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Medica Prime Solution Focus (Cost)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Medica Prime Solution Focus (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 Focus (Cost) in 2025, please refer to our full plan details page.
Medica Prime Solution Focus (Cost) is a Cost plan offered by Medica Holding Company available for enrollment in 2025 to people living in Select counties in WI. This plan received an overall rating of 4 out of 5 stars in 2025.
It's important to know that Medica Prime Solution Focus (Cost) is a Medicare Advantage (MA) Plan without drug coverage. That means that this plan covers medical services but doesn't cover prescription drugs. If you are looking for a plan with prescription drug coverage, please search for other MA and PDP plans offered in your area.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Medica Prime Solution Focus (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 Focus (Cost), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. 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.
Drugs are not covered by this plan, so a prescription drug deductible is not applicable.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $4000.00 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:
Sign up for Medica Prime Solution Focus (Cost)
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Drug Coverage
Prescription drugs are not covered by Medica Prime Solution Focus (Cost).
Additional Benefits
The Medica Prime Solution Focus (Cost) plan offers a variety of benefits with varying costs. Inpatient hospital stays have a $350 copay for the first 4 days, then no copay, while outpatient services have copays ranging from $15 to $300. This plan also covers ambulance services with a $100 copay, emergency services with a $125 copay, and primary care with a $15 copay. Additional benefits include hearing exams with no copay and up to $400 per year for hearing aids, vision services with a $0-$15 copay for eye exams and eyewear, and dental services with a $200 annual maximum. The plan also covers home health services with no copay, and skilled nursing facility services with a copay after 20 days. Other services such as over-the-counter items are covered up to $50 every six months.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For the first 4 days, there is a $350 copay, and for days 5-90 there is no copay.
Outpatient Services See details
Outpatient Services are covered by the Medica Prime Solution Focus (Cost) plan, including outpatient hospital services with a $300 copay, observation services with a $300 copay, ambulatory surgical center (ASC) services with a $200 copay, and outpatient substance abuse services with a $15 copay for both individual and group sessions. Outpatient blood services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered under the Medica Prime Solution Focus (Cost) plan. You will have a $20 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered. Ground and Air Ambulance Services have a $100 copay, and there is no coinsurance. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services are covered under the Medica Prime Solution Focus (Cost) plan. Emergency Services have a $125 copay and no coinsurance. Urgently Needed Services have a copay between $0 and $20, with no coinsurance. Worldwide Emergency Coverage has a $125 copay and no coinsurance. Worldwide Urgent Coverage and Worldwide Emergency Transportation are not covered.
Primary Care See details
The Medica Prime Solution Focus (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, and physical therapy and speech-language pathology services with a $15 copay. Individual and group sessions for psychiatric services, and Opioid Treatment Program Services are covered with a $15 copay. 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
The Medica Prime Solution Focus (Cost) plan covers preventive services, including Medicare-covered services, annual physical exams, health education, fitness benefits, kidney disease education services, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following Welcome Visit. However, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge in-home medication reconciliation, re-admission prevention, wigs for hair loss related to chemotherapy, weight management programs, alternative therapies, therapeutic massage, adult day health services, nutritional/dietary benefits, home-based palliative care, in-home support services, support for caregivers, additional sessions of smoking and tobacco cessation counseling, enhanced disease management, telemonitoring services, remote access technologies, home and bathroom safety devices, and counseling services are not covered.
Hearing Services See details
Hearing exams are covered with no copay, and routine hearing exams are covered once per year. Fitting/evaluation for hearing aids are covered, and prescription hearing aids are covered up to $400 per year. OTC hearing aids are also covered. However, prescription hearing aids for the inner ear, outer ear, and over the ear are not covered.
Vision Services See details
The Medca Prime Solution Focus (Cost) plan covers vision services, including routine eye exams with a copay of $0-$15, and eyewear, with a $30 copay for contact lenses and a combined maximum benefit of $100 per year for all eyewear.
Dental Services See details
Dental services are covered, with a maximum benefit of $200 per year. Medicare Dental Services have a copay between $0 and $15, while other services include oral exams, dental x-rays, other diagnostic dental services, 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.
Home Infusion bundled Services See details
Home Infusion bundled Services, including Medicare Part B Insulin Drugs, are covered under the Medica Prime Solution Focus (Cost) plan. Medicare Part B Insulin Drugs have a $35 copay, while 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 Focus (Cost) plan. There is no information on the cost of this service.
Medical Equipment See details
Medical Equipment, including Durable Medical Equipment, Prosthetics, and Diabetic Equipment, is covered. Durable Medical Equipment has a 20% coinsurance, while Durable Medical Equipment for use outside the home is not covered. Prosthetics and Medicare-covered medical supplies have a 20% coinsurance, while diabetic supplies have a 0-20% coinsurance, and diabetic therapeutic shoes/inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered under the Medica Prime Solution Focus (Cost) plan. Diagnostic Procedures/Tests have a copay between $0 and $15, Diagnostic Radiological Services have a copay of at most $150, Therapeutic Radiological Services have a copay of at most $80, and Outpatient X-Ray Services have a $50 copay; however, Lab Services are not covered.
Home Health Services See details
Home Health Services are covered by the Medica Prime Solution Focus (Cost) plan with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Medica Prime Solution Focus (Cost) plan. The plan does not cover Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, or Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Medica Prime Solution Focus (Cost) plan. There is no copay for days 1-20, but there is a $214 copay for days 21-100.
Other Services See details
Other Services include Over-the-Counter (OTC) Items, with a maximum plan benefit coverage amount of $50.00 every six months. 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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