Balance by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers)

21333OK0060045
Gold
PPO

Balance by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers) is a Gold PPO plan by Medica.

IMPORTANT: You are viewing the 2023 version of Balance by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers) 21333OK0060045. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

Balance by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers) is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of Balance by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers) 21333OK0060045.
Insurer: Medica
Network Type: PPO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 21333OK0060045

Cost-Sharing Overview

Balance by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers) offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Balance by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers)?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

Balance by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers) offers the following features and referral requirements.

Wellness Program: No
Disease Program: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy
Notice Pregnancy: No
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what Balance by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers) covers when you are out of the service area or out of the country.

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 and Out of Network services received in the state of Oklahoma
National Network: No

Additional Benefits and Cost-Sharing

Balance by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers) includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
$0.00 50.00% Coinsurance after deductible 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.
Specialist Visit
Covered
$75.00 50.00% Coinsurance after deductible
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$0.00 50.00% Coinsurance after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Hospice Services
Covered
30.00% Coinsurance after deductible 100.00%
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Not Covered
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible85 Visit(s) per Benefit Period
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$0.00 $0.00
Home Health Care Services
Covered
30.00% Coinsurance after deductible 100.00%30 Visit(s) per Benefit Period
Emergency Room Services
Covered
30.00% Coinsurance after deductible 30.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
30.00% Coinsurance after deductible 30.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Inpatient Physician and Surgical Services
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible30 Days per Benefit Period
Prenatal and Postnatal Care
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Delivery and All Inpatient Services for Maternity Care
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services
Covered
$0.00 50.00% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services
Covered
$0.00 50.00% Coinsurance after deductible
Substance Abuse Disorder Inpatient Services
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Generic Drugs
Covered
$0.00 100.00% 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.
Preferred Brand Drugs
Covered
$70.00 100.00% Prescription insulin will not exceed $25 per prescription unit
Non-Preferred Brand Drugs
Covered
50.00% Coinsurance after deductible 100.00%
Specialty Drugs
Covered
$550.00 100.00%
Outpatient Rehabilitation Services
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible30 Days per Benefit Period
Habilitation Services
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible30 Visit(s) per Benefit Period
Chiropractic Care
Covered
$0.00 50.00% Coinsurance after deductible
Durable Medical Equipment
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Hearing Aids
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible One hearing aid per ear every 48 months.
Imaging (CT/PET Scans, MRIs)
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Preventive Care/Screening/Immunization
Covered
No Charge 50.00% Coinsurance after deductible
Routine Foot Care
Not Covered
Acupuncture
Not Covered
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
$0.00 50.00% Coinsurance after deductible1 Exam(s) per Year
Eye Glasses for Children
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible1 Item(s) per Year
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible25 Visit(s) per Benefit Period Maximum of 25 Outpatient visits for Physical Therapy, Occupational Therapy and Speech Therapy (combined).
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible25 Visit(s) per Benefit Period Maximum of 25 Outpatient visits for Physical Therapy, Occupational Therapy and Speech Therapy (combined).
Well Baby Visits and Care
Covered
No Charge 50.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible
X-rays and Diagnostic Imaging
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Basic Dental Care – Child
Not Covered
Orthodontia – Child
Not Covered
Major Dental Care – Child
Not Covered
Basic Dental Care – Adult
Not Covered
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Not Covered
Abortion for Which Public Funding is Prohibited
Not Covered
Transplant
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Accidental Dental
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Dialysis
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Allergy Testing
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Chemotherapy
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Radiation
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Diabetes Education
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Prosthetic Devices
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Infusion Therapy
Covered
30.00% Coinsurance after deductible 100.00%25 Visit(s) per Benefit Period Covered under Outpatient Therapy Services.
Treatment for Temporomandibular Joint Disorders
Not Covered
Nutritional Counseling
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible Diabetes self-management training and training related to medical nutrition therapy.
Reconstructive Surgery
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Gender Affirming Care
Covered
30.00% Coinsurance after deductible 50.00% Coinsurance after deductible

Free Preventive Services

There is no copayment or coinsurance for any of the following Balance by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers) preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for Balance by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers) including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for Balance by Medica Gold Copay $0 PCP ($0 Virtual Care with Designated Providers)?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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