Altru Prime by Medica Bronze Copay $0 PCP ($0 Virtual Care with Designated Providers) - 73751ND0120041 Health Insurance Plan

Medica Health Plans health insurance plan with the Plan ID 73751ND0120041. The plan is called Altru Prime by Medica Bronze Copay $0 PCP ($0 Virtual Care with Designated Providers).

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 64.74% (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 35.26% 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 73751ND0120041
Health Insurance Plan Year 2023
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 73751ND0120041-00
Provider Network(s) ['NDN003']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Wed, 27 Mar 2024 12:10 GMT).

Providers North Dakota All US States
All N/A N/A
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A
Available Variants of the Health Plan

Standard Off Exchange Plan - 73751ND0120041-00

Standard On Exchange Plan - 73751ND0120041-01

Open to Indians below 300% FPL - 73751ND0120041-02

Open to Indians above 300% FPL - 73751ND0120041-03

Last Plan Update Date Thu, 18 Aug 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Altru Prime by Medica Bronze Copay $0 PCP ($0 Virtual Care with Designated Providers) Health Insurance Plan, 73751ND0120041-00

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

Tier 1 preferred generic drugs on Medica's Drug List are $25 and tier 2 generic drugs are $30. Go to Plan Documents to see the List of Covered Drugs.

YES

$25.00

100.00%
Habilitation Services

Limit: 30.0 Visit(s) per Benefit Period

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

70.00% 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

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

$200.00

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
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.

YES

50.00% Coinsurance after deductible

100.00%
Rehabilitative Speech Therapy

Limit: 30.0 Visit(s) per Year

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

$150.00

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 Bronze Copay $0 PCP ($0 Virtual Care with Designated Providers) Health Insurance Plan Variant 73751ND0120041-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.647377523
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2023
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Standard Bronze 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
First Tier Utilization 100%
Formulary ID NDF022
Formulary URL URL
HIOS Product ID 73751ND012
Import Date 8/18/2022 1:00
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 73751
Issuer Marketplace Marketing Name Medica
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Expanded Bronze
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 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 73751ND0120041-00
Plan Marketing Name Altru Prime by Medica Bronze Copay $0 PCP ($0 Virtual Care with Designated Providers)
Plan Type HMO
Plan Variant Marketing Name Altru Prime by Medica Bronze Copay $0 PCP ($0 Virtual Care with Designated Providers)
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $2,090
SBC Scenario, Having a Baby, Copayment $10
SBC Scenario, Having a Baby, Deductible $7,000
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $900
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 73751ND0120041
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 $14000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $7000 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $7,000
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 $18200 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $9100 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $9,100
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 Bronze Copay $0 PCP ($0 Virtual Care with Designated Providers) Health Insurance Plan, 73751ND0120041

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

Frequently Asked Questions(FAQ) about Altru Prime by Medica Bronze Copay $0 PCP ($0 Virtual Care with Designated Providers), 73751ND0120041 Health Insurance Plan, 73751ND0120041

  • Does Altru Prime by Medica Bronze Copay $0 PCP ($0 Virtual Care with Designated Providers) Health Insurance Plan, 73751ND0120041 support Mail Ordering?

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

  • Does (73751ND0120041) Health Insurance Plan, Variant (73751ND0120041-00) 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 (73751ND0120041) Health Insurance Plan, Variant (73751ND0120041-00) have Out Of Country Coverage?

    Yes. Details: Emergency Services

    Does (73751ND0120041) Health Insurance Plan, Variant (73751ND0120041-00) have Out of Service Area Coverage?

    Yes. Details: Emergency Services

    Does (73751ND0120041) Health Insurance Plan, Variant (73751ND0120041-00) 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 Altru Prime by Medica Bronze Copay $0 PCP ($0 Virtual Care with Designated Providers) Health Insurance Plan, Variant (73751ND0120041-00) offer Disease Management Programs for Asthma?

    Yes, the Altru Prime by Medica Bronze Copay $0 PCP ($0 Virtual Care with Designated Providers) Health Insurance Plan Variant 73751ND0120041-00 offers Disease Management Program for Asthma.

    Does Altru Prime by Medica Bronze Copay $0 PCP ($0 Virtual Care with Designated Providers) Health Insurance Plan, Variant (73751ND0120041-00) offer Disease Management Programs for Heart disease?

    Yes, the Altru Prime by Medica Bronze Copay $0 PCP ($0 Virtual Care with Designated Providers) Health Insurance Plan Variant 73751ND0120041-00 offers Disease Management Program for Heart disease.

    Does Altru Prime by Medica Bronze Copay $0 PCP ($0 Virtual Care with Designated Providers) Health Insurance Plan, Variant (73751ND0120041-00) offer Disease Management Programs for Depression?

    Yes, the Altru Prime by Medica Bronze Copay $0 PCP ($0 Virtual Care with Designated Providers) Health Insurance Plan Variant 73751ND0120041-00 offers Disease Management Program for Depression.

    Does Altru Prime by Medica Bronze Copay $0 PCP ($0 Virtual Care with Designated Providers) Health Insurance Plan, Variant (73751ND0120041-00) offer Disease Management Programs for Diabetes?

    Yes, the Altru Prime by Medica Bronze Copay $0 PCP ($0 Virtual Care with Designated Providers) Health Insurance Plan Variant 73751ND0120041-00 offers Disease Management Program for Diabetes.

    Does Altru Prime by Medica Bronze Copay $0 PCP ($0 Virtual Care with Designated Providers) Health Insurance Plan, Variant (73751ND0120041-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Altru Prime by Medica Bronze Copay $0 PCP ($0 Virtual Care with Designated Providers) Health Insurance Plan Variant 73751ND0120041-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Altru Prime by Medica Bronze Copay $0 PCP ($0 Virtual Care with Designated Providers) Health Insurance Plan, Variant (73751ND0120041-00) offer Disease Management Programs for Low back pain?

    Yes, the Altru Prime by Medica Bronze Copay $0 PCP ($0 Virtual Care with Designated Providers) Health Insurance Plan Variant 73751ND0120041-00 offers Disease Management Program for Low back pain.

    Does Altru Prime by Medica Bronze Copay $0 PCP ($0 Virtual Care with Designated Providers) Health Insurance Plan, Variant (73751ND0120041-00) offer Disease Management Programs for Pregnancy?

    Yes, the Altru Prime by Medica Bronze Copay $0 PCP ($0 Virtual Care with Designated Providers) Health Insurance Plan Variant 73751ND0120041-00 offers Disease Management Program for Pregnancy.

 

Disclaimer: This is based on the import(Date: Wed, 27 Mar 2024 12:10 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