Medica Pinnacle Gold Share ($0 Non-Urgent Virtual Care with Designated Providers)

32311AZ0010025
Gold
HMO

Medica Pinnacle Gold Share ($0 Non-Urgent Virtual Care with Designated Providers) is a Gold HMO plan by Medica.

IMPORTANT: You are viewing the 2023 version of Medica Pinnacle Gold Share ($0 Non-Urgent Virtual Care with Designated Providers) 32311AZ0010025. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

Medica Pinnacle Gold Share ($0 Non-Urgent Virtual Care with Designated Providers) is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of Medica Pinnacle Gold Share ($0 Non-Urgent Virtual Care with Designated Providers) 32311AZ0010025.
Insurer: Medica
Network Type: HMO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 32311AZ0010025

Cost-Sharing Overview

Medica Pinnacle Gold Share ($0 Non-Urgent 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 Medica Pinnacle Gold Share ($0 Non-Urgent 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

Medica Pinnacle Gold Share ($0 Non-Urgent 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 Medica Pinnacle Gold Share ($0 Non-Urgent 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
National Network: No

Additional Benefits and Cost-Sharing

Medica Pinnacle Gold Share ($0 Non-Urgent 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
30.00% Coinsurance after deductible 100.00% Virtual visits are unlimited with a $0 copayment when provided by designated providers for non-urgent medical symptoms.
Specialist Visit
Covered
30.00% Coinsurance after deductible 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
30.00% Coinsurance after deductible 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
30.00% Coinsurance after deductible 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
30.00% Coinsurance after deductible 100.00%
Hospice Services
Covered
30.00% Coinsurance after deductible 100.00% 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.
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 100.00%
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
30.00% Coinsurance after deductible 30.00% Coinsurance after deductible
Home Health Care Services
Covered
30.00% Coinsurance after deductible 100.00%42 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.
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 100.00%
Inpatient Physician and Surgical Services
Covered
30.00% Coinsurance after deductible 100.00%
Bariatric Surgery
Covered
30.00% Coinsurance after deductible 100.00% 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.
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
30.00% Coinsurance after deductible 100.00%90 Days per Year
Prenatal and Postnatal Care
Covered
30.00% Coinsurance after deductible 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
30.00% Coinsurance after deductible 100.00%
Mental/Behavioral Health Outpatient Services
Covered
30.00% Coinsurance after deductible 100.00%
Mental/Behavioral Health Inpatient Services
Covered
30.00% Coinsurance after deductible 100.00%
Substance Abuse Disorder Outpatient Services
Covered
30.00% Coinsurance after deductible 100.00%
Substance Abuse Disorder Inpatient Services
Covered
30.00% Coinsurance after deductible 100.00%
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
$80.00 100.00% 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 100.00%60 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.
Habilitation Services
Covered
30.00% Coinsurance after deductible 100.00% 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.
Chiropractic Care
Covered
30.00% Coinsurance after deductible 100.00%20 Visit(s) per Year
Durable Medical Equipment
Covered
30.00% Coinsurance after deductible 100.00%
Hearing Aids
Covered
30.00% Coinsurance after deductible 100.00%1 Item(s) per Benefit Period Hearing aid devices limited to one per ear, per Plan Year when determined to be medically necessary.
Imaging (CT/PET Scans, MRIs)
Covered
30.00% Coinsurance after deductible 100.00%
Preventive Care/Screening/Immunization
Covered
No Charge 100.00%1 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.
Routine Foot Care
Not Covered
Acupuncture
Not Covered
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
30.00% Coinsurance after deductible 100.00%
Eye Glasses for Children
Covered
30.00% Coinsurance after deductible 100.00%
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
30.00% Coinsurance after deductible 100.00%60 Visit(s) per Year Visit limit is for all therapy types combined (PT, OT, ST).
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
30.00% Coinsurance after deductible 100.00%60 Visit(s) per Year Visit limit is for all therapy types combined (PT, OT, ST).
Well Baby Visits and Care
Covered
No Charge 100.00% Well Child visits and immunizations are covered through 47 months as recommended by the American Academy of Pediatrics.
Laboratory Outpatient and Professional Services
Covered
30.00% Coinsurance after deductible 100.00%
X-rays and Diagnostic Imaging
Covered
30.00% Coinsurance after deductible 100.00%
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 100.00% There is a lifetime maximum of $10,000 per member for all transportation and lodging expenses incurred by you and your companion(s).
Accidental Dental
Covered
30.00% Coinsurance after deductible 100.00% 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.
Dialysis
Covered
30.00% Coinsurance after deductible 100.00%
Allergy Testing
Covered
30.00% Coinsurance after deductible 100.00%
Chemotherapy
Covered
30.00% Coinsurance after deductible 100.00%
Radiation
Covered
30.00% Coinsurance after deductible 100.00%
Diabetes Education
Covered
30.00% Coinsurance after deductible 100.00%
Prosthetic Devices
Covered
30.00% Coinsurance after deductible 100.00%
Infusion Therapy
Covered
30.00% Coinsurance after deductible 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
30.00% Coinsurance after deductible 100.00%
Nutritional Counseling
Covered
30.00% Coinsurance after deductible 100.00%
Reconstructive Surgery
Covered
30.00% Coinsurance after deductible 100.00%
Gender Affirming Care
Covered
30.00% Coinsurance after deductible 100.00%

Free Preventive Services

There is no copayment or coinsurance for any of the following Medica Pinnacle Gold Share ($0 Non-Urgent 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 Medica Pinnacle Gold Share ($0 Non-Urgent 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 Medica Pinnacle Gold Share ($0 Non-Urgent 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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