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Medica Advantage Solution H8889-002 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Medica Advantage Solution H8889-002 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Medica Advantage Solution H8889-002 (PPO) in 2026, please refer to our full plan details page.
Medica Advantage Solution H8889-002 (PPO) is a PPO plan offered by Medica Holding Company available for enrollment in 2025 to people living in Select Counties in MN. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that Medica Advantage Solution H8889-002 (PPO) 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 Advantage Solution H8889-002 (PPO).
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 Advantage Solution H8889-002 (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $120.00. 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 $355.00 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 combined Maximum Out-Of-Pocket cost of $4200.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $4200.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
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 Advantage Solution H8889-002 (PPO) Medicare prescription drug plan features an annual drug deductible of $355. For Tier 1 preferred generic drugs, there is no copay when using a standard pharmacy or preferred mail order, while standard mail order starts at a $10 copay for a one-month supply. Tier 2 generic medications cost an $11 copay per month at standard pharmacies and through preferred mail order, or a $20 copay per month via standard mail order. For higher tier medications, costs transition to coinsurance percentages across all pharmacy and mail order channels. Tier 3 preferred brand drugs require a 21% coinsurance, while Tier 4 non-preferred drugs have a 50% coinsurance. Specialty drugs in Tier 5 carry a 29% coinsurance for a one-month supply.
Additional Benefits
The Medica Advantage Solution H8889-002 (PPO) plan offers comprehensive medical coverage featuring no copay and no coinsurance for primary care visits, home health services, and annual preventive physicals. Specialist visits and physical therapy require a $50 copay, while inpatient acute hospital stays carry a $400 copay per stay with no coinsurance. Emergency room visits have a $150 copay, which is waived if you are admitted to the hospital within one day. For supplemental benefits, the plan provides routine hearing and dental exams with no copay, including up to $700 annually for covered dental care and a $200 annual allowance for eyewear with no copay. Skilled nursing facility stays feature no copay for days 1 through 20 and days 42 through 100, though a $218 daily copay applies for days 21 through 41. Additionally, members receive up to $40 every six months in over-the-counter item reimbursements with no copay or coinsurance.
Inpatient Hospital See details
Medica Advantage Solution H8889-002 (PPO) covers inpatient acute hospital stays with a $400 copay per stay and no coinsurance, while inpatient psychiatric hospital stays require a $395 copay per stay and no coinsurance. Prior authorization is required for both services, and upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Medica Advantage Solution H8889-002 (PPO) covers outpatient services with no coinsurance, including outpatient hospital services with a $0 to $350 copay and observation services with a $400 copay per stay. Ambulatory surgical center and outpatient blood services feature no copay and no coinsurance, while outpatient substance abuse services carry a copay of $30 for group sessions and $40 for individual sessions.
Partial Hospitalization See details
Partial hospitalization is covered by Medica Advantage Solution H8889-002 (PPO) with a $100 copay and no coinsurance.
Ambulance and Transportation Services See details
Medica Advantage Solution H8889-002 (PPO) covers ground ambulance services with a $395.00 copay and air ambulance services with a $475.00 copay, with no coinsurance required for either service. Transportation services to health-related locations are not covered under this plan.
Emergency Services See details
Emergency services under Medica Advantage Solution H8889-002 (PPO) are covered with a $150 copay (waived if admitted to the hospital within one day) and no coinsurance, while urgently needed services require a $0 to $45 copay and no coinsurance. Worldwide emergency and transportation services are partially covered with no copay and a 20% coinsurance, though worldwide urgent coverage is not covered.
Primary Care See details
Medica Advantage Solution H8889-002 (PPO) offers primary care physician services with no copay and no coinsurance, while specialist, occupational therapy, and physical therapy visits require a $50 copay and no coinsurance. Mental health and psychiatric sessions have a $30 to $40 copay and no coinsurance, some chiropractic services are covered with a $15 copay and no coinsurance (routine and other chiropractic care are not covered), and podiatry services are not covered.
Preventive Services See details
Preventive services are covered by Medica Advantage Solution H8889-002 (PPO) with no copay and no coinsurance for annual physicals, kidney disease education, and diabetes self-management. The plan partially covers additional preventive benefits, offering fitness benefits and remote access technologies, while excluding services like health education, personal emergency response systems, and nutritional counseling.
Hearing Services See details
Medica Advantage Solution H8889-002 (PPO) covers annual routine hearing exams and fitting evaluations with no copay and no coinsurance. Prescription hearing aids are partially covered with no coinsurance and a copay ranging from $549.00 to $1,299.00, excluding inner ear, outer ear, and over the ear hearing aids. Over-the-counter (OTC) hearing aids are also covered with a $499.50 copay and no coinsurance.
Vision Services See details
Medica Advantage Solution H8889-002 (PPO) vision services include annual routine and refraction eye exams with a $0 to $50 copay, no coinsurance, and no deductible. Eyewear, including contacts and glasses, is covered with no copay, no coinsurance, and no deductible up to a combined maximum benefit of $200 per year.
Dental Services See details
Medica Advantage Solution H8889-002 (PPO) provides partially covered dental services with a $700 annual maximum benefit for both in-network and out-of-network care. Covered preventive and comprehensive services have no copay and no coinsurance, while Medicare-covered dental services require a $0 to $50 copay and no coinsurance; orthodontic services are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Medica Advantage Solution H8889-002 (PPO) with no copay, though prior authorization is required. Medicare Part B insulin drugs under this benefit require a $35 copay and no coinsurance, while Part B chemotherapy, radiation, and other drugs have a coinsurance ranging from 0% to 20%.
Dialysis Services See details
Dialysis Services are covered under the Medica Advantage Solution H8889-002 (PPO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Medica Advantage Solution H8889-002 (PPO) covers medical equipment with no copays across all categories, though coinsurance and prior authorization may apply. Durable medical equipment and diabetic supplies carry no coinsurance to 20% coinsurance, while prosthetic devices, medical supplies, and diabetic therapeutic shoes or inserts require 20% coinsurance.
Diagnostic and Radiological Services See details
Medica Advantage Solution H8889-002 (PPO) partially covers diagnostic and radiological services with no coinsurance, though prior authorization is required and lab services are not covered. Diagnostic tests range from no copay to a $90 copay, outpatient x-rays carry a $25 copay, therapeutic radiology requires a minimum $85 copay, and diagnostic radiology has no copay.
Home Health Services See details
Home health services are covered under the Medica Advantage Solution H8889-002 (PPO) plan with no copay and no coinsurance.
Cardiac Rehabilitation Services See details
Cardiac rehabilitation services are covered under the Medica Advantage Solution H8889-002 (PPO) with no coinsurance, but in practice, some services are covered while cardiac, intensive cardiac, pulmonary, and SET for PAD services are not covered and require copays of $25 to $35.
Skilled Nursing Facility (SNF) See details
Medica Advantage Solution H8889-002 (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but no prior three-day inpatient hospital stay. There is no copay for days 1 through 20 and days 42 through 100, while days 21 through 41 require a $218 daily copay, with no coverage provided for additional days beyond the standard Medicare limit.
Other Services See details
Other services are partially covered under the Medica Advantage Solution H8889-002 (PPO) plan, which offers up to $40 every six months in over-the-counter (OTC) item reimbursements with no copay and no coinsurance. Acupuncture, meal benefits, nicotine replacement therapy, and naloxone are not covered.
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