Medica Pinnacle Gold Copay ($0 Non-Urgent Virtual Care with Designated Providers) - 32311AZ0010001 Health Insurance Plan

Medica Community Health Plan health insurance plan with the Plan ID 32311AZ0010001. The plan is called Medica Pinnacle Gold Copay ($0 Non-Urgent Virtual Care with Designated Providers).

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 80.10% (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 19.90% 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 32311AZ0010001
Health Insurance Plan Year 2023
State Arizona
Health Insurance Issuer Medica Community Health Plan
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 32311AZ0010001-00
Provider Network(s) ['AZN001']
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 Arizona 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 - 32311AZ0010001-00

Standard On Exchange Plan - 32311AZ0010001-01

Open to Indians below 300% FPL - 32311AZ0010001-02

Open to Indians above 300% FPL - 32311AZ0010001-03

Last Plan Update Date Tue, 25 Oct 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Medica Pinnacle Gold Copay ($0 Non-Urgent Virtual Care with Designated Providers) Health Insurance Plan, 32311AZ0010001-00

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

Benefits are payable for the services of a Physician, dentist, or dental surgeon, provided the services are rendered for treatment of an accidental injury to sound natural teeth where the continuous course of treatment is started within six (6) months of the accident.

YES

30.00% Coinsurance after deductible

100.00%
Acupuncture
NO
Allergy Testing
YES

30.00% Coinsurance after deductible

100.00%
Bariatric Surgery

1. The patient must have a body-mass index (BMI) greather than equal to 35.; 2. Have at least one co-morbidity related to obesity.; 3. Previously unsuccessful with medical treatment for obesity. The following medical information must be documented in the patient's medical record: Active participation within the last two years in one physician?supervised weight-management program for a minimum of six months without significant gaps. The weight-management program must include monthly documentation of all of the following components:a. Weight; b. Current dietary program; c. Physical activity (e.g., exercise program); 4. In addition, the procedure must be performed at an approved Center of Excellence facility that is credentialed by your Health Network to perform bariatric surgery.; 5. The member must be 18 years or older, or have reached full expected skeletal growth.

YES

30.00% Coinsurance after deductible

100.00%
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Chemotherapy
YES

30.00% Coinsurance after deductible

100.00%
Chiropractic Care

Limit: 20.0 Visit(s) per Year

YES

$15.00

100.00%
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care
YES

30.00% Coinsurance after deductible

100.00%
Dental Check-Up for Children
NO
Diabetes Education
YES

30.00% Coinsurance after deductible

100.00%
Dialysis
YES

30.00% Coinsurance after deductible

100.00%
Durable Medical Equipment
YES

30.00% Coinsurance after deductible

100.00%
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
YES

30.00% Coinsurance after deductible

100.00%
Gender Affirming Care
YES

30.00% Coinsurance after deductible

100.00%
Generic Drugs

Tier 1 preferred generic drugs on Medica's Drug List are $0 and tier 2 generic drugs are $15. Go to Plan Documents to see the List of Covered Drugs.

YES

$0.00

100.00%
Habilitation Services

Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.

YES

30.00% Coinsurance after deductible

100.00%
Hearing Aids

Limit: 1.0 Item(s) per Benefit Period

Hearing aid devices limited to one per ear, per Plan Year when determined to be medically necessary.

YES

30.00% Coinsurance after deductible

100.00%
Home Health Care Services

Limit: 42.0 Visit(s) per Year

1. The physician must have determined a medical need for home health care and developed a plan of care that is reviewed at thirty day intervals by the physician.; 2. The care described in the plan of care must be for intermittent skilled nursing, therapy, or speech services.; 3. The patient must be homebound unless services are determined to be medically necessary.; 4. The home health agency delivering care must be certified within the state the care is received.; 5. The care that is being provided is not custodial care. A Home Health visit is considered to be up to four hours of services.

YES

30.00% Coinsurance after deductible

100.00%
Hospice Services

The Plan covers hospice care services which are provided under an approved hospice care program when provided to a Member who has been diagnosed by a Participating Provider as having a terminal illness with a prognosis of six (6) months or less to live.

