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2021 Altru Prime by Medica Plan Documents

To see your summary of benefits and coverage (SBC) and policy of coverage documents, select your state and plan below.

Looking for the 2020 documents?

Minnesota Plans

Document Care Type    
Summary of Benefits and Coverage (SBC) Gold Copay (PDF) Silver Copay (PDF) Bronze Copay (PDF)
Policy of Coverage
Gold Copay (PDF) Silver Copay (PDF) Bronze Copay (PDF)
Document Care Type  
Summary of Benefits and Coverage (SBC) Silver HSA (PDF)  Bronze HSA (PDF)
Policy of Coverage
Silver HSA (PDF) Bronze HSA (PDF)
Document Care Type
Summary of Benefits and Coverage (SBC) Silver Share (PDF) Bronze Share Plus (PDF)
Policy of Coverage Silver Share (PDF) Bronze Share Plus (PDF)

North Dakota Plans

Document Care Type    
Summary of Benefits and Coverage (SBC) Gold Copay (PDF) Silver Copay (PDF) Bronze Copay (PDF)
Policy of Coverage
Gold Copay (PDF) Silver Copay (PDF) Bronze Copay (PDF)
Document Care Type
Summary of Benefits and Coverage (SBC) Bronze HSA (PDF)
Policy of Coverage
Bronze HSA (PDF)
Document Care Type
Summary of Benefits and Coverage (SBC) Silver Share (PDF) Bronze Share Plus (PDF)
Policy of Coverage Silver Share (PDF) Bronze Share Plus (PDF)
Document Care Type
Summary of Benefits and Coverage (SBC) Bronze Value (PDF)
Policy of Coverage Bronze Value (PDF)

North Dakota Rate Increase Justification 2019: These ACA-compliant policies received a weighted average premium increase of 26.0%. These adjustments were made based on historical claim information, projected cost increases, and relative risk assessments by plan.

 

Date: 7/31/2021 11:18:32 AM Version: 4.0.30319.42000 Machine Name: PWIVE-CDWEB02