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Medica Advantage Solution H8889-004 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Medica Advantage Solution H8889-004 (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 H8889-004 (PPO) in 2025, please refer to our full plan details page.
Medica Advantage Solution H8889-004 (PPO) is a PPO plan offered by Medica Holding Company available for enrollment in 2025 to people living in Southern Minnesota. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that Medica Advantage Solution H8889-004 (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 H8889-004 (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 H8889-004 (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $149.00. 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 $395.00 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 $4900.00 (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 $4900.00 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 H8889-004 (PPO) plan has a $395.00 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy type. For preferred generic drugs, you'll pay a $13.00 copay at a preferred pharmacy, or a $20.00 copay at a standard pharmacy. For preferred brand drugs, you'll pay 50% coinsurance. After your total drug costs reach $2000.00, you will enter the catastrophic coverage phase and pay nothing for your Part D covered drugs.
Additional Benefits
The Medica Advantage Solution H8889-004 (PPO) plan offers a range of benefits, including inpatient hospital stays with a $325 copay per admission. Outpatient services vary in cost, with some services having no copay, while others have copays ranging from $20 to $395. Emergency services have copays of $125, and primary care visits, specialist visits, and mental health services have copays between $20 and $45. Preventive services are covered, along with hearing exams and hearing aid fittings with no copay, and prescription hearing aids with copays ranging from $549 to $1299. The plan also provides vision and dental coverage, with no copay for eye exams, and a maximum benefit of $500 per year for other dental services. Additionally, the plan covers home health services, skilled nursing facility stays, and home infusion bundled services.
Inpatient Hospital See details
Inpatient Hospital services, including Acute and Psychiatric, are covered with a copay of $325 per admission or stay. Additional days for Inpatient Hospital-Acute are covered, while Non-Medicare-covered stays and Upgrades for Inpatient Hospital-Acute, and Additional Days and Non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services for the Medica Advantage Solution H8889-004 (PPO) plan include coverage for outpatient hospital services with a copay between $0 and $395, observation services with a $325 copay, ambulatory surgical center services with no copay, outpatient substance abuse services with a $40 copay for individual sessions and a $30 copay for group sessions, and outpatient blood services.
Partial Hospitalization See details
Partial Hospitalization is covered by the Medica Advantage Solution H8889-004 (PPO) plan, but requires prior authorization. You will have a $95 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered under the Medica Advantage Solution H8889-004 (PPO) plan. Ground Ambulance Services have a $325 copay, and Air Ambulance Services have a $375 copay, with no coinsurance for either service. Transportation Services are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered. Emergency Services have a $125 copay, and Urgently Needed Services have a copay between $0 and $45; there is no coinsurance for either. Worldwide Emergency Coverage and Worldwide Emergency Transportation have a 20% coinsurance, while Worldwide Urgent Coverage is not covered.
Primary Care See details
The Medica Advantage Solution H8889-004 (PPO) plan covers primary care, chiropractic services with a $20 copay, occupational therapy with a $45 copay, and physician specialist services with a $40 copay. Mental health specialty services have a copay of $40 for individual sessions and $30 for group sessions, and physical therapy and speech-language pathology services have a $40 copay. Additional telehealth benefits are covered with a copay ranging from $0-$45, and opioid treatment program services are covered with a $40 copay.
Preventive Services See details
The Medica Advantage Solution H8889-004 (PPO) plan covers various preventive services, including Medicare-covered services, annual physical exams, and additional preventive services. Some additional preventive services are not covered, including Health Education, 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. The plan also covers Fitness Benefits, Remote Access Technologies, Kidney Disease Education Services, and Other Preventive Services like Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit.
Hearing Services See details
Hearing Services include routine hearing exams and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are covered with a copay between $549 and $1299, but inner ear, outer ear, and over the ear hearing aids are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams with a copay of $0-$45 and eyewear with a combined maximum plan benefit of $100 per year, covering contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades. Routine eye exams and other eye exam services are covered once per year.
Dental Services See details
The Medica Advantage Solution H8889-004 (PPO) plan covers various dental services, including oral exams, dental X-rays, and other diagnostic services, with no copay. Other dental services have a maximum plan benefit of $500 per year. Orthodontics is not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including 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%. Prior authorization is required for this benefit.
Dialysis Services See details
Dialysis Services are covered with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical equipment benefits include Durable Medical Equipment (DME) with 20% coinsurance and authorization required, Prosthetics/Medical Supplies with no copay and 20% coinsurance, and Diabetic Equipment with a coinsurance that varies from 0% to 20% depending on the specific service, with some services limited to specific manufacturers. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for Diagnostic Procedures/Tests with a maximum copay of $85, and Diagnostic Radiological Services with a maximum copay of $85, Therapeutic Radiological Services with a copay of $80, and Outpatient X-Ray Services with a $20 copay, but Lab Services are not covered. Prior authorization is required for all services.
Home Health Services See details
Home Health Services are covered by the Medica Advantage Solution H8889-004 (PPO) 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 Advantage Solution H8889-004 (PPO) 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 Advantage Solution H8889-004 (PPO) plan, but require prior authorization. For days 1-20 and 44-100, there is no copay, but for days 21-43, there is a $214 copay.
Other Services See details
The "Medica Advantage Solution H8889-004 (PPO)" plan covers Over-the-Counter (OTC) Items with a maximum benefit coverage amount 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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