YES

30.00% Coinsurance after deductible

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

30.00% Coinsurance after deductible

100.00%
Infertility Treatment
NO
Infusion Therapy
YES

30.00% Coinsurance after deductible

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

30.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

30.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

30.00% 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

30.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services
YES

$15.00

100.00%
Non-Preferred Brand Drugs
YES

50.00% Coinsurance after deductible

100.00%
Nutritional Counseling
YES

30.00% Coinsurance after deductible

100.00%
Orthodontia - Adult
NO
Orthodontia - Child
NO
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

$15.00

100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

30.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 60.0 Visit(s) per Year

Short-term rehabilitative therapy includes services in an outpatient facility or physician?s office that is part of a rehabilitation program, including physical, speech, occupational, cardiac rehabilitation and pulmonary rehabilitation therapy. Visit limit is for all therapy types combined.

YES

30.00% Coinsurance after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

30.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs

Prescription insulin will not exceed $25 per prescription unit

YES

$80.00

100.00%
Prenatal and Postnatal Care
YES

30.00% Coinsurance after deductible

100.00%
Preventive Care/Screening/Immunization

Limit: 1.0 Exam(s) per Year

Benefits are limited to one preventive physical exam per calendar year, unless additional visits are necessary to obtain all covered preventive health care.

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 designated providers for non-urgent medical symptoms.

YES

$15.00

100.00%
Private-Duty Nursing
YES

30.00% Coinsurance after deductible

100.00%
Prosthetic Devices
YES

30.00% Coinsurance after deductible

100.00%
Radiation
YES

30.00% Coinsurance after deductible

100.00%
Reconstructive Surgery
YES

30.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 60.0 Visit(s) per Year

Visit limit is for all therapy types combined (PT, OT, ST).

YES

30.00% Coinsurance after deductible

100.00%
Rehabilitative Speech Therapy

Limit: 60.0 Visit(s) per Year

Visit limit is for all therapy types combined (PT, OT, ST).

YES

30.00% Coinsurance after deductible

100.00%
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children
YES

$15.00

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 90.0 Days per Year

YES

30.00% Coinsurance after deductible

100.00%
Specialist Visit
YES

$60.00

100.00%
Specialty Drugs
YES

$550.00

100.00%
Substance Abuse Disorder Inpatient Services
YES

30.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services
YES

$15.00

100.00%
Transplant

There is a lifetime maximum of $10,000 per member for all transportation and lodging expenses incurred by you and your companion(s).

YES

30.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders
YES

30.00% Coinsurance after deductible

100.00%
Urgent Care Centers or Facilities
YES

$15.00

$15.00
Weight Loss Programs
NO
Well Baby Visits and Care

Well Child visits and immunizations are covered through 47 months as recommended by the American Academy of Pediatrics.

YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

30.00% Coinsurance after deductible

100.00%

Medica Pinnacle Gold Copay ($0 Non-Urgent Virtual Care with Designated Providers) Health Insurance Plan Variant 32311AZ0010001-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.801018334
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 Gold 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 AZF001
Formulary URL URL
HIOS Product ID 32311AZ001
Import Date 10/25/2022 1:01
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 32311
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 AZN001
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) 32311AZ0010001-00
Plan Marketing Name Medica Pinnacle Gold Copay ($0 Non-Urgent Virtual Care with Designated Providers)
Plan Type HMO
Plan Variant Marketing Name Medica Pinnacle Gold Copay ($0 Non-Urgent Virtual Care with Designated Providers)
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $3,000
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $1,300
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $600
SBC Scenario, Having Diabetes, Deductible $1,100
SBC Scenario, Having Diabetes, Limit $0
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $400
SBC Scenario, Treatment of a Simple Fracture, Copayment $100
SBC Scenario, Treatment of a Simple Fracture, Deductible $1,300
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID AZS001
Source Name HIOS
Plan ID 32311AZ0010001
State Code AZ
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 $2600 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $1300 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $1,300
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 $16900 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $8450 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $8,450
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 Medica Pinnacle Gold Copay ($0 Non-Urgent Virtual Care with Designated Providers) Health Insurance Plan, 32311AZ0010001

