Altru Prime by Medica Silver Copay $0 PCP - 73751ND0120047 Health Insurance Plan
Medica Health Plans health insurance plan with the Plan ID 73751ND0120047. The plan is called Altru Prime by Medica Silver Copay $0 PCP.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.43% (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 29.57% 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 | 73751ND0120047 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | North Dakota | ||||||||||||||||||
| Health Insurance Issuer | Medica Health Plans | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 73751ND0120047-00 | ||||||||||||||||||
| Provider Network(s) | STANDARDTIER PREFERRED PREFERREDTIER | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 03 Dec 2024 06:24 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 73751ND0120047-00 Standard On Exchange Plan - 73751ND0120047-01 Open to Indians below 300% FPL - 73751ND0120047-02 Open to Indians above 300% FPL - 73751ND0120047-03 73% AV Silver Plan - 73751ND0120047-04 |
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| Last Plan Update Date | Sat, 18 Nov 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 03 Dec 2024 06:24 GMT |
Benefits of Altru Prime by Medica Silver Copay $0 PCP Health Insurance Plan, 73751ND0120047-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Bariatric Surgery
Limit: 1.0 Procedure(s) per Lifetime |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Limit: 20.0 Visit(s) per Benefit Period |
YES | $0.00 |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Dialysis
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Benefit Period Frames are limited to one every other benefit period. Lenses are limited to one pair per benefit period. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Gender Affirming Care
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Generic Drugs
Preferred generic drugs on Medica's Drug List are $15 and generic drugs are $25. Go to Plan Documents to see the List of Covered Drugs. |
YES | $15.00 |
100.00% |
| Habilitation Services
Limit: 30.0 Visit(s) per Benefit Period This visit limit does not apply to services for treatment of autism spectrum disorder. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Limit: 40.0 Visit(s) per Benefit Period |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Hospice Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | $0.00 |
100.00% |
| Non-Preferred Brand Drugs
|
YES | 60.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
Limit: 4.0 Visit(s) per Benefit Period |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $0.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 30.0 Visit(s) per Benefit Period This visit limit does not apply to services for treatment of autism spectrum disorder. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
Prescription insulin will not exceed $25 per prescription unit |
YES | $125.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
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 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Year 30-visit limit is for each of PT and OT. This visit limit does not apply to services for treatment of autism spectrum disorder. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Year This visit limit does not apply to services for treatment of autism spectrum disorder. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Benefit Period |
YES | $0.00 |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 30.0 Days per Benefit Period |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | $90.00 |
100.00% |
| Specialty Drugs
|
YES | $750.00 |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $0.00 |
100.00% |
| Transplant
Limit: 1.0 Exam(s) per Transplant One evaluation is allowed per transplant procedure. Services must be performed at a qualified transplant center. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Limit: 2.0 Treatment(s) per Lifetime Benefits are subject to a Lifetime Maximum of 2 surgical procedures per Member and a Maximum Benefit Allowance of 1 splint per Member per Benefit Period. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $0.00 |
$0.00 |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Altru Prime by Medica Silver Copay $0 PCP Health Insurance Plan Variant 73751ND0120047-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.7042560591046271 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2024 |
| 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 | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | NDF024 |
| Formulary URL | URL |
| HIOS Product ID | 73751ND012 |
| Import Date | 2023-11-18 14:46:48 |
| 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 | 73751 |
| 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 | NDN003 |
| 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 | 2024-01-01 |
| Plan Expiration Date | 2024-12-31 |
| Plan ID (Standard Component ID with Variant) | 73751ND0120047-00 |
| Plan Marketing Name | Altru Prime by Medica Silver Copay $0 PCP |
| Plan Type | HMO |
| Plan Variant Marketing Name | Altru Prime by Medica Silver Copay $0 PCP |
| 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 | $5,000 |
| 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 | NDS003 |
| Source Name | HIOS |
| Plan ID | 73751ND0120047 |
| State Code | ND |
| 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 | 50.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $10000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $5000 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $5,000 |
| 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 | $18400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9200 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,200 |
| 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 Altru Prime by Medica Silver Copay $0 PCP Health Insurance Plan, 73751ND0120047
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Altru Prime by Medica Silver Copay $0 PCP, 73751ND0120047 Health Insurance Plan, 73751ND0120047
-
Does Altru Prime by Medica Silver Copay $0 PCP Health Insurance Plan, 73751ND0120047 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (73751ND0120047) Health Insurance Plan, Variant (73751ND0120047-00) offer Disease Management Programs?
Does (73751ND0120047) Health Insurance Plan, Variant (73751ND0120047-00) have Out Of Country Coverage?
Does (73751ND0120047) Health Insurance Plan, Variant (73751ND0120047-00) have Out of Service Area Coverage?
Does (73751ND0120047) Health Insurance Plan, Variant (73751ND0120047-00) offer Disease Management Programs?
Does Altru Prime by Medica Silver Copay $0 PCP Health Insurance Plan, Variant (73751ND0120047-00) offer Disease Management Programs for Asthma?
Does Altru Prime by Medica Silver Copay $0 PCP Health Insurance Plan, Variant (73751ND0120047-00) offer Disease Management Programs for Heart disease?
Does Altru Prime by Medica Silver Copay $0 PCP Health Insurance Plan, Variant (73751ND0120047-00) offer Disease Management Programs for Depression?
Does Altru Prime by Medica Silver Copay $0 PCP Health Insurance Plan, Variant (73751ND0120047-00) offer Disease Management Programs for Diabetes?
Does Altru Prime by Medica Silver Copay $0 PCP Health Insurance Plan, Variant (73751ND0120047-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Altru Prime by Medica Silver Copay $0 PCP Health Insurance Plan, Variant (73751ND0120047-00) offer Disease Management Programs for Low back pain?
Does Altru Prime by Medica Silver Copay $0 PCP Health Insurance Plan, Variant (73751ND0120047-00) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 03 Dec 2024 06:24 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