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Medica Advantage Preferred (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Medica Advantage Preferred (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Medica Advantage Preferred (PPO) in 2026, please refer to our full plan details page.
Medica Advantage Preferred (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 Preferred (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 Preferred (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 Preferred (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $155.00. 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 $275.00 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 $3800.00 (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 $3800.00 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 Preferred (PPO) prescription drug plan features an annual drug deductible of $275. For Tier 1 preferred generic drugs, members enjoy no copay when using standard pharmacies or preferred mail order services. Tier 2 generic drugs are highly affordable, costing just $7 for a one-month supply at standard pharmacies and preferred mail order, compared to a $20 copay for standard mail order. For brand-name and specialty medications, costs are determined by coinsurance rather than flat copays. Tier 3 preferred brand drugs require a 20% coinsurance, while Tier 4 non-preferred drugs carry a 50% coinsurance across all delivery methods. Specialty drugs in Tier 5 require a 29% coinsurance for a one-month supply.
Additional Benefits
The Medica Advantage Preferred (PPO) plan offers robust coverage for essential medical needs, featuring no copays or coinsurance for primary care visits, preventive care, and home health services. Specialist visits, physical therapy, and outpatient mental health services are also highly accessible with low flat copays and no coinsurance. For more intensive care, inpatient hospital stays and emergency services are covered with predictable, fixed copayments and no coinsurance. This plan also includes valuable supplemental benefits, such as dental coverage up to $750 annually and routine vision exams with a $175 yearly allowance for eyewear. Members enjoy no copays on routine hearing exams, affordable options for prescription hearing aids, and a $50 over-the-counter product allowance every six months. Additionally, skilled nursing facility stays require no coinsurance and feature no copay for the first 20 days of your stay.
Inpatient Hospital See details
Inpatient hospital services are partially covered by Medica Advantage Preferred (PPO) with no coinsurance, requiring a $200 copay per stay for acute care and a $225 copay per stay for psychiatric care. Prior authorization is required for these services, and upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Medica Advantage Preferred (PPO) covers outpatient services with no coinsurance, featuring a $0 to $195 copay for outpatient hospital services and a $200 copay per stay for observation services. Ambulatory surgical center and outpatient blood services are covered with no copay and no coinsurance, while outpatient substance abuse sessions require a $10 copay.
Partial Hospitalization See details
Partial hospitalization is covered under the Medica Advantage Preferred (PPO) plan with a $50.00 copay and no coinsurance.
Ambulance and Transportation Services See details
Ambulance and transportation services under Medica Advantage Preferred (PPO) include coverage for ground ambulance with a $250 copay and air ambulance with a $350 copay, both with no coinsurance. Transportation services to plan-approved or other health-related locations are not covered.
Emergency Services See details
Emergency services are covered by Medica Advantage Preferred (PPO) with a $150 copay and no coinsurance, which is waived if you are admitted to the hospital within one day. Urgently needed services feature a $0 to $40 copay and no coinsurance, while worldwide emergency and transportation services are partially covered with no copay and 20% coinsurance, as worldwide urgent coverage is not covered.
Primary Care See details
Primary care services under the Medica Advantage Preferred (PPO) plan feature no copay and no coinsurance, while specialist visits, physical therapy, and occupational therapy require a $20 copay and no coinsurance. Mental health, psychiatric, and opioid treatment services have a $10 copay and no coinsurance, but podiatry and routine chiropractic services are not covered.
Preventive Services See details
Medica Advantage Preferred (PPO) preventive services are partially covered, offering annual physical exams, Medicare-covered preventive care, kidney disease education, and fitness benefits with no copay and no coinsurance. However, several supplemental benefits, including health education, in-home safety assessments, and personal emergency response systems, are not covered.
Hearing Services See details
Medica Advantage Preferred (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 of $549.00 to $1,299.00 and no coinsurance, though inner ear, outer ear, and over the ear models are not covered. Over-the-counter hearing aids are also covered with a $499.50 copay and no coinsurance.
Vision Services See details
Medica Advantage Preferred (PPO) covers routine and refraction eye exams with a $0 to $20 copay, no coinsurance, and no deductible. Eyewear is also covered with no copay, no coinsurance, and no deductible up to a $175 combined annual limit for contacts, lenses, and frames.
Dental Services See details
Dental services are partially covered by Medica Advantage Preferred (PPO) up to an annual maximum of $750 for both in-network and out-of-network care, excluding orthodontic services which are not covered. Most covered dental services require no copay and no coinsurance, while Medicare-covered dental services have a $0 to $20 copay and no coinsurance.
Home Infusion bundled Services See details
Medica Advantage Preferred (PPO) covers Home Infusion bundled Services with no copay, though prior authorization is required. Under this benefit, Medicare Part B insulin is covered with a $35 copay and no coinsurance, while other Part B chemotherapy, radiation, and miscellaneous drugs require no copay and 0% to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the Medica Advantage Preferred (PPO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Medica Advantage Preferred (PPO) covers medical equipment with no copays, though prior authorization is required for durable medical equipment and prosthetics. Coinsurance ranges from no coinsurance to 20% for durable medical equipment and diabetic supplies, while prosthetic devices, medical supplies, and diabetic shoes carry a flat 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are partially covered under the Medica Advantage Preferred (PPO) plan with no coinsurance, though lab services and outpatient X-ray services are not covered. Covered diagnostic procedures and tests require no copay to a $95 copay, diagnostic radiological services have no copay, and therapeutic radiological services require a copay starting at $50.
Home Health Services See details
Home Health Services are covered under the Medica Advantage Preferred (PPO) plan with no copay and no coinsurance.
Cardiac Rehabilitation Services See details
Medica Advantage Preferred (PPO) covers Cardiac Rehabilitation Services with no coinsurance, though some services are covered. Standard cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) services are not covered and require a $20 copay.
Skilled Nursing Facility (SNF) See details
Medica Advantage Preferred (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but no prior three-day inpatient hospital stay. There is no copay for days 1 to 20 and days 40 to 100, a daily copay of $218 for days 21 to 39, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Medica Advantage Preferred (PPO) partially covers other services, offering up to $50 every six months in reimbursement for over-the-counter (OTC) items with no copay and no coinsurance. Acupuncture, meal benefits, and other additional services under this category are not covered.
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1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
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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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