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Medica Prime Solution Total w/Rx (Cost)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Medica Prime Solution Total 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 Total w/Rx (Cost) in 2025, please refer to our full plan details page.
Medica Prime Solution Total 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 4 out of 5 stars in 2025.
It's important to know that Medica Prime Solution Total 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 Total 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 Total w/Rx (Cost), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $293.40. 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 $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
The Medica Prime Solution Total w/Rx (Cost) plan has a $590 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance for your prescriptions depending on the drug tier and pharmacy. For example, you'll pay a $12 copay for preferred generic drugs at a preferred pharmacy. This plan uses coinsurance, with 16% for standard generics, 50% for preferred brand drugs, and 25% for non-preferred drugs. Once your total drug costs reach $2000, you enter the catastrophic coverage phase and pay nothing for covered drugs.
Additional Benefits
The Medica Prime Solution Total w/Rx (Cost) plan offers a range of benefits with varying cost-sharing. Inpatient hospital stays have a copay, while outpatient services have copays depending on the service. Primary care visits, including specialist and therapy services, have a $10 copay. Preventive services, hearing exams, and some vision services have no copay. The plan also covers ambulance services, emergency services, and home health services with specific copays or coinsurance. Dental and medical equipment services have coverage, with some services having copays or coinsurance.
Inpatient Hospital See details
Inpatient Hospital benefits are covered under the Medica Prime Solution Total w/Rx (Cost) plan, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For Inpatient Hospital-Acute, there is a $350 copay for days 1-4, and no copay for days 5-90; Non-Medicare-covered Stay and Upgrades are not covered. For Inpatient Hospital Psychiatric, there is a $350 copay for days 1-4, and no copay for days 5-90; Non-Medicare-covered Stay is not covered.
Outpatient Services See details
Outpatient Services are covered, including outpatient hospital services and observation services with a $300 copay, ambulatory surgical center services with a $250 copay, and outpatient substance abuse services with a $10 copay for individual and group sessions. Outpatient blood services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered under this plan, with a $10 copay.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Medica Prime Solution Total w/Rx (Cost) plan. Ground and air ambulance services have a $75 copay, with no coinsurance, while 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 Total w/Rx (Cost) plan. Emergency Services has a $100 copay, and Urgently Needed Services has a copay between $0 and $10; both have no coinsurance. Worldwide Emergency Coverage has a $100 copay and no coinsurance. Worldwide Urgent Coverage and Worldwide Emergency Transportation are not covered.
Primary Care See details
The "Medica Prime Solution Total w/Rx (Cost)" plan covers Primary Care Physician Services, Chiropractic Services, Occupational Therapy Services, Physician Specialist Services, Physical Therapy and Speech-Language Pathology Services, Psychiatric Services, and Opioid Treatment Program Services. Chiropractic Services, Occupational Therapy Services, Physician Specialist Services, Physical Therapy and Speech-Language Pathology Services, and Opioid Treatment Program Services all have a $10 copay, while Individual and Group Psychiatric Sessions also have a $10 copay. The plan does not cover Routine Chiropractic Care, Individual Sessions for Mental Health Specialty Services, Group Sessions for Mental Health Specialty Services, Podiatry Services, or Additional Telehealth Benefits.
Preventive Services See details
Preventive Services are covered, including Medicare-covered preventive services, annual physical exams, and additional preventive services like Health Education, Fitness Benefit, and Remote Access Technologies. However, In-Home Safety Assessment, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), 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 Benefit, 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, Home and Bathroom Safety Devices and Modifications, and Counseling Services are not covered.
Hearing Services See details
Hearing exams are covered with no copay. Prescription Hearing Aids are covered up to a maximum of $400 per year.
Vision Services See details
Vision Services include coverage for eye exams with a copay of $0-$10, and eyewear with a $30 copay for contact lenses. Eyewear services such as contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental Services includes coverage for Medicare dental services with a copay of $0 - $10, as well as other dental services that have a maximum benefit of $300 per year. Other covered dental 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 are covered under the Medica Prime Solution Total w/Rx (Cost) plan, including Medicare Part B Insulin Drugs with a $35 copay. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs are also covered with coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the plan. There is no copay or coinsurance for this benefit.
Medical Equipment See details
Medical Equipment is covered by the Medica Prime Solution Total w/Rx (Cost) plan, with Durable Medical Equipment (DME) covered with 15% coinsurance and no copay. Prosthetic devices and medical supplies have a 15% coinsurance and no copay. Diabetic equipment is covered, including diabetic supplies with 0-20% coinsurance and diabetic therapeutic shoes/inserts with 15% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, with Diagnostic Procedures/Tests requiring a copay between $0 and $10, while Lab Services are not covered. Diagnostic Radiological Services have a maximum copay of $100, Therapeutic Radiological Services have a maximum copay of $50, and Outpatient X-Ray Services have a $25 copay.
Home Health Services See details
Home Health Services are covered under the Medica Prime Solution Total 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 not covered by the Medica Prime Solution Total w/Rx (Cost) plan. This includes Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the Medica Prime Solution Total w/Rx (Cost) plan. For days 1-20, there is no copay, and for days 21-100, there is a $214 copay. Additional days beyond Medicare-covered for SNF are covered as an optional supplemental benefit, and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services includes coverage for Over-the-Counter (OTC) Items, with a maximum benefit of $50.00 every six months, but 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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