Medica Insurance Company health insurance plan with the Plan ID 21333OK0070002. The plan is called Harmony by Medica Silver $0 Copay PCP Visits + Adult Eye Exam.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.01% (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 29.99% 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 | 21333OK0070002 | ||||||||||||||||||
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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 | 21333OK0070002-00 | ||||||||||||||||||
Provider Network(s) | PREFERRED PREFERREDTIER STANDARDTIER | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 10 Dec 2024 06:32 GMT). |
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Available Variants of the Health Plan | Standard Off Exchange Plan - 21333OK0070002-00 Standard On Exchange Plan - 21333OK0070002-01 Open to Indians below 300% FPL - 21333OK0070002-02 Open to Indians above 300% FPL - 21333OK0070002-03 73% AV Silver Plan - 21333OK0070002-04 |
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Last Plan Update Date | Thu, 19 Sep 2024 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 10 Dec 2024 06:32 GMT |
Benefit | Covered | In Network | Out Of Network |
---|---|---|---|
Abortion for Which Public Funding is Prohibited
|
NO | ||
Accidental Dental
|
YES | 40.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Acupuncture
|
NO | ||
Allergy Testing
|
YES | 40.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Bariatric Surgery
|
NO | ||
Basic Dental Care - Adult
|
NO | ||
Basic Dental Care - Child
|
NO | ||
Chemotherapy
|
YES | $80.00 |
50.00% Coinsurance after deductible |
Chiropractic Care
|
YES | $0.00 |
50.00% Coinsurance after deductible |
Cosmetic Surgery
|
NO | ||
Delivery and All Inpatient Services for Maternity Care
|
YES | 40.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Dental Check-Up for Children
|
NO | ||
Diabetes Education
|
YES | No Charge |
50.00% Coinsurance after deductible |
Dialysis
|
YES | 40.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Durable Medical Equipment
|
YES | 40.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Emergency Room Services
|
YES | 40.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
Emergency Transportation/Ambulance
|
YES | 40.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | 40.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Gender Affirming Care
|
YES | 40.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Generic Drugs
|
YES | $25.00 |
100.00% |
Habilitation Services
Limit: 30.0 Visit(s) per Benefit Period See policy or plan document for additional benefit explanation. |
YES | 40.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Hearing Aids
See policy or plan document for additional benefit explanation. |
YES | 40.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Home Health Care Services
Limit: 30.0 Visit(s) per Benefit Period |
YES | 40.00% Coinsurance after deductible |
100.00% |
Hospice Services
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Imaging (CT/PET Scans, MRIs)
|
YES | 40.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Infertility Treatment
|
NO | ||
Infusion Therapy
Limit: 25.0 Visit(s) per Benefit Period See policy or plan document for additional benefit explanation. |
YES | 40.00% Coinsurance after deductible |
100.00% |
Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 40.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Inpatient Physician and Surgical Services
|
YES | 40.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Laboratory Outpatient and Professional Services
|
YES | 40.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Long-Term/Custodial Nursing Home Care
|
NO | ||
Major Dental Care - Adult
|
NO | ||
Major Dental Care - Child
|
NO | ||
Mental/Behavioral Health Inpatient Services
|
YES | 40.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Mental/Behavioral Health Outpatient Services
|
YES | $0.00 |
50.00% Coinsurance after deductible |
Non-Preferred Brand Drugs
|
YES | $225.00 |
100.00% |
Nutritional Counseling
See policy or plan document for additional benefit explanation. |
YES | 40.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Orthodontia - Adult
|
NO | ||
Orthodontia - Child
|
NO | ||
Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $0.00 |
50.00% Coinsurance after deductible |
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 40.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Outpatient Rehabilitation Services
Limit: 30.0 Days per Benefit Period See policy or plan document for additional benefit explanation. |
YES | 40.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Outpatient Surgery Physician/Surgical Services
