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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)

Copay Plans

Document Care Type    
Summary of Benefits and Coverage (SBC) Silver Copay (94% AV Level) – (PDF) Silver Copay (87% AV Level) – (PDF) Silver Copay (73% AV Level) – (PDF)
Policy of Coverage
 Silver Copay (94% AV Level) – (PDF) Silver Copay (87% AV Level) – (PDF) Silver Copay (73% AV Level) – (PDF)

HSA Plans

Document Care Type    
Summary of Benefits and Coverage (SBC) Silver HSA (94% AV Level) – (PDF) Silver HSA (87% AV Level) – (PDF) Silver HSA (73% AV Level) – (PDF)
Policy of Coverage
 Silver HSA (94% AV Level) – (PDF) Silver HSA (87% AV Level) – (PDF) Silver HSA (73% AV Level) – (PDF)

Share Plans

Document Care Type    
Summary of Benefits and Coverage (SBC) Silver Share (94% AV Level) – (PDF) Silver Share (87% AV Level) – (PDF) Silver Share (73% AV Level) – (PDF)
Policy of Coverage
 Silver Share (94% AV Level) – (PDF) Silver Share (87% AV Level) – (PDF) Silver Share (73% AV Level) – (PDF)
Catastrophic
Summary of Benefits and Coverage (PDF)
Policy of Coverage (PDF)
Document Care Type            
Summary of Benefits and Coverage (SBC) Gold Copay Limited (PDF) Silver HSA Limited (PDF)  Silver Copay Limited (PDF) Silver Share Limited (PDF) Bronze Copay Limited (PDF) Bronze HSA Limited (PDF) Bronze Share Plus Limited (PDF)
Policy of Coverage
 Gold Copay Limited (PDF) Silver HSA Limited (PDF) Silver Copay Limited (PDF) Silver Share Limited (PDF) Bronze Copay Limited (PDF) Bronze HSA Limited (PDF) Bronze Share Plus Limited (PDF)
Document Care Type
Summary of Benefits and Coverage (SBC) Gold Copay Zero (PDF) Silver HSA Zero (PDF) Silver Copay Zero (PDF) Silver Share Zero (PDF) Bronze Copay Zero (PDF) Bronze HSA Zero (PDF) Bronze Share Plus Zero (PDF)
Policy of Coverage
 Gold Copay Zero (PDF) Silver HSA Zero (PDF) Silver Copay Zero (PDF) Silver Share Zero (PDF) Bronze Copay Zero (PDF) Bronze HSA Zero (PDF) Bronze Share Plus Zero (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 Copay (94% AV Level) – (PDF) Silver Copay (87% AV Level) – (PDF) Silver Copay (73% AV Level) – (PDF)
Policy of Coverage
 Silver Copay (94% AV Level) – (PDF) Silver Copay (87% AV Level) – (PDF) Silver Copay (73% AV Level) – (PDF)
Catastrophic
Summary of Benefits and Coverage (PDF)
Policy of Coverage (PDF)
Document Care Type          
Summary of Benefits and Coverage (SBC) Gold Copay Limited (PDF) Silver Copay Limited (PDF) Bronze Copay Limited (PDF) Bronze HSA Limited (PDF) Bronze Share Plus Limited (PDF) Bronze Value Limited (PDF)
Policy of Coverage
 Gold Copay Limited (PDF) Silver Copay Limited (PDF) Bronze Copay Limited (PDF) Bronze HSA Limited (PDF) Bronze Share Plus Limited (PDF) Bronze Value Limited (PDF)
Document Care Type          
Summary of Benefits and Coverage (SBC) Gold Copay Zero (PDF) Silver Copay Zero (PDF) Bronze Copay Zero (PDF) Bronze HSA Zero (PDF) Bronze Share Plus Zero (PDF) Bronze Value Zero (PDF)
Policy of Coverage
 Gold Copay Zero (PDF) Silver Copay Zero (PDF) Bronze Copay Zero (PDF) Bronze HSA Zero (PDF) Bronze Share Plus Zero (PDF) Bronze Value Zero (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.

 

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