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Medica Advantage Solution H8889-005 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Medica Advantage Solution H8889-005 (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 H8889-005 (PPO) in 2025, please refer to our full plan details page.
Medica Advantage Solution H8889-005 (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 2025.
It's important to know that Medica Advantage Solution H8889-005 (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 H8889-005 (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 H8889-005 (PPO), 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.
This plan has a $495.00 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 $3700.00 (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 $3700.00 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 H8889-005 (PPO) plan has a $495.00 deductible for prescription drugs. After you meet your deductible, your cost will vary depending on the drug tier and pharmacy you use. For example, for preferred generic drugs, you will pay a $15 copay at a preferred pharmacy. For standard generic drugs, you'll pay 17% coinsurance, and for preferred brand drugs, you'll pay 50% coinsurance. Once your total drug costs reach $2000.00, you enter the catastrophic coverage phase and pay nothing for Part D covered drugs.
Additional Benefits
The Medica Advantage Solution H8889-005 (PPO) plan offers a range of benefits, including inpatient hospital stays with a copay, outpatient services with varying copays, and coverage for emergency services. The plan also covers primary care, preventive, vision, dental, and hearing services, often with no or low copays, and offers additional benefits like home health services with no copay and coverage for medical equipment and home infusion services. However, the plan does not cover certain services like cardiac rehabilitation, additional hours of home health care, and some alternative therapies.
Inpatient Hospital See details
Inpatient Hospital benefits, including services not usually covered by Medicare plans, are covered, with a copay of $355 for days 1-5, and no copay for days 6-90. Additional days for Inpatient Hospital-Acute are covered with no copay, but Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute are not covered. Inpatient Hospital Psychiatric benefits are covered with a copay of $355 for days 1-5, and no copay for days 6-90, but Additional Days for Inpatient Hospital Psychiatric and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a copay between $0 and $495, Observation Services with a $355 copay, Ambulatory Surgical Center (ASC) Services with no copay, and Outpatient Substance Abuse Services, including individual sessions with a $40 copay and group sessions with a $30 copay. Outpatient Blood Services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Medica Advantage Solution H8889-005 (PPO) plan, with a $95 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Medica Advantage Solution H8889-005 (PPO) plan. Ground ambulance services have a copay of $325.00, and air ambulance services have a copay of $375.00; there is no coinsurance for either. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services are covered, with a $125 copay and no coinsurance. Urgently Needed Services are covered with a copay between $25 and $55, and no coinsurance. Worldwide Emergency Services are covered; Worldwide Emergency Coverage and Worldwide Emergency Transportation have 20% coinsurance, while Worldwide Urgent Coverage is not covered.
Primary Care See details
The Medica Advantage Solution H8889-005 (PPO) plan covers primary care physician services, chiropractic services with a $20 copay, occupational therapy services with a $45 copay, physician specialist services with a $40 copay, and mental health specialty services with a copay that ranges from $30 to $40 depending on the service. The plan does not cover podiatry services, but it does cover other healthcare professionals with a copay that ranges from $0 to $40, psychiatric services with a copay that ranges from $30 to $40 depending on the service, physical therapy and speech-language pathology services with a $40 copay, additional telehealth benefits with a copay that ranges from $0 to $55, and opioid treatment program services with a $40 copay.
Preventive Services See details
The Medica Advantage Solution H8889-005 (PPO) plan covers preventive services, including Medicare-covered services with no copay, annual physical exams with no copay, and additional preventive services like Fitness Benefits, Remote Access Technologies, Glaucoma Screenings, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visits. However, Health Education, In-Home Safety Assessments, Personal Emergency Response Systems (PERS), Medical Nutrition Therapy (MNT), Post-discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss, 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, Additional Sessions of Smoking and Tobacco Cessation Counseling, Enhanced Disease Management, Telemonitoring Services, Home and Bathroom Safety Devices, and Counseling Services are not covered.
Hearing Services See details
Hearing services include routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are covered with a copay between $549 and $1299, while inner ear, outer ear, and over the ear prescription 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 benefit of $200 every year for contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades. Routine eye exams are covered once per year, and other eye exam services are covered once per year for additional refraction.
Dental Services See details
Dental services include coverage for oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, and implant services with a copay of $0 - $45. Orthodontic services and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. Medicare Part B Insulin Drugs have a $35 copay, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the plan, with a coinsurance of 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 20% coinsurance, Prosthetics/Medical Supplies with 20% coinsurance, and Diabetic Equipment with 0-20% coinsurance depending on the service. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services, including diagnostic procedures/tests, diagnostic radiological services, therapeutic radiological services, and outpatient X-ray services, are covered. Lab services are not covered. Diagnostic procedures/tests have a copay between $0.00 and $125.00, diagnostic radiological services have a copay of at most $125.00, therapeutic radiological services have a copay of $80.00, and outpatient X-ray services have a copay of $20.00.
Home Health Services See details
Home Health Services are covered by the Medica Advantage Solution H8889-005 (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 H8889-005 (PPO) plan. The plan does not cover Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, or Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but require prior authorization. For days 1-20 and 38-100, there is no copay, while days 21-37 have a $214 copay. Additional days beyond Medicare-covered for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services for the Medica Advantage Solution H8889-005 (PPO) plan includes Over-the-Counter (OTC) Items with a maximum benefit coverage of $75 every six months, while acupuncture, meal benefit, 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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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.
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