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Medica Prime Solution Core w/Rx (Cost)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Medica Prime Solution Core w/Rx (Cost). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Medica Prime Solution Core w/Rx (Cost) in 2025, please refer to our full plan details page.
Medica Prime Solution Core w/Rx (Cost) is a Cost plan offered by Medica Holding Company available for enrollment in 2025 to people living in Select counties in ND and SD. This plan received an overall rating of 4 out of 5 stars in 2025.
It's important to know that Medica Prime Solution Core w/Rx (Cost) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Medica Prime Solution Core w/Rx (Cost).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Medica Prime Solution Core w/Rx (Cost), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $182.80. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $590.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $3750.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Medica Prime Solution Core w/Rx (Cost) plan has a $590 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy you use. For example, you will pay a $12 copay for preferred generic drugs at a standard pharmacy. For standard generic drugs, you will pay 17% coinsurance at a standard pharmacy. For preferred brand drugs, you will pay 50% coinsurance, and for non-preferred drugs, you will pay 25% coinsurance. Once your total drug costs reach $2000, you will enter the catastrophic coverage phase and pay nothing for covered drugs.
Additional Benefits
The Medica Prime Solution Core w/Rx (Cost) plan offers a wide range of benefits with varying cost-sharing. This plan includes coverage for inpatient hospital stays with a $300 copay, outpatient services with copays ranging from $15 to $150, and emergency services with a $50 copay. The plan also covers primary care, preventive, hearing, vision, and dental services, often with no copay or low copays, and provides coverage for medical equipment and diagnostic services, with varying coinsurance amounts.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered by the Medica Prime Solution Core w/Rx (Cost) plan. For a Medicare-covered stay, there is a $300 copay, and there is no coinsurance. Additional days for Inpatient Hospital-Acute are covered, but Non-Medicare-covered Stay for Inpatient Hospital-Acute, Upgrades for Inpatient Hospital-Acute, Additional Days for Inpatient Hospital Psychiatric, and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services are covered by the Medica Prime Solution Core w/Rx (Cost) plan, including outpatient hospital services with a $150 copay, observation services with a $150 copay, ambulatory surgical center (ASC) services with a $100 copay, outpatient substance abuse services with a $15 copay for individual and group sessions, and outpatient blood services with a waived three-pint deductible.
Partial Hospitalization See details
Partial Hospitalization is covered with a $20 copay.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered under the Medica Prime Solution Core w/Rx (Cost) plan. Ground Ambulance Services have a $50 copay, and Air Ambulance Services have a $100 copay, with no coinsurance for either. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage are covered by the Medica Prime Solution Core w/Rx (Cost) plan. Emergency Services and Worldwide Emergency Coverage have a $50 copay, and Urgently Needed Services have a copay between $0 and $20; there is no coinsurance for any of these services. Worldwide Urgent Coverage and Worldwide Emergency Transportation are not covered.
Primary Care See details
The Medica Prime Solution Core w/Rx (Cost) plan covers primary care physician services, chiropractic services with a $15 copay, occupational therapy services with a $15 copay, physician specialist services with a $15 copay, psychiatric services with a $15 copay for individual and group sessions, physical therapy and speech-language pathology services with a $15 copay, and opioid treatment program services with a $15 copay. However, routine chiropractic care, individual and group sessions for mental health specialty services, podiatry services, and additional telehealth benefits are not covered.
Preventive Services See details
Preventive Services are covered by the Medica Prime Solution Core w/Rx (Cost) plan, including Medicare-covered preventive services, annual physical exams, health education, fitness benefits, kidney disease education services, and other preventive services such as glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKG following a Welcome Visit. However, in-home safety assessments, personal emergency response systems, medical nutrition therapy, and several other services are not covered.
Hearing Services See details
Hearing Services include coverage for hearing exams with no copay, and routine hearing exams are covered once per year. Prescription hearing aids are covered up to a maximum of $400 per year, while OTC hearing aids are covered with no limitations. Fitting/evaluation for hearing aids is also covered. Prescription hearing aids - inner ear, outer ear, and over the ear are not covered.
Vision Services See details
Vision Services include coverage for eye exams with a copay of $0-$15, and eyewear with a $30 copay. The plan covers routine eye exams, other eye exam services, contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades.
Dental Services See details
The Medica Prime Solution Core w/Rx (Cost) plan covers dental services, including oral exams, dental x-rays, and other diagnostic dental services with no copay. The plan also covers prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, oral and maxillofacial surgery, and orthodontics, all with no copay.
Home Infusion bundled Services See details
Home Infusion bundled Services, including Medicare Part B Insulin Drugs, are covered by the Medica Prime Solution Core w/Rx (Cost) plan. For Medicare Part B Insulin Drugs, there is a $35 copay. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Medica Prime Solution Core w/Rx (Cost) plan. There is no copay or coinsurance for this benefit.
Medical Equipment See details
Medical equipment is covered by the Medica Prime Solution Core w/Rx (Cost) plan. Durable Medical Equipment (DME) has a 20% coinsurance, while Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices and Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance, and Medical Supplies have a 0-20% coinsurance. Diabetic Supplies have a 0-20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, with Diagnostic Procedures/Tests having a copay between $0 and $15, Diagnostic Radiological Services having a copay up to $150 (minimum $30), Therapeutic Radiological Services having a copay up to $30 (minimum $30), and Outpatient X-Ray Services with a $10 copay; however, Lab Services are not covered.
Home Health Services See details
Home Health Services are covered by the Medica Prime Solution Core w/Rx (Cost) plan with no copay or coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by the Medica Prime Solution Core w/Rx (Cost) plan, but the plan does not cover any of the sub-services. There is a copay for these services, but the amount is not specified.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the Medica Prime Solution Core w/Rx (Cost) plan. There is no copay for days 1-20, but there is a $50 copay for days 21-100; additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
Other Services for the Medica Prime Solution Core w/Rx (Cost) plan include Over-the-Counter (OTC) Items with a $50 maximum benefit every six months, while acupuncture, meal benefits, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.
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