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Medica Prime Solution Standard (Cost)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Medica Prime Solution Standard (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 (Cost) in 2026, please refer to our full plan details page.
Medica Prime Solution Standard (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 Standard (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 Standard (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 (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 $5900.00 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 Standard (Cost)
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Drug Coverage
Prescription drugs are not covered by Medica Prime Solution Standard (Cost).
Additional Benefits
The Medica Prime Solution Standard (Cost) plan offers comprehensive medical coverage with fixed copays and no coinsurance for many key services. Members enjoy no copays for preventive care, home health services, and the first 20 days of skilled nursing facility stays. For other essential care, the plan features predictable copays, such as $15 for primary care visits, $60 for specialists, and a daily copay of $450 for the first five days of inpatient hospital stays. While routine dental is not covered, the plan provides partial coverage for hearing exams and vision care, including annual eye exams and an allowance for eyewear. Prescription drugs and medical equipment may require coinsurance, such as 20% for dialysis and up to 30% for durable medical equipment, though diabetic supplies feature a low $25 copay. Additionally, members receive a $25 allowance every six months for over-the-counter health items with no copay.
Inpatient Hospital See details
Medica Prime Solution Standard (Cost) covers inpatient acute and psychiatric hospital stays with no coinsurance, requiring a $450 daily copay for days 1 through 5 and no copay for days 6 through 90. This benefit is partially covered as upgrades and non-Medicare-covered stays are not covered, though it features unlimited additional acute days and up to 175 additional psychiatric days.
Outpatient Services See details
Medica Prime Solution Standard (Cost) covers outpatient services with no coinsurance, featuring a $0 to $500 copay for outpatient hospital services and a $500 copay per stay for observation services. Ambulatory surgical center and outpatient blood services require no copay and no coinsurance, while outpatient substance abuse sessions have a $30 copay and no coinsurance.
Partial Hospitalization See details
Partial hospitalization is covered by the Medica Prime Solution Standard (Cost) plan with a $40.00 copay and no coinsurance.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered by Medica Prime Solution Standard (Cost), offering ground ambulance services for a $350 copay and air ambulance services for a $500 copay with no coinsurance. Transportation services to plan-approved or any other health-related locations are not covered under this plan.
Emergency Services See details
Emergency Services under Medica Prime Solution Standard (Cost) are covered with a $130 copay (waived if admitted within 24 hours) and no coinsurance, while urgently needed services require a $50 copay and no coinsurance. Worldwide emergency services are partially covered with a $130 copay and no coinsurance for emergency care, but worldwide urgent coverage and worldwide emergency transportation are not covered.
Primary Care See details
Medica Prime Solution Standard (Cost) covers primary care visits for a $15 copay, occupational therapy for a $45 copay, and opioid treatment for a $30 copay, all with no coinsurance. Specialist visits, mental health sessions, psychiatric services, physical therapy, and speech-language pathology require a $60 copay with no coinsurance, while chiropractic, podiatry, and telehealth services are not covered.
Preventive Services See details
Preventive services are covered under the Medica Prime Solution Standard (Cost) plan with no copay and no coinsurance, including annual physical exams, kidney disease education, and select screenings. Additional preventive benefits are partially covered, excluding in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional/dietary benefits, palliative care, in-home support, caregiver support, additional smoking cessation, enhanced disease management, telemonitoring, home/bathroom safety modifications, and counseling.
Hearing Services See details
Medica Prime Solution Standard (Cost) offers partially covered hearing services, including annual exams with a $60 copay, no deductible, and no coinsurance. Prescription hearing aids require 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 Standard (Cost) covers vision services with no coinsurance, featuring a $15.00 to $60.00 copay for annual routine eye exams and an additional yearly refraction exam. Eyewear is also covered with no coinsurance, featuring a $45.00 copay for contact lenses and a $100.00 annual maximum combined benefit for contacts, eyeglasses, and upgrades.
Dental Services See details
Medica Prime Solution Standard (Cost) partially covers dental services, offering coverage only for Medicare-covered dental care with a copay of $15.00 to $60.00 and no coinsurance. Other dental services, including preventive cleanings, oral exams, x-rays, and restorative or orthodontic treatments, are not covered.
Home Infusion bundled Services See details
Medica Prime Solution Standard (Cost) covers Home Infusion bundled Services with no copay, which includes mandatory Part D home infusion drugs. Medicare Part B insulin is covered with a $35 copay and no coinsurance, while Medicare Part B chemotherapy, radiation, and other Part B drugs require a 0% to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the Medica Prime Solution Standard (Cost) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Medica Prime Solution Standard (Cost) covers medical equipment, including durable medical equipment and medical supplies with no copay and up to 30% coinsurance, and prosthetic devices with no copay and 30% coinsurance. Diabetic supplies are covered with a $25 copay and no coinsurance, while diabetic therapeutic shoes or inserts have no copay and 30% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are partially covered under Medica Prime Solution Standard (Cost) with no coinsurance, though lab services are not covered. Covered diagnostic procedures and tests have a copay of $15.00 to $60.00, outpatient X-rays require a $60.00 copay, and diagnostic and therapeutic radiological services carry minimum copays of $225.00 and $85.00, respectively.
Home Health Services See details
Home Health Services are covered by Medica Prime Solution Standard (Cost) with no copay and no coinsurance.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the Medica Prime Solution Standard (Cost) plan, as standard cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for peripheral artery disease (PAD) services are all excluded from coverage.
Skilled Nursing Facility (SNF) See details
Medica Prime Solution Standard (Cost) covers Skilled Nursing Facility services with no coinsurance, featuring no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. This benefit is partially covered as a prior three-day inpatient hospital stay is required, and additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Other services are partially covered by Medica Prime Solution Standard (Cost), offering hospice consultations and up to $25 every six months in over-the-counter (OTC) items with no copay and no coinsurance. Acupuncture and meal benefits are not covered.
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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.
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