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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 2026, 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 2026.
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 a $615.00 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 $6750.00 (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 $6750.00 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) prescription drug plan features an annual drug deductible of $615. For Tier 1 preferred generic drugs, members pay no copay at standard pharmacies or through preferred mail order, though standard mail order copays range from $10 to $30. Tier 2 generic drugs are also affordable, with standard pharmacy and preferred mail order copays starting at $5 for a one-month supply. Higher-tier medications under this plan are subject to coinsurance rather than flat copays. Tier 3 preferred brand drugs require an 18% coinsurance, while Tier 4 non-preferred drugs require a 50% coinsurance across standard pharmacies and mail-order options. Specialty medications in Tier 5 are covered at a 25% coinsurance for a one-month supply.
Additional Benefits
The Medica Advantage Value (PPO) plan offers comprehensive medical coverage with predictable costs, featuring no copay and no coinsurance for primary care visits and home health services. Specialist visits require a $55 copay with no coinsurance, while emergency room visits carry a $130 copay that is waived if you are admitted. For inpatient hospital stays, members pay a daily copay of $550 for the first five days and no copay for subsequent days, all with no coinsurance. Members also benefit from routine hearing exams, preventive care, and most dental services with no copays and no coinsurance. Routine eye exams feature copays ranging from no copay to $55, and the plan includes a $75 annual allowance for eyewear with no copay or coinsurance. Additionally, essential medical equipment is covered with no copay and coinsurance ranging from 0% to 20% depending on the item.
Inpatient Hospital See details
Inpatient Hospital services are covered by Medica Advantage Value (PPO) with no coinsurance, requiring prior authorization. For acute stays, there is a $550 daily copay for days 1 through 5 and no copay for days 6 and beyond, while psychiatric stays require a $450 daily copay for days 1 through 5 and no copay for days 6 through 90. This benefit is partially covered as upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Medica Advantage Value (PPO) covers outpatient services with no coinsurance, featuring no copay for ambulatory surgical center and blood services. Outpatient hospital services require a copay of $0 to $550, observation services have a $550 daily copay, and outpatient substance abuse individual and group sessions carry copays of $50 and $40, respectively.
Partial Hospitalization See details
Medica Advantage Value (PPO) covers partial hospitalization services with a $140.00 copay and no coinsurance.
Ambulance and Transportation Services See details
Medica Advantage Value (PPO) covers ground ambulance services with a $375 copay and air ambulance services with a $475 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 are covered under the Medica Advantage Value (PPO) with a $130 copay and no coinsurance, which is waived if admitted to the hospital within one day, and urgently needed services are covered with a $25 to $50 copay and no coinsurance. Worldwide emergency services are partially covered with no copay and a 20% coinsurance for emergency care and transportation, though worldwide urgent coverage is not covered.
Primary Care See details
Medica Advantage Value (PPO) provides primary care visits with no copay and no coinsurance, while specialist visits require a $55 copay and no coinsurance. Other covered benefits like therapies, mental health, and telehealth carry copays ranging from $0 to $55 with no coinsurance, whereas podiatry is not covered and chiropractic services are only partially covered, with routine and other chiropractic services excluded.
Preventive Services See details
Medica Advantage Value (PPO) offers partially covered preventive services with no copay and no coinsurance for covered services like annual physical exams, kidney disease education, glaucoma screenings, diabetes self-management, and fitness benefits. However, several sub-services are not covered, including health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional benefits, home-based palliative care, in-home support, caregiver support, additional smoking cessation counseling, enhanced disease management, telemonitoring, home safety devices, and counseling.
Hearing Services See details
Medica Advantage Value (PPO) covers hearing services, including annual routine exams and fitting evaluations with no copay and no coinsurance. Prescription hearing aids are partially covered with no coinsurance and copays ranging from $549.00 to $1,299.00, though inner ear, outer ear, and over the ear models are not covered. OTC hearing aids are also covered with a $499.50 copay and no coinsurance.
Vision Services See details
Medica Advantage Value (PPO) covers annual routine eye exams and refractions with no coinsurance and copays ranging from $0 to $55. Eyewear, including contacts and eyeglasses, is also covered with no copay or coinsurance up to a combined maximum benefit of $75 annually.
Dental Services See details
Medica Advantage Value (PPO) partially covers dental services, offering no copay and no coinsurance for most preventive and comprehensive services up to a $450 annual limit, though orthodontics is not covered. Medicare-covered dental services are available with a copay ranging from $0 to $55 and no coinsurance.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Medica Advantage Value (PPO) with no copay and no coinsurance, though prior authorization and step therapy are required. Under this benefit, Medicare Part B insulin is covered with a $35 copay and no coinsurance, while chemotherapy and other Part B drugs have no copay and a 0% to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the Medica Advantage Value (PPO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Medical equipment is covered by Medica Advantage Value (PPO) with no copay for all categories, including durable medical equipment, prosthetics, and diabetic supplies. Coinsurance for these covered items ranges from no coinsurance up to 20% depending on the specific equipment or supply.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are partially covered by the Medica Advantage Value (PPO) plan, as lab services are not covered. Covered services require prior authorization and feature no coinsurance, with copays ranging from no copay to $250 for diagnostic procedures, no minimum copay for diagnostic radiological services, a minimum $85 copay for therapeutic radiological services, and a $50 copay for outpatient X-rays.
Home Health Services See details
Home Health Services are covered under the Medica Advantage Value (PPO) plan with no copay and no coinsurance.
Cardiac Rehabilitation Services See details
Medica Advantage Value (PPO) covers Cardiac Rehabilitation Services with no coinsurance, but some services are covered while standard cardiac ($40 copay), intensive cardiac ($35 copay), pulmonary ($35 copay), and SET for PAD ($25 copay) rehabilitation services are not covered.
Skilled Nursing Facility (SNF) See details
Medica Advantage Value (PPO) partially covers Skilled Nursing Facility (SNF) services with no coinsurance, featuring no copay for days 1 to 20 and 53 to 100, and a $218 daily copay for days 21 to 52. Prior authorization is required, and additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Medica Advantage Value (PPO) partially covers other services, offering an over-the-counter (OTC) benefit with no copay and no coinsurance for up to $40 of covered items every six months via reimbursement. Acupuncture, meal benefits, nicotine replacement therapy, and naloxone are not covered under this benefit.
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Every year, Medicare evaluates plans based on a 5-star rating system.
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.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
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