A non-government entity
Medica Prime Solution Focus w/Rx (Cost)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Medica Prime Solution Focus 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 Focus w/Rx (Cost) in 2026, please refer to our full plan details page.
Medica Prime Solution Focus w/Rx (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 3.5 out of 5 stars in 2026.
It's important to know that Medica Prime Solution Focus 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 Focus 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 Focus w/Rx (Cost), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $236.70. 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 $615.00 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 $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 w/Rx (Cost)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
The Medica Prime Solution Focus w/Rx (Cost) Medicare plan has an annual drug deductible of $615. For Tier 1 preferred generic drugs, you will pay no copay at standard pharmacies and through preferred mail order, or a $10 monthly copay for standard mail order. Tier 2 generic drugs carry a $10 monthly copay at standard pharmacies and preferred mail order, which increases to a $20 copay for standard mail order. For brand-name and specialty prescriptions, the plan utilizes coinsurance instead of flat copays. Tier 3 preferred brand drugs require a 16% coinsurance, while Tier 4 non-preferred drugs have a 50% coinsurance across standard pharmacies and mail order options. Specialty drugs in Tier 5 carry a 25% coinsurance for a one-month supply.
Additional Benefits
The Medica Prime Solution Focus w/Rx (Cost) plan offers robust coverage with no coinsurance for most medical services, making healthcare costs highly predictable. You will enjoy no copay for primary care doctor visits, annual physicals, home health services, and dialysis. For specialized care, there is a low $15 copay for specialist visits, while inpatient hospital stays require a $400 daily copay for the first five days and no copay for remaining days. Emergency care is accessible with a $125 copay, which is waived if you are admitted to the hospital, and ambulance services require a $100 copay. Routine dental, vision, and hearing exams are covered with no copay, alongside specific allowances and copays for hearing aids, eyewear, and comprehensive dental treatments. While most services feature no coinsurance, durable medical equipment and select Part B drugs require a coinsurance ranging up to 20%.
Inpatient Hospital See details
Medica Prime Solution Focus w/Rx (Cost) partially covers inpatient hospital services with no coinsurance, requiring a $400 daily copay for days 1 to 5 and no copay for days 6 to 90 for both acute and psychiatric stays. Unlimited additional acute days and up to 175 additional psychiatric days are covered, while non-Medicare-covered stays and acute upgrades are not covered.
Outpatient Services See details
Medica Prime Solution Focus w/Rx (Cost) covers outpatient services with no coinsurance, offering ambulatory surgical center and outpatient blood services with no copay. Outpatient hospital services have a copay of $0 to $300, observation services require a $300 copay per stay, and outpatient substance abuse sessions have a $15 copay, all with no coinsurance.
Partial Hospitalization See details
Medica Prime Solution Focus w/Rx (Cost) covers partial hospitalization benefits with a $20.00 copay and no coinsurance.
Ambulance and Transportation Services See details
Medica Prime Solution Focus w/Rx (Cost) partially covers ambulance and transportation services, offering ground and air ambulance services with a $100 copay and no coinsurance. Transportation services to plan-approved health-related locations and any other health-related locations are not covered.
Emergency Services See details
Emergency services are covered by Medica Prime Solution Focus w/Rx (Cost) with a $125 copay (waived if admitted to the hospital within 24 hours) and no coinsurance, while urgently needed services require a $25 copay and no coinsurance. Worldwide emergency services are partially covered with a $125 copay and no coinsurance for emergency care, but worldwide urgent coverage and emergency transportation are not covered.
Primary Care See details
Medica Prime Solution Focus w/Rx (Cost) covers primary care physician visits with no copay and no coinsurance, while specialist, physical therapy, occupational therapy, psychiatric, and opioid treatment services require a $15 copay and no coinsurance. Podiatry and telehealth are not covered, and although some chiropractic and mental health specialty services are covered, routine chiropractic, other chiropractic, and individual or group mental health sessions are not.
Preventive Services See details
Preventive Services are covered by Medica Prime Solution Focus w/Rx (Cost) with no copay and no coinsurance for annual physicals, kidney disease education, and select screenings. Additional preventive benefits are partially covered, excluding services such as in-home safety assessments, personal emergency response systems, weight management programs, and medical nutrition therapy.
Hearing Services See details
Hearing services are covered by the Medica Prime Solution Focus w/Rx (Cost) plan, including routine hearing exams and fitting evaluations with no copay and no coinsurance. Prescription hearing aids are partially covered with a copay of $549.00 to $1,299.00 and no coinsurance—excluding inner ear, outer ear, and over the ear models—while OTC hearing aids are covered with a $499.50 copay and no coinsurance.
Vision Services See details
Medica Prime Solution Focus w/Rx (Cost) covers annual eye exams with no copay to a $15 copay and no coinsurance. Eyewear is also covered with no coinsurance, a $30 copay for contact lenses, and a combined maximum benefit of $100 per year for contacts, lenses, and frames.
Dental Services See details
Medica Prime Solution Focus w/Rx (Cost) covers Medicare-covered dental services with a $0 to $15 copay and no coinsurance. Other preventive and comprehensive dental services, including cleanings, x-rays, and oral surgeries, are covered with no copay and no coinsurance up to a maximum annual plan benefit of $300.
Home Infusion bundled Services See details
Home infusion bundled services are covered under the Medica Prime Solution Focus w/Rx (Cost) plan with no copay, though Medicare Part B chemotherapy, radiation, and other Part B drugs require a 0% to 20% coinsurance. Part B insulin is covered with a $35 copay and no coinsurance, and Part D home infusion drugs are included as a mandatory supplemental benefit.
Dialysis Services See details
Dialysis Services are covered under the Medica Prime Solution Focus w/Rx (Cost) plan with no copay and no coinsurance.
Medical Equipment See details
Medica Prime Solution Focus w/Rx (Cost) partially covers medical equipment with no copays, though coinsurance ranging from no coinsurance to 20% applies to durable medical equipment, medical supplies, prosthetics, and diabetic therapeutic shoes. Diabetic supplies are not covered under this benefit.
Diagnostic and Radiological Services See details
Medica Prime Solution Focus w/Rx (Cost) covers diagnostic and radiological services with no coinsurance, although lab services are not covered. Diagnostic procedures and tests have a copay of $0 to $15, while radiological services require copays of $50 for X-rays, a minimum of $80 for therapeutic radiology, and a minimum of $175 for diagnostic radiology.
Home Health Services See details
Medica Prime Solution Focus w/Rx (Cost) covers Home Health Services in full with no copay and no coinsurance.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are offered with no coinsurance under the Medica Prime Solution Focus w/Rx (Cost) plan, though only some services are covered in practice. Standard cardiac, intensive cardiac, and pulmonary rehabilitation services are not covered and require a $15 copay, while Supervised Exercise Therapy (SET) for symptomatic peripheral artery disease (PAD) is also not covered and requires a $10 copay.
Skilled Nursing Facility (SNF) See details
Medica Prime Solution Focus w/Rx (Cost) covers Skilled Nursing Facility (SNF) services with no coinsurance, featuring no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. A prior three-day inpatient hospital stay is required for admission, and coverage is available for additional days beyond the standard Medicare limit.
Other Services See details
Other Services are partially covered under the Medica Prime Solution Focus w/Rx (Cost) plan, which offers hospice consultation and over-the-counter (OTC) items with no copay and no coinsurance. OTC items are covered up to a maximum of $50 every six months, while acupuncture and meal benefits are not covered.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved