Harmony by Medica Silver Standard - 21333OK0010057 Health Insurance Plan

Medica Insurance Company health insurance plan with the Plan ID 21333OK0010057. The plan is called Harmony 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 21333OK0010057
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 21333OK0010057-05
Provider Network(s) PREFERRED PREFERREDTIER STANDARDTIER
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 03 Dec 2024 06:24 GMT).

Providers Oklahoma All US States
All 9548 86633
PCP 953 2580
Allergy 1 18
OB/GYN 26 76
Dentists N/A 4
Available Variants of the Health Plan

Standard Off Exchange Plan - 21333OK0010057-00

Standard On Exchange Plan - 21333OK0010057-01

Open to Indians below 300% FPL - 21333OK0010057-02

Open to Indians above 300% FPL - 21333OK0010057-03

73% AV Silver Plan - 21333OK0010057-04

87% AV Silver Plan - 21333OK0010057-05

94% AV Silver Plan - 21333OK0010057-06

Last Plan Update Date Thu, 19 Sep 2024 00:00 GMT
Last Import Date Tue, 03 Dec 2024 06:24 GMT

Benefits of Harmony by Medica Silver Standard Health Insurance Plan, 21333OK0010057-05

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
NO
Accidental Dental
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Acupuncture
NO
Allergy Testing
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Chemotherapy
YES

$40.00

50.00% Coinsurance after deductible
Chiropractic Care
YES

$20.00

50.00% Coinsurance after deductible
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care
YES

30.00% 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

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Durable Medical Equipment
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Emergency Room Services
YES

30.00% Coinsurance after deductible

30.00% Coinsurance after deductible
Emergency Transportation/Ambulance
YES

30.00% Coinsurance after deductible

30.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Gender Affirming Care
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Generic Drugs
YES

$10.00

100.00%
Habilitation Services

Limit: 30.0 Visit(s) per Benefit Period

See policy or plan document for additional benefit explanation.

YES

$20.00

50.00% Coinsurance after deductible
Hearing Aids

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

YES

30.00% Coinsurance after deductible

100.00%
Hospice Services
YES

30.00% Coinsurance after deductible

100.00%
Imaging (CT/PET Scans, MRIs)
YES

30.00% 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

30.00% Coinsurance after deductible

100.00%
Inpatient Hospital Services (e.g., Hospital Stay)
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Inpatient Physician and Surgical Services
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services
YES

30.00% 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

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services
YES

$20.00

50.00% Coinsurance after deductible
Non-Preferred Brand Drugs
YES

$60.00 Copay after deductible

100.00%
Nutritional Counseling

See policy or plan document for additional benefit explanation.

YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Orthodontia - Adult
NO
Orthodontia - Child
NO
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

$20.00

50.00% Coinsurance after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

30.00% 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

$20.00

50.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Preferred Brand Drugs
YES

$20.00

100.00%
Prenatal and Postnatal Care
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Preventive Care/Screening/Immunization
YES

0.00%

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

$20.00

50.00% Coinsurance after deductible
Private-Duty Nursing

Limit: 85.0 Visit(s) per Benefit Period

YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Prosthetic Devices
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Radiation
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Reconstructive Surgery
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

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

See policy or plan document for additional benefit explanation.

YES

$20.00

50.00% Coinsurance after deductible
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children

Limit: 1.0 Exam(s) per Year

YES

$20.00

50.00% Coinsurance after deductible
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 30.0 Days per Benefit Period

YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Specialist Visit
YES

$40.00

50.00% Coinsurance after deductible
Specialty Drugs
YES

$250.00 Copay after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services
YES

$20.00

50.00% Coinsurance after deductible
Transplant
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Treatment for Temporomandibular Joint Disorders
NO
Urgent Care Centers or Facilities
YES

$30.00

$30.00
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

50.00% Coinsurance after deductible
X-rays and Diagnostic Imaging
YES

30.00% Coinsurance after deductible

50.00% Coinsurance after deductible

Harmony by Medica Silver Standard Health Insurance Plan Variant 21333OK0010057-05 Attributes

Plan Attribute Value
AV Calculator Output Number 0.8733413803485369
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, 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 OKF002
Formulary URL URL
HIOS Product ID 21333OK001
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 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 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) 21333OK0010057-05
Plan Marketing Name Harmony by Medica Silver Standard
Plan Type PPO
Plan Variant Marketing Name Harmony 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 OKS007
Source Name HIOS
Plan ID 21333OK0010057
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 Harmony by Medica Silver Standard Health Insurance Plan, 21333OK0010057

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about Harmony by Medica Silver Standard, 21333OK0010057 Health Insurance Plan, 21333OK0010057

  • Does Harmony by Medica Silver Standard Health Insurance Plan, 21333OK0010057 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (21333OK0010057) Health Insurance Plan, Variant (21333OK0010057-05) 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 (21333OK0010057) Health Insurance Plan, Variant (21333OK0010057-05) have Out Of Country Coverage?

    No, unfortunately there is no Out Of Country Coverage for this Health Insurance Plan (variant of plan).

    Does (21333OK0010057) Health Insurance Plan, Variant (21333OK0010057-05) have Out of Service Area Coverage?

    Yes. Details: Emergency Services and Out of Network services received in the state of Oklahoma

    Does (21333OK0010057) Health Insurance Plan, Variant (21333OK0010057-05) 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 Harmony by Medica Silver Standard Health Insurance Plan, Variant (21333OK0010057-05) offer Disease Management Programs for Asthma?

    Yes, the Harmony by Medica Silver Standard Health Insurance Plan Variant 21333OK0010057-05 offers Disease Management Program for Asthma.

    Does Harmony by Medica Silver Standard Health Insurance Plan, Variant (21333OK0010057-05) offer Disease Management Programs for Heart disease?

    Yes, the Harmony by Medica Silver Standard Health Insurance Plan Variant 21333OK0010057-05 offers Disease Management Program for Heart disease.

    Does Harmony by Medica Silver Standard Health Insurance Plan, Variant (21333OK0010057-05) offer Disease Management Programs for Depression?

    Yes, the Harmony by Medica Silver Standard Health Insurance Plan Variant 21333OK0010057-05 offers Disease Management Program for Depression.

    Does Harmony by Medica Silver Standard Health Insurance Plan, Variant (21333OK0010057-05) offer Disease Management Programs for Diabetes?

    Yes, the Harmony by Medica Silver Standard Health Insurance Plan Variant 21333OK0010057-05 offers Disease Management Program for Diabetes.

    Does Harmony by Medica Silver Standard Health Insurance Plan, Variant (21333OK0010057-05) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Harmony by Medica Silver Standard Health Insurance Plan Variant 21333OK0010057-05 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Harmony by Medica Silver Standard Health Insurance Plan, Variant (21333OK0010057-05) offer Disease Management Programs for Low back pain?

    Yes, the Harmony by Medica Silver Standard Health Insurance Plan Variant 21333OK0010057-05 offers Disease Management Program for Low back pain.

    Does Harmony by Medica Silver Standard Health Insurance Plan, Variant (21333OK0010057-05) offer Disease Management Programs for Pregnancy?

    Yes, the Harmony by Medica Silver Standard Health Insurance Plan Variant 21333OK0010057-05 offers Disease Management Program 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