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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 2026, 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 2026.
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 $159.00. 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 $435.00 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 $5600.00 (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 $5600.00 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) prescription drug plan features an annual drug deductible of $435. Tier 1 preferred generic drugs have no copay when filled at standard pharmacies or through preferred mail order, though standard mail order copays start at $10. Tier 2 generic drugs cost $9 for a one-month supply at standard pharmacies and preferred mail order, or $20 through standard mail order. For higher tier medications, you will pay a percentage of the drug cost rather than a flat copay. Tier 3 preferred brand drugs require a 17% coinsurance, while Tier 4 non-preferred drugs carry a 50% coinsurance across all pharmacy and mail order channels. Tier 5 specialty drugs require a 28% coinsurance for a one-month supply.
Additional Benefits
The Medica Advantage Solution H8889-004 (PPO) plan offers comprehensive coverage with many services requiring no copayments or coinsurance, including primary care physician visits, home health services, and preventive care. For inpatient hospital stays, members pay a $400 copay per admission with no coinsurance, while emergency room visits require a $130 copay that is waived if admitted. Outpatient services and specialist visits are also covered, with specialist visits requiring a $45 copay and outpatient hospital services ranging from no copay to a $375 copay. Additional benefits include dental, vision, and hearing services, which feature no deductibles and options for no copays on routine exams and preventive care. Prescription hearing aids require copays between $549 and $1,299, while covered dental services and eyewear are available with no copays up to specified annual maximums. Members also benefit from no copays on home infusion services and certain skilled nursing facility stays, alongside a $40 over-the-counter reimbursement every six months.
Inpatient Hospital See details
Medica Advantage Solution H8889-004 (PPO) inpatient hospital services are partially covered, requiring a $400 copay per admission or stay and no coinsurance, subject to prior authorization. While acute care includes unlimited additional days, upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Medica Advantage Solution H8889-004 (PPO) covers outpatient services with no coinsurance, featuring a $0 to $375 copay for outpatient hospital services and a $400 copay per stay for observation services. Ambulatory surgical center and blood services are covered with no copay and no coinsurance, while outpatient substance abuse services require a $35 copay for individual sessions and a $25 copay for group sessions.
Partial Hospitalization See details
Partial hospitalization is covered under the Medica Advantage Solution H8889-004 (PPO) plan with a $120.00 copay and no coinsurance.
Ambulance and Transportation Services See details
Medica Advantage Solution H8889-004 (PPO) covers ground ambulance services with a $395 copay and air ambulance services with a $475 copay, with no coinsurance for either service. Transportation services to health-related locations are not covered under this plan.
Emergency Services See details
Medica Advantage Solution H8889-004 (PPO) covers emergency services with a $130 copay, which is waived if admitted to the hospital within one day, and no coinsurance. Urgently needed services are covered with a copay of up to $45 and no coinsurance, while worldwide emergency services and transportation are partially covered with no copay and a 20% coinsurance, excluding worldwide urgent care.
Primary Care See details
Primary care and professional services under the Medica Advantage Solution H8889-004 (PPO) feature primary care physician visits with no copay and no coinsurance, while specialist visits require a $45 copay and no coinsurance. Physical, occupational, and speech therapies have copays of $45 to $50, and mental health or psychiatric sessions range from $25 to $35, all with no coinsurance, whereas chiropractic and podiatry services are not covered.
Preventive Services See details
Preventive Services are partially covered by Medica Advantage Solution H8889-004 (PPO) with no copay and no coinsurance for covered care like annual physicals, glaucoma screenings, and fitness benefits. However, several supplemental services are not covered, including health education, personal emergency response systems, medical nutrition therapy, weight management, alternative therapies, and in-home support.
Hearing Services See details
Medica Advantage Solution H8889-004 (PPO) covers annual routine hearing exams and fitting evaluations with no copay, no coinsurance, and no deductible. Prescription hearing aids are partially covered with a copay ranging from $549.00 to $1,299.00 and no coinsurance, excluding inner ear, outer ear, and over the ear models, while over-the-counter hearing aids are covered with a $499.50 copay and no coinsurance.
Vision Services See details
Medica Advantage Solution H8889-004 (PPO) covers vision services with no deductibles, offering eye exams for a $0 to $45 copay and no coinsurance, which includes one routine exam and one refraction exam annually. Eyewear is also covered with no copay and no coinsurance, providing up to a $100 combined annual maximum benefit for contacts, frames, lenses, and upgrades.
Dental Services See details
Dental Services are partially covered by Medica Advantage Solution H8889-004 (PPO), offering no copay and no coinsurance for preventive and comprehensive dental care up to a $400 annual maximum, though orthodontics are not covered. Medicare-covered dental services require a $0 to $45 copay and no coinsurance.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by Medica Advantage Solution H8889-004 (PPO) with no copay, though prior authorization is required. Covered Medicare Part B insulin drugs require a $35 copay and no coinsurance, while chemotherapy and other Part B drugs have a 0% to 20% coinsurance and no copay.
Dialysis Services See details
Dialysis Services are covered by the Medica Advantage Solution H8889-004 (PPO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Medica Advantage Solution H8889-004 (PPO) covers medical equipment, including durable medical equipment (DME), prosthetics, medical supplies, and diabetic equipment, with no copays and coinsurance ranging from no coinsurance up to 20%. Prior authorization is required for DME and prosthetics, and diabetic supplies are limited to specified manufacturers.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services under Medica Advantage Solution H8889-004 (PPO) are partially covered with no coinsurance, though prior authorization is required and lab services are not covered. Covered diagnostic procedures and tests have a copay ranging from no copay to $90, diagnostic radiological services have no copay, therapeutic radiological services have a copay starting at $85, and outpatient X-rays require a $25 copay.
Home Health Services See details
Medica Advantage Solution H8889-004 (PPO) covers Home Health Services in full, requiring no copay and no coinsurance.
Cardiac Rehabilitation Services See details
Medica Advantage Solution H8889-004 (PPO) covers some Cardiac Rehabilitation Services with no coinsurance, though standard Cardiac Rehabilitation, Intensive Cardiac Rehabilitation, Pulmonary Rehabilitation, and SET for PAD services are not covered. These non-covered services require copayments of $25 for SET for PAD and $35 for the other rehabilitation services.
Skilled Nursing Facility (SNF) See details
Medica Advantage Solution H8889-004 (PPO) partially covers Skilled Nursing Facility (SNF) services with no coinsurance and no prior three-day hospital stay requirement, though prior authorization is required. There is no copay for days 1 to 20 and days 48 to 100, a $218 daily copay for days 21 to 47, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Medica Advantage Solution H8889-004 (PPO) partially covers other services, offering an over-the-counter (OTC) reimbursement benefit of up to $40 every six months with no copay and no coinsurance. Acupuncture, meal benefits, nicotine replacement therapy, and naloxone are not covered under this benefit.
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