East Grand Forks

Altru Prime by Medica Silver Copay (First 3) – EPO

Network type: EPO
Coverage tier: Silver
Primary care visit: first 3 visit(s) $15 then 30% after deductible copay, first 3 visit(s) $15 then 30% after deductible
Specialist visit: first 3 visit(s) $15 then 30% after deductible copay, first 3 visit(s) $15 then 30% after deductible
Urgent care visit: first 3 visit(s) $15 then 30% after deductible copay, first 3 visit(s) $15 then 30% after deductible

SKU: 31616MN0450039 Categories: Alvarado, Argyle, Badger, Bagley, Beltrami, Brooks, Clearbrook, Climax, Crookston, Donaldson, East Grand Forks, Erskine, Euclid, Fertile, Fisher, Fosston, Gatzke, Gonvick, Goodridge, Greenbush, Gully, Hallock, Halma, Humboldt, Karlstad, Kennedy, Lake Bronson, Lancaster, Lengby, Mcintosh, Mentor, Middle River, Minnesota, Newfolden, Nielsville, Oklee, Oslo, Plummer, Red Lake Falls, Roosevelt, Roseau, Saint Hilaire, Saint Vincent, Salol, Stephen, Strandquist, Strathcona, Thief River Falls, Trail, Viking, Wannaska, Warren, Warroad, Winger

Description

Description

Health Care Plan Details

Network type	EPO
Deductible	$3,500 per person $3,500 per person
Out-of-pocket max	$8,700 per person $17,400 per family
Metal tier	Silver

Visit Copay

Primary care visit	first 3 visit(s) $15 then 30% after deductible copay, first 3 visit(s) $15 then 30% after deductible
Specialist visit	first 3 visit(s) $15 then 30% after deductible copay, first 3 visit(s) $15 then 30% after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	first 3 visit(s) $15 then 30% after deductible copay, first 3 visit(s) $15 then 30% after deductible
Emergency room	30% after deductible
Ambulance	30% after deductible
Hospital stay (facility)	30% after deductible
Hospital stay (physician)	30% after deductible
Outpatient procedure (facility)	30% after deductible
Outpatient procedure (physician)	30% after deductible
Physical rehabilitation	30% after deductible

Maternitowny and Pregnancy

Labor, delivery, hospital stay

30% after deductible

Pharmacy, Drugs, and Medication

Generic	$10 per script copay
Brand	$150 per script copay
Non-preferred Brand	60% after deductible
Specialty	$700 per script copay

Lab Tests and Diagnostic Procedures

X-rays	30% after deductible
Imaging (CT/PET/MRI)	30% after deductible
Blood work	30% after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	first 3 visit(s) $15 then 30% after deductible copay, first 3 visit(s) $15 then 30% after deductible
Psychiatric hospital stay	30% after deductible

Health Plan Provider Information

Health Plan Benefits	https://d2ed110nmrd591.cloudfront.net/blobs/48TMVGdLZGoom49jupPtZfUG.pdf
Drug and medication plan formulary	https://www.medica.com/MNClosedDrugList-2024