Altru Prime by Medica Gold Standard
Medica
Plan overview
Medical deductible
Individual: $2000
Family: $4000
Per Person: $2000
Prescription drug deductible
Individual: $0
Family: $0
Per Person: $0
Combined medical and drug out of pocket maximum
Individual: $8200
Family: $16400
Per Person: $8200
Office visit
Primary Doctor
CoPay: $30.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Virtual visits are unlimited with no charge when provided by a designated in-network virtual care provider for non-urgent medical symptoms for common illnesses.
Specialist
CoPay: $60.00
CoInsurance: Not Applicable
Covered: Covered
Prescription drug information
Preferred brand drugs
CoPay: $30.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation:
Non preferred brand drugs
CoPay: $60.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation:
Generic drugs
CoPay: $15.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation:
Specialty drugs
CoPay: $250.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: See policy or plan document for additional benefit explanation.
Inpatient coverage
Hospital services
CoPay: Not Applicable
CoInsurance: 25.00% Coinsurance after deductible
Covered: Covered
Inpatient services
CoPay: Not Applicable
CoInsurance: 25.00% Coinsurance after deductible
Covered: Covered
Emergency and urgent care
Emergency room
CoPay: Not Applicable
CoInsurance: 25.00% Coinsurance after deductible
Covered: Covered
Urgent care facility
CoPay: $45.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation:
Maternity
Labor and delivery hospital stay
CoPay: Not Applicable
CoInsurance: 25.00% Coinsurance after deductible
Covered: Covered
Pre and Postnatal office visit
CoPay: Not Applicable
CoInsurance: 25.00% Coinsurance after deductible
Covered: Covered
Vision
Routine Eye Exams for Children
CoPay: $30.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit: Exam(s) per Benefit Period
Major dental care
Routine dental checkups for children
CoPay:
CoInsurance:
Covered: Not Covered
Limit Quantity:
Limit Unit:
Routine dental checkups for adults
CoPay:
CoInsurance:
Covered: Not Covered
Limit Quantity:
Limit Unit:
Benefit Explanation:
These policies have exclusions, limitations, reduction of benefits, terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company (whichever is applicable).