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Medica Advantage Value (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Medica Advantage Value (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Medica Advantage Value (PPO) in 2025, please refer to our full plan details page.
Medica Advantage Value (PPO) is a PPO plan offered by Medica Holding Company available for enrollment in 2025 to people living in Select counties in NE and IA. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that Medica Advantage Value (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 Value (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 Value (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 no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $3900.00 (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 $3900.00 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 Value (PPO) plan has a $0 deductible for prescription drugs. In the initial coverage phase, you'll pay a copay or coinsurance depending on the drug tier and pharmacy. For example, standard generic drugs have a 24% coinsurance, while preferred brand drugs have a 50% coinsurance. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for Part D covered drugs.
Additional Benefits
The Medica Advantage Value (PPO) plan offers a range of benefits with varying cost-sharing. Inpatient hospital stays have a copay, but outpatient services can have copays ranging from $0 to $450. Emergency services and primary care visits also involve copays, and some services like dental and vision have annual maximums. Preventive services, hearing exams, and home health services have no copay, while other services like ambulance, and medical equipment have coinsurance. The plan also covers partial hospitalization, skilled nursing, and home infusion services, each with its own cost structure.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered, with a $425 copay for days 1-5 and no copay for days 6-90. Additional days for Inpatient Hospital-Acute are covered with no copay, while Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute are not covered. Non-Medicare-covered stays and additional days 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 $450, Observation Services with a $425 copay, Ambulatory Surgical Center (ASC) Services with no copay, Individual Sessions for Outpatient Substance Abuse with a $50 copay, Group Sessions for Outpatient Substance Abuse with a $40 copay, and Outpatient Blood Services.
Partial Hospitalization See details
Partial hospitalization is covered by the Medica Advantage Value (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 under the Medica Advantage Value (PPO) plan. Ground ambulance services have a $295 copay, and air ambulance services have a $375 copay, with no coinsurance for either. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Medica Advantage Value (PPO) plan. Emergency Services have a $125 copay, and Urgently Needed Services have a $25-$55 copay, with 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 Value (PPO) plan covers primary care physician services, chiropractic services with a $20 copay, occupational therapy with a $45 copay, physician specialist services with a $50 copay, mental health specialty services with a $40-$50 copay, other health care professionals with a $0-$50 copay, psychiatric services with a $40-$50 copay, physical therapy and speech-language pathology services with a $50 copay, additional telehealth benefits with a $0-$55 copay, and opioid treatment program services with a $50 copay. Routine Chiropractic Care and Podiatry Services are not covered.
Preventive Services See details
Preventive services are covered, including services not usually covered by Medicare plans, such as fitness benefits, and remote access technologies, with no copay or coinsurance. However, health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, and several other services are not covered.
Hearing Services See details
Hearing exams are covered with no copay, including routine hearing exams and fitting/evaluation for hearing aids. Prescription hearing aids are covered with a copay between $549 and $1299, while OTC hearing aids are not covered, and some prescription hearing aid types are not covered.
Vision Services See details
Vision Services include routine eye exams with a copay between $0 and $50, and eyewear with a combined maximum of $150 per year for contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades.
Dental Services See details
The Medica Advantage Value (PPO) plan covers a range of dental services. There is no copay for Medicare dental services, and other dental services have a maximum plan benefit of $600 per year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and require prior authorization. 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 under the Medica Advantage Value (PPO) plan, with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical Equipment, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment, is covered under the Medica Advantage Value (PPO) plan. DME has a 20% coinsurance, while Diabetic Supplies have a 0-20% coinsurance, and Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance; other services have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, with prior authorization required. Diagnostic Procedures/Tests have a minimum copay of $0 and a maximum copay of $125, while Lab Services are not covered. Diagnostic Radiological Services have a maximum copay of $125, Therapeutic Radiological Services have an $80 copay, and Outpatient X-Ray Services have a $20 copay.
Home Health Services See details
Home Health Services are covered by the Medica Advantage Value (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 covered by the Medica Advantage Value (PPO) plan, but the specific services are not covered. No copay or coinsurance information is available.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the Medica Advantage Value (PPO) plan, but require prior authorization. For days 1-20, there is a $10 copay, for days 21-38 there is a $214 copay, and for days 39-100, there is no copay. Additional days beyond Medicare-covered and non-Medicare-covered SNF stays are not covered.
Other Services See details
Other Services includes coverage for over-the-counter (OTC) items with a maximum plan benefit coverage amount of $50 every six months, but does not cover acupuncture, meal benefits, or other listed services.
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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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