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Medica Prime Solution Standard (Cost)

Medica Prime Solution Standard (Cost) H2450-044 Plan Details
4 out of 5 stars

Medica Prime Solution Standard (Cost) is a Medicare Advantage (Medicare Part C) plan offered by Medica Holding Company.
Plan ID: H2450-044.

$0.00
Monthly Premium

Medica Prime Solution Standard (Cost) is a Medicare Advantage (Medicare Part C) plan offered by Medica Holding Company.
Plan ID: H2450-044.

Medica Prime Solution Standard (Cost) H2450-044 Plan Details
4 out of 5 stars

Medica Prime Solution Standard (Cost) is a Medicare Advantage (Medicare Part C) plan offered by Medica Holding Company.
Plan ID: H2450-044.

$0.00
Monthly Premium

Minnesota Counties Served

Aitkin Carlton Cook Goodhue Itasca Kanabec Koochiching Lake Le Sueur McLeod Meeker Mille Lacs Pine Pipestone Rice Rock Sibley St. Louis Stevens Traverse Yellow Medicine

Nebraska Counties Served

Adams Antelope Boone Boyd Buffalo Burt Cedar Cheyenne Clay Colfax Cuming Custer Dakota Dawes Dixon Fillmore Franklin Frontier Furnas Gage Garfield Gosper Greeley Hall Hamilton Harlan Holt Howard Jefferson Johnson Kearney Keya Paha Knox Loup Madison Merrick Nance Nemaha Nuckolls Otoe Pawnee Phelps Pierce Platte Polk Rock Saline Seward Sherman Stanton Thayer Thurston Valley Wayne Webster Wheeler York

North Dakota Counties Served

Adams Barnes Benson Billings Bowman Burleigh Cass Cavalier Dickey Dunn Eddy Emmons Foster Grand Forks Grant Griggs Hettinger Kidder LaMoure Logan McHenry McIntosh McLean Mercer Morton Nelson Oliver Pembina Pierce Ramsey Ransom Richland Rolette Sargent Sheridan Sioux Slope Stark Steele Stutsman Towner Traill Walsh Ward Wells Williams

South Dakota Counties Served

Aurora Beadle Bennett Bon Homme Brookings Brown Brule Buffalo Butte Campbell Charles Mix Clark Clay Codington Corson Custer Davison Day Deuel Dewey Douglas Edmunds Fall River Faulk Grant Gregory Haakon Hamlin Hand Hanson Harding Hughes Hutchinson Hyde Jackson Jerauld Jones Kingsbury Lake Lawrence Lincoln Lyman Marshall McCook McPherson Meade Mellette Miner Minnehaha Moody Oglala Lakota Pennington Perkins Potter Roberts Sanborn Spink Stanley Sully Todd Tripp Turner Union Walworth Yankton Ziebach

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $-1
Out of Pocket Max In-Network: $-1
Out-of-Network: 4500
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 $35.00
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$280.00 per day for days 1 to 5
$0.00 per day for days 6 to 90
Urgent Care
Copayment for Urgent Care $0.00 to $35.00

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 $90.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $90.00
Ambulance Transportation
In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $200.00

Air Ambulance:
Copayment for Air Ambulance Services $400.00

Health Care Services and Medical Supplies

Medica Prime Solution Standard (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 $20.00
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Coinsurance for Medicare-covered Diabetic Supplies 20%
Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20%
Maximum out of Pocket $35.00 (Please see Evidence of Coverage fo
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 $0.00 to $35.00
Copayment for Medicare-covered Lab Services $0.00

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $35.00 to $150.00
Copayment for Medicare-covered Therapeutic Radiological Services $35.00 to $150.00
Copayment for Medicare-covered X-Ray Services $0.00 to $35.00
Home Health Care
In-Network:
Copayment for Medicare-covered Home Health Services $0.00
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
$280.00 per day for days 1 to 5
$0.00 per day for days 6 to 90
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $30.00
Copayment for Medicare-covered Group Sessions $30.00
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $200.00

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $200.00

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $150.00
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $30.00
Copayment for Medicare-covered Group Sessions $30.00
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 $25.00 every three months
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $35.00
Skilled Nursing Facility Care
In-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$170.50 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 $500.00 every year for Preventive and Non-Medicare Covered Comprehensive combined

Comprehensive Dental:
Copayment for Medicare-covered Benefits $0.00 to $35.00
Maximum Plan Allowance of $500.00 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 $35.00
Copayment for Routine Eye Exams $0.00
  • Maximum 1 Routine Eye Exam every year

Eyewear:
Copayment for Medicare-Covered Benefits $45.00
Maximum Plan Allowance of $150.00 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 $35.00
Copayment for Routine Hearing Exams $0.00 to $35.00
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0.00
Maximum Plan Benefit of $600.00 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:
  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
    • Tobacco use cessation
    Yearly "Wellness" visit
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