||
| Prosthetic Devices
Exclusions: See policy or plan document for additional benefit exclusions. nan |
YES | $0.00, 0.00% |
100.00% |
| Radiation
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Reconstructive Surgery
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 20.0 Visit(s) per Year Exclusions: See policy or plan document for additional benefit exclusions. See policy or plan document for additional benefit explanation. |
YES | $0.00, 0.00% |
100.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Year Exclusions: See policy or plan document for additional benefit exclusions. See policy or plan document for additional benefit explanation. |
YES | $0.00, 0.00% |
100.00% |
| 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: See policy or plan document for additional benefit exclusions. See policy or plan document for additional benefit explanation. |
YES | $0.00, 0.00% |
100.00% |
| Routine Foot Care
Exclusions: nan nan |
NO | ||
| Skilled Nursing Facility
Limit: 30.0 Days per Stay Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Specialist Visit
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Specialty Drugs
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Substance Abuse Disorder Inpatient Services
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Substance Abuse Disorder Outpatient Services
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Transplant
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| Urgent Care Centers or Facilities
Exclusions: nan nan |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Weight Loss Programs
Exclusions: nan nan |
NO | ||
| Well Baby Visits and Care
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
| X-rays and Diagnostic Imaging
Exclusions: nan nan |
YES | $0.00, 0.00% |
100.00% |
Engage by Medica Gold Standard Health Insurance Plan Variant 57845WI0050055-02 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 1.0 |
| 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 | Zero Cost Sharing Plan Variation |
| 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 | WIF001 |
| Formulary URL | URL |
| HIOS Product ID | 57845WI005 |
| 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 | 57845 |
| 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 | WIN003 |
| 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 |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 57845WI0050055-02 |
| Plan Marketing Name | Engage by Medica Gold Standard |
| Plan Type | EPO |
| Plan Variant Marketing Name | Engage by Medica Gold Standard |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | WIS003 |
| Source Name | HIOS |
| Plan ID | 57845WI0050055 |
| State Code | WI |
| 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 | 0.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $0 |
| 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 Engage by Medica Gold Standard Health Insurance Plan, 57845WI0050055
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Engage by Medica Gold Standard, 57845WI0050055 Health Insurance Plan, 57845WI0050055
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Does Engage by Medica Gold Standard Health Insurance Plan, 57845WI0050055 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (57845WI0050055) Health Insurance Plan, Variant (57845WI0050055-02) offer Disease Management Programs?
Does (57845WI0050055) Health Insurance Plan, Variant (57845WI0050055-02) have Out Of Country Coverage?
Does (57845WI0050055) Health Insurance Plan, Variant (57845WI0050055-02) have Out of Service Area Coverage?
Does (57845WI0050055) Health Insurance Plan, Variant (57845WI0050055-02) offer Disease Management Programs?
Does Engage by Medica Gold Standard Health Insurance Plan, Variant (57845WI0050055-02) offer Disease Management Programs for Asthma?
Does Engage by Medica Gold Standard Health Insurance Plan, Variant (57845WI0050055-02) offer Disease Management Programs for Heart disease?
Does Engage by Medica Gold Standard Health Insurance Plan, Variant (57845WI0050055-02) offer Disease Management Programs for Depression?
Does Engage by Medica Gold Standard Health Insurance Plan, Variant (57845WI0050055-02) offer Disease Management Programs for Diabetes?
Does Engage by Medica Gold Standard Health Insurance Plan, Variant (57845WI0050055-02) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Engage by Medica Gold Standard Health Insurance Plan, Variant (57845WI0050055-02) offer Disease Management Programs for Low back pain?
Does Engage by Medica Gold Standard Health Insurance Plan, Variant (57845WI0050055-02) 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