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Medica Prime Solution Total (Cost)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Medica Prime Solution Total (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 Total (Cost) in 2025, please refer to our full plan details page.
Medica Prime Solution Total (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 Total (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 Total (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 Total (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 $3000.00 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
Prescription drugs are not covered by Medica Prime Solution Total (Cost).
Additional Benefits
The Medica Prime Solution Total (Cost) plan offers a variety of benefits with varying costs. Inpatient hospital stays have a copay, and outpatient services like hospital visits and substance abuse treatment have copays. Emergency, primary care, and preventive services are covered, with no copays for some services like home health and dialysis. The plan also covers hearing and vision services, with no copays for hearing exams and eye exams. Dental services, including exams and orthodontics, are covered with no copay, but have a maximum annual benefit. Home infusion services, medical equipment, and diagnostic services are also included, with some services having coinsurance.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, you will pay a $350 copay for days 1-4, and no copay for days 5-90. Additional days for Inpatient Hospital-Acute are covered, but non-Medicare covered stays and upgrades are not covered. Additional days for Inpatient Hospital Psychiatric are covered for up to 175 days, but non-Medicare-covered stays are not covered.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a $300 copay, Observation Services with a $300 copay, Ambulatory Surgical Center (ASC) Services with a $250 copay, and Outpatient Substance Abuse Services with a $10 copay for both individual and group sessions. Outpatient Blood Services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the plan, with a copay of $10.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Medica Prime Solution Total (Cost) plan. Ground and Air Ambulance Services have a $75 copay, and there is no coinsurance, while Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services are covered, with a $100 copay and no coinsurance. Urgently Needed Services have a copay between $0 and $10, and no coinsurance. Worldwide Emergency Coverage is covered with a $100 copay, and no coinsurance; however, Worldwide Urgent Coverage and Worldwide Emergency Transportation are not covered.
Primary Care See details
The Medca Prime Solution Total (Cost) plan covers Primary Care Physician Services, Chiropractic Services, Occupational Therapy Services, Physician Specialist Services, Physical Therapy and Speech-Language Pathology Services, and Opioid Treatment Program Services with a $10 copay. Mental Health Specialty Services are only partially covered, as individual and group sessions are not covered. Podiatry Services and Additional Telehealth Benefits are not covered.
Preventive Services See details
The Medcia Prime Solution Total (Cost) plan covers preventive services, including health education, fitness benefits, kidney disease education services, glaucoma screening, 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, 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 of enrollees, additional sessions of smoking and tobacco cessation counseling, enhanced disease management, telemonitoring services, remote access technologies, home and bathroom safety devices and modifications, and counseling services are not covered.
Hearing Services See details
Hearing services include hearing exams with no copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are covered up to a maximum of $400 per year, and OTC hearing aids are also covered. Prescription hearing aids - inner ear, outer ear, and over the ear are not covered.
Vision Services See details
Vision services include eye exams with a copay of $0-$10, with routine eye exams and other eye exam services covered once per year. Eyewear benefits are partially covered, with a $30 copay for contact lenses, but contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The Medica Prime Solution Total (Cost) plan covers dental services, including oral exams, dental x-rays, and other diagnostic services with a copay between $0 and $10, as well as other preventive services, restorative services, and orthodontics with no copay. This plan has a maximum annual benefit of $300.
Home Infusion bundled Services See details
Home Infusion bundled Services, including Medicare Part B Insulin Drugs, are covered. 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 this plan. There is no copay or coinsurance for this benefit.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has a 15% coinsurance, while Durable Medical Equipment for use outside the home is not covered. Medical Supplies have a 0-15% coinsurance, and Prosthetic Devices have a 15% coinsurance. Diabetic Supplies have a 0-20% coinsurance, while Diabetic Therapeutic Shoes/Inserts have a 15% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, but Lab Services are not covered. Diagnostic Procedures/Tests have a copay between $0 and $10, Diagnostic Radiological Services have a copay up to $100, Therapeutic Radiological Services have a copay up to $50, and Outpatient X-Ray Services have a $25 copay.
Home Health Services See details
Home Health Services are covered by the Medica Prime Solution Total (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 covered by Medica Prime Solution Total (Cost), but none of the sub-services are covered. The plan does not specify the copay or coinsurance for this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Medica Prime Solution Total (Cost) plan. There is no copay for days 1-20, and a $214 copay for days 21-100.
Other Services See details
Under the "Other Services" benefit, 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. Over-the-counter items are covered up to $50 every six months.
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