Medica Prime Solution Core (Cost)
Medica Prime Solution Core (Cost) H2450-045 Plan Details
Medica Prime Solution Core (Cost) is a Medicare Advantage (Medicare Part C) plan offered by Medica Holding Company.
Plan ID: H2450-045.
$69.00
Monthly Premium
Medica Prime Solution Core (Cost) is a Medicare Advantage (Medicare Part C) plan offered by Medica Holding Company.
Plan ID: H2450-045.
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $-1 |
| Out of Pocket Max |
In-Network: $-1 Out-of-Network: 4000 |
| Initial Coverage Limit | $0 |
| Catastrophic Coverage Limit | $7,050 |
| Primary Care Doctor Visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0.00 |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $15.00 |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: Copayment for Acute Hospital Services per Stay $300.00 Your plan covers an unlimited number of days for an inpatient stay. |
| Urgent Care | Copayment for Urgent Care $0.00 to $20.00 Minimum copayment amount applies to care received at retail Convenience Care clinics. Maximum copayment amount applies to care received at traditional Urgent Care Centers. |
| Emergency Room Visit | Copayment for Emergency Care $50.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $50.00 |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $50.00 Air Ambulance: Copayment for Air Ambulance Services $100.00 |
Health Care Services and Medical Supplies
Medica Prime Solution Core (Cost) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).
| Coverage | Cost |
|---|---|
| Chiropractic Services | In-Network: Copayment for Medicare-covered Chiropractic Services $15.00 |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Copayment for Medicare-covered Diabetic Supplies $0.00 Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20% |
| Durable Medical Eqipment (DME) | In-Network: Coinsurance for Medicare-covered Durable Medical Equipment 20% |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $10.00 Copayment for Medicare-covered Lab Services $0.00 Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $30.00 Copayment for Medicare-covered Therapeutic Radiological Services $30.00 Copayment for Medicare-covered X-Ray Services $10.00 |
| Home Health Care | In-Network: Copayment for Medicare-covered Home Health Services $0.00 |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: Copayment for Psychiatric Hospital Services per Stay $300.00 |
| Mental Health Outpatient Care | In-Network: Copayment for Medicare-covered Individual Sessions $0.00 Copayment for Medicare-covered Group Sessions $0.00 |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $100.00 Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $100.00 Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $100.00 |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $15.00 Copayment for Medicare-covered Group Sessions $15.00 |
| Over-the-counter (OTC) Items | In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0.00 Maximum Plan Benefit of $75.00 every three months |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $15.00 |
| Skilled Nursing Facility Care | In-Network: Skilled Nursing Facility Services: $0.00 per day for days 1 to 20 $50.00 per day for days 21 to 100 |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | In-Network: Preventive Dental: Maximum Plan Allowance of $300.00 every year for Preventive and Non-Medicare Covered Comprehensive combined Comprehensive Dental: Copayment for Medicare-covered Benefits $0.00 to $15.00 Maximum Plan Allowance of $300.00 every year for Preventive and Non-Medicare Covered Comprehensive combined |
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | In-Network: Eye Exams: Copayment for Medicare Covered Benefits $0.00 to $15.00 Copayment for Routine Eye Exams $0.00
Eyewear: Copayment for Medicare-Covered Benefits $30.00 Maximum Plan Allowance of $100.00 every year for all Non-Medicare covered eyewear |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $0.00 to $15.00 Copayment for Routine Hearing Exams $0.00
Maximum Plan Benefit of $400.00 every yearfor Exams and Hearing Aids combined Hearing Aids: Copayment for Hearing Aids $0.00 There is no provider network for this service category. Hearing Aids may be purchased in or out-of-network. |
Preventive Services and Health/Wellness Education Programs
The following services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Preventive Services and Health/Wellness Education Programs | In-Network: $0.00 copay for Medicare Covered Preventive Services: Abdominal aortic aneurysm screening Alcohol misuse screenings & counseling Bone mass measurements (bone density) Cardiovascular disease screenings Cardiovascular disease (behavioral therapy) Cervical & vaginal cancer screening Colorectal cancer screenings Depression screenings Diabetes screenings Diabetes self-management training Glaucoma tests Hepatitis B (HBV) infection screening Hepatitis C screening test HIV screening Lung cancer screening Mammograms (screening) Nutrition therapy services Obesity screenings & counseling One-time Welcome to Medicare preventive visit Prostate cancer screenings(PSA) Sexually transmitted infections screening & counseling Shots:
Yearly "Wellness" visit |
