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Medica Prime Solution Standard w/Rx (Cost)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Medica Prime Solution Standard 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 Standard w/Rx (Cost) in 2025, please refer to our full plan details page.
Medica Prime Solution Standard w/Rx (Cost) is a Cost plan offered by Medica Holding Company available for enrollment in 2025 to people living in Select counties in MN ND SD WY. This plan received an overall rating of 4 out of 5 stars in 2025.
It's important to know that Medica Prime Solution Standard 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 Standard 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 Standard w/Rx (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.
This plan has a $250.00 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 $5000.00 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 Standard w/Rx (Cost) plan has a $250 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For a 30-day supply at a standard pharmacy, you'll pay a $20 copay for preferred generic drugs, 15% coinsurance for standard generic drugs, 50% coinsurance for preferred brand drugs, and 30% coinsurance for non-preferred drugs. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for covered drugs.
Additional Benefits
The Medica Prime Solution Standard w/Rx (Cost) plan offers a range of benefits with varying costs. Inpatient hospital stays have a $325 copay for the first four days, with no copay for the remaining days. Outpatient services have copays ranging from $30 to $500, and emergency services have a $125 copay. The plan includes coverage for primary care with a $15 copay, preventive services with no copay for annual physical exams, and hearing and vision services with copays for exams and eyewear. Dental services are covered, with a maximum benefit, and the plan also covers home health services with no copay.
Inpatient Hospital See details
Inpatient Hospital coverage includes Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For days 1-4, the copay is $325, and for days 5-90, there is no copay. Additional days for Inpatient Hospital Psychiatric and Non-Medicare-covered stays for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient services include coverage for outpatient hospital services with a $500 copay, observation services with a $500 copay, ambulatory surgical center services with a $300 copay, outpatient substance abuse services with a $30 copay for both individual and group sessions, and outpatient blood services.
Partial Hospitalization See details
Partial Hospitalization is covered by the plan and has a $40 copay.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Medica Prime Solution Standard w/Rx (Cost) plan. Ground ambulance services have a $350 copay, and air ambulance services have a $500 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 Standard w/Rx (Cost) plan. Emergency Services and Worldwide Emergency Coverage have a $125 copay, while Urgently Needed Services have a copay between $25 and $55; all have no coinsurance. Worldwide Urgent Coverage and Worldwide Emergency Transportation are not covered.
Primary Care See details
Primary Care Physician Services have a $15 copay, Chiropractic Services have a $20 copay, and Occupational Therapy Services have a $45 copay. Physician Specialist Services have a $60 copay, while Individual and Group Sessions for Mental Health Specialty Services have a $35 copay. Physical Therapy and Speech-Language Pathology Services have a $60 copay, and Opioid Treatment Program Services have a $30 copay. Routine Chiropractic Care and Additional Telehealth Benefits are not covered, and Podiatry Services are not covered.
Preventive Services See details
The Medica Prime Solution Standard w/Rx (Cost) plan covers preventive services, including annual physical exams, with no copay. Other covered services include Health Education, Fitness Benefit, Remote Access Technologies, Kidney Disease Education Services, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit. However, it does not cover 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.
Hearing Services See details
Hearing Services include hearing exams with a $60 copay, and routine hearing exams with a copay between $15 and $60. Fitting/evaluation for hearing aids, prescription hearing aids, and OTC hearing aids are not covered.
Vision Services See details
Vision Services include eye exams with a copay of $15-$60 and eyewear with a $45 copay for contact lenses. Eyewear has a combined maximum plan benefit coverage of $150 every year.
Dental Services See details
Dental Services include coverage for Medicare Dental Services with a copay between $15 and $60, and other dental services with a maximum benefit of $400 per year. 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 are also covered. Orthodontic services are covered under Diagnostic and Preventive Dental.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered under the Medica Prime Solution Standard w/Rx (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 Standard w/Rx (Cost) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
The Medica Prime Solution Standard w/Rx (Cost) plan covers Durable Medical Equipment with a 30% coinsurance, and covers Prosthetic Devices with a 30% coinsurance. It also covers Medical Supplies with 0-30% coinsurance and Diabetic Supplies with 0-20% coinsurance and a $25 copay, but Durable Medical Equipment for use outside the home is not covered. Diabetic Therapeutic Shoes/Inserts are covered with 30% coinsurance and a $25 copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered under the Medica Prime Solution Standard w/Rx (Cost) plan. Diagnostic Procedures/Tests have a copay between $15 and $60, while Lab Services are not covered. Diagnostic Radiological Services have a copay up to $155 with a minimum copay of $55, Therapeutic Radiological Services have a copay up to $80 with a minimum copay of $55, and Outpatient X-Ray Services have a $15 copay.
Home Health Services See details
Home Health Services are covered by the Medica Prime Solution Standard w/Rx (Cost) plan with no copay and no coinsurance. However, Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the listed sub-services are not covered, including Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services. There is a copay for some services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Medica Prime Solution Standard w/Rx (Cost) plan. There is no copay for days 1-20, and a $214 copay per day for days 21-100. Additional days beyond Medicare-covered, and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other services offered by the plan include Over-the-Counter (OTC) Items with a maximum benefit coverage amount of $25.00 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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