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 during open enrollment 2023, which started November 1st and ends January 15th, 2023, in most states.

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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