|
YES | 40.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Preferred Brand Drugs
|
YES | $125.00 |
100.00% |
Prenatal and Postnatal Care
|
YES | 40.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Preventive Care/Screening/Immunization
|
YES | No Charge |
50.00% Coinsurance after deductible |
Primary Care Visit to Treat an Injury or Illness
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 | $0.00 |
50.00% Coinsurance after deductible |
Private-Duty Nursing
Limit: 85.0 Visit(s) per Benefit Period |
YES | 40.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Prosthetic Devices
|
YES | 40.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Radiation
|
YES | 40.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Reconstructive Surgery
|
YES | 40.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 25.0 Visit(s) per Benefit Period See policy or plan document for additional benefit explanation. |
YES | 40.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Rehabilitative Speech Therapy
Limit: 25.0 Visit(s) per Benefit Period See policy or plan document for additional benefit explanation. |
YES | 40.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Routine Dental Services (Adult)
|
NO | ||
Routine Eye Exam (Adult)
|
YES | $0.00 |
50.00% Coinsurance after deductible |
Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year |
YES | $0.00 |
50.00% Coinsurance after deductible |
Routine Foot Care
|
NO | ||
Skilled Nursing Facility
Limit: 30.0 Days per Benefit Period |
YES | 40.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Specialist Visit
|
YES | $80.00 |
50.00% Coinsurance after deductible |
Specialty Drugs
|
YES | $700.00 |
100.00% |
Substance Abuse Disorder Inpatient Services
|
YES | 40.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Substance Abuse Disorder Outpatient Services
|
YES | $0.00 |
50.00% Coinsurance after deductible |
Transplant
|
YES | 40.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Treatment for Temporomandibular Joint Disorders
|
NO | ||
Urgent Care Centers or Facilities
|
YES | $0.00 |
$0.00 |
Weight Loss Programs
|
NO | ||
Well Baby Visits and Care
|
YES | No Charge |
50.00% Coinsurance after deductible |
X-rays and Diagnostic Imaging
|
YES | 40.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Plan Attribute | Value |
---|---|
AV Calculator Output Number | 0.700066538552825 |
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 | Standard Silver Off Exchange Plan |
Dental Only Plan | No |
Design Type | Not Applicable |
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 | 0.9940000000000001 |
First Tier Utilization | 100% |
Formulary ID | OKF005 |
Formulary URL | URL |
HIOS Product ID | 21333OK007 |
Import Date | 2024-09-19 01:01:32 |
Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
Inpatient Copayment Maximum Days | 0 |
HSA Eligible | No |
New/Existing Plan | New |
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 | OKN001 |
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) | 21333OK0070002-00 |
Plan Marketing Name | Harmony by Medica Silver $0 Copay PCP Visits + Adult Eye Exam |
Plan Type | PPO |
Plan Variant Marketing Name | Harmony by Medica Silver $0 Copay PCP Visits + Adult Eye Exam |
QHP/Non QHP | Both |
SBC Scenario, Having a Baby, Coinsurance | $3,100 |
SBC Scenario, Having a Baby, Copayment | $10 |
SBC Scenario, Having a Baby, Deductible | $3,500 |
SBC Scenario, Having a Baby, Limit | $60 |
SBC Scenario, Having Diabetes, Coinsurance | $0 |
SBC Scenario, Having Diabetes, Copayment | $800 |
SBC Scenario, Having Diabetes, Deductible | $1,100 |
SBC Scenario, Having Diabetes, Limit | $0 |
SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
SBC Scenario, Treatment of a Simple Fracture, Copayment | $200 |
SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,600 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Service Area ID | OKS008 |
Source Name | HIOS |
Plan ID | 21333OK0070002 |
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 | 40.00% |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $7000 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $3500 per person |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $3,500 |
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 | $18000 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9000 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,000 |
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 |
Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Disclaimer: This is based on the import(Date: Tue, 10 Dec 2024 06:32 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