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

Frequently Asked Questions(FAQ) about Medica Pinnacle Gold Copay ($0 Non-Urgent Virtual Care with Designated Providers), 32311AZ0010001 Health Insurance Plan, 32311AZ0010001

  • Does Medica Pinnacle Gold Copay ($0 Non-Urgent Virtual Care with Designated Providers) Health Insurance Plan, 32311AZ0010001 support Mail Ordering?

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

  • Does (32311AZ0010001) Health Insurance Plan, Variant (32311AZ0010001-00) 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 (32311AZ0010001) Health Insurance Plan, Variant (32311AZ0010001-00) have Out Of Country Coverage?

    Yes. Details: Emergency Services

    Does (32311AZ0010001) Health Insurance Plan, Variant (32311AZ0010001-00) have Out of Service Area Coverage?

    Yes. Details: Emergency Services

    Does (32311AZ0010001) Health Insurance Plan, Variant (32311AZ0010001-00) 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 Medica Pinnacle Gold Copay ($0 Non-Urgent Virtual Care with Designated Providers) Health Insurance Plan, Variant (32311AZ0010001-00) offer Disease Management Programs for Asthma?

    Yes, the Medica Pinnacle Gold Copay ($0 Non-Urgent Virtual Care with Designated Providers) Health Insurance Plan Variant 32311AZ0010001-00 offers Disease Management Program for Asthma.

    Does Medica Pinnacle Gold Copay ($0 Non-Urgent Virtual Care with Designated Providers) Health Insurance Plan, Variant (32311AZ0010001-00) offer Disease Management Programs for Heart disease?

    Yes, the Medica Pinnacle Gold Copay ($0 Non-Urgent Virtual Care with Designated Providers) Health Insurance Plan Variant 32311AZ0010001-00 offers Disease Management Program for Heart disease.

    Does Medica Pinnacle Gold Copay ($0 Non-Urgent Virtual Care with Designated Providers) Health Insurance Plan, Variant (32311AZ0010001-00) offer Disease Management Programs for Depression?

    Yes, the Medica Pinnacle Gold Copay ($0 Non-Urgent Virtual Care with Designated Providers) Health Insurance Plan Variant 32311AZ0010001-00 offers Disease Management Program for Depression.

    Does Medica Pinnacle Gold Copay ($0 Non-Urgent Virtual Care with Designated Providers) Health Insurance Plan, Variant (32311AZ0010001-00) offer Disease Management Programs for Diabetes?

    Yes, the Medica Pinnacle Gold Copay ($0 Non-Urgent Virtual Care with Designated Providers) Health Insurance Plan Variant 32311AZ0010001-00 offers Disease Management Program for Diabetes.

    Does Medica Pinnacle Gold Copay ($0 Non-Urgent Virtual Care with Designated Providers) Health Insurance Plan, Variant (32311AZ0010001-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Medica Pinnacle Gold Copay ($0 Non-Urgent Virtual Care with Designated Providers) Health Insurance Plan Variant 32311AZ0010001-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Medica Pinnacle Gold Copay ($0 Non-Urgent Virtual Care with Designated Providers) Health Insurance Plan, Variant (32311AZ0010001-00) offer Disease Management Programs for Low back pain?

    Yes, the Medica Pinnacle Gold Copay ($0 Non-Urgent Virtual Care with Designated Providers) Health Insurance Plan Variant 32311AZ0010001-00 offers Disease Management Program for Low back pain.

    Does Medica Pinnacle Gold Copay ($0 Non-Urgent Virtual Care with Designated Providers) Health Insurance Plan, Variant (32311AZ0010001-00) offer Disease Management Programs for Pregnancy?

    Yes, the Medica Pinnacle Gold Copay ($0 Non-Urgent Virtual Care with Designated Providers) Health Insurance Plan Variant 32311AZ0010001-00 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