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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 2025, 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 4 out of 5 stars in 2025.
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 $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:
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 coverage, with varying costs depending on the service. Inpatient hospital stays have a copay, while outpatient services, including emergency care, have copays ranging from $30 to $500. Preventive services, home health, and skilled nursing facility services are covered, with no copay for some services. The plan also includes coverage for vision and dental services and offers additional benefits such as over-the-counter items.
Inpatient Hospital See details
Inpatient Hospital services are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For days 1-4, there is a $325 copay, and for days 5-90, there is no copay; however, Non-Medicare-covered Stay for Inpatient Hospital-Acute and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered, and Upgrades for Inpatient Hospital-Acute are not covered.
Outpatient Services See details
Outpatient Services are covered under the Medica Prime Solution Standard (Cost) plan. This includes outpatient hospital services and observation services, each with a $500 copay. Ambulatory Surgical Center (ASC) Services have a $300 copay, and outpatient substance abuse services have a $30 copay for both individual and group sessions. Outpatient blood services are also covered, with three pints deductible waived.
Partial Hospitalization See details
Partial Hospitalization is covered by the plan with a $40 copay.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Medica Prime Solution Standard (Cost) plan, with no coinsurance for any services. Ground ambulance services have a $350 copay, while air ambulance services have a $500 copay; however, transportation services to and from health-related locations are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage are covered under the Medica Prime Solution Standard (Cost) plan. Emergency Services and Worldwide Emergency Coverage have a $125 copay, and 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
The Medca Prime Solution Standard (Cost) plan covers primary care physician services with a $15 copay, chiropractic services with a $20 copay, occupational therapy services with a $45 copay, physician specialist services with a $60 copay, and physical therapy and speech-language pathology services with a $60 copay. Mental health specialty services and psychiatric services are covered with a $35-$60 copay, and opioid treatment program services are covered with a $30 copay. Routine chiropractic care and additional telehealth benefits are not covered, and podiatry services are not covered.
Preventive Services See details
Preventive services, including annual physical exams, are covered by the Medica Prime Solution Standard (Cost) plan. Health education, fitness benefits, remote access technologies, kidney disease education services, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a Welcome Visit are also covered. 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, home and bathroom safety devices and modifications, and counseling services are not covered.
Hearing Services See details
Hearing Services includes Routine Hearing Exams with a copay between $15 and $60, and Fitting/Evaluation for Hearing Aid is not covered. Prescription Hearing Aids and OTC Hearing Aids are not covered.
Vision Services See details
The Medca Prime Solution Standard (Cost) plan covers vision services, including routine eye exams with a copay of $15-$60, and eyewear. Eyewear includes contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades, all with a $45 copay for contact lenses and a combined maximum benefit of $150 per year.
Dental Services See details
Dental Services are partially covered under the Medica Prime Solution Standard (Cost), with a copay between $15 and $60 for Medicare Dental Services, but does not cover Orthodontic Services, Restorative Services, Adjunctive General Services, Endodontics, Periodontics, Prosthodontics (removable and fixed), Maxillofacial Prosthetics, Implant Services, Oral and Maxillofacial Surgery, or Orthodontics.
Home Infusion bundled Services See details
Home Infusion bundled Services includes coverage for Medicare Part B Insulin Drugs with a $35 copay, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Medica Prime Solution Standard (Cost) plan with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical Equipment includes Durable Medical Equipment (DME) with 30% coinsurance, Prosthetics/Medical Supplies with coinsurance for Medicare-covered items, and Diabetic Equipment. Diabetic Supplies have a $25 copay and 0-20% coinsurance, while Diabetic Therapeutic Shoes/Inserts have 30% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, with copays applying to various services. 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, Therapeutic Radiological Services have a copay up to $80, 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 (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 not covered by the Medica Prime Solution Standard (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 by the Medica Prime Solution Standard (Cost) plan. There is no copay for days 1-20, and a $214 copay for days 21-100. Additional days beyond Medicare-covered for SNF are not covered.
Other Services See details
Other Services includes coverage for Over-the-Counter (OTC) Items, with a maximum benefit of $25 every six months, and all of the drugs on the CMS OTC list are covered. Acupuncture, meal benefits, and several other services are not covered.
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