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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 2025, 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 2025.
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 $137.00. 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 $2500.00 (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 $2500.00 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) plan has a $0 deductible for prescription drugs. In the initial coverage phase, you will pay either a copay or coinsurance depending on the drug tier and pharmacy. For example, for a standard pharmacy, you will pay an $11 copay for preferred generic drugs, 25% coinsurance for standard generic drugs, and 50% coinsurance for preferred brand drugs. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The Medica Advantage Preferred (PPO) plan offers a range of benefits with varying cost-sharing. Hospital stays require a $100 copay, while outpatient services have copays ranging from $0 to $150. Emergency services have a $120 copay, and primary care visits, including specialist and therapy services, have a $10 copay. Preventive services and home health services are covered with no copay, and hearing and vision services have no or low copays, including coverage for hearing aids, eye exams, and eyewear. Dental services are covered with a $1,500 annual maximum benefit. Other benefits include coverage for ambulance services, home infusion, dialysis, and medical equipment with copays or coinsurance.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, with a $100 copay per admission or stay for Medicare-covered stays for both Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. Additional Days for Inpatient Hospital-Acute benefits are covered without limit, but Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute, as well as Additional Days 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 of $0 to $150, observation services with a $100 copay, and ambulatory surgical center services with no copay. Outpatient substance abuse services are covered with a copay of $10 for both individual and group sessions, and outpatient blood services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Medica Advantage Preferred (PPO) plan, with a $10 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Medica Advantage Preferred (PPO) plan. Ground ambulance services have a $100 copay, and air ambulance services have a $200 copay, but there is no coinsurance; however, 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. Emergency Services has a $120 copay, and Urgently Needed Services have a copay between $0 and $10. 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 Preferred (PPO) plan covers primary care, chiropractic, occupational therapy, physician specialist, mental health specialty, psychiatric, physical therapy, speech-language pathology, additional telehealth, and opioid treatment program services. The plan has a $10 copay for chiropractic services, physician specialist services, individual and group mental health specialty sessions, individual and group psychiatric sessions, occupational therapy services, physical therapy, and speech-language pathology services, and a $0-$10 copay for additional telehealth services.
Preventive Services See details
The Medica Advantage Preferred (PPO) plan covers preventive services including Medicare-covered preventive services, annual physical exams, kidney disease education services, and other preventive services. Additional preventive services are partially covered, with services like health education, in-home safety assessments, and personal emergency response systems not covered. The plan also covers a fitness benefit, remote access technologies, glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a welcome visit.
Hearing Services See details
Hearing exams are covered with no copay, with one routine hearing exam and one fitting/evaluation for hearing aid covered per year. Prescription hearing aids are covered with a copay between $549 and $1299, but prescription hearing aids for the inner ear, outer ear, and over the ear are not covered.
Vision Services See details
The Medica Advantage Preferred (PPO) plan covers vision services, including eye exams with a copay of $0-$10. Eyewear is covered with a combined maximum benefit of $300 every year for both in-network and out-of-network services, while contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are also covered.
Dental Services See details
Dental Services are covered by the Medica Advantage Preferred (PPO) plan, with a maximum benefit of $1,500 per year for both in-network and out-of-network services. Oral exams have a copay between $0 and $10, while Dental X-Rays, Other Diagnostic Dental Services, Prophylaxis (Cleaning), Fluoride Treatment, Other Preventive Dental Services, Restorative Services, Adjunctive General Services, Endodontics, Periodontics, Prosthodontics (removable), Maxillofacial Prosthetics, Implant Services, Prosthodontics (fixed), and Oral and Maxillofacial Surgery are covered with no copay. Orthodontics is not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the Medica Advantage Preferred (PPO) plan and require prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Medica Advantage Preferred (PPO) plan with a 20% coinsurance.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has a 20% coinsurance, but Durable Medical Equipment for use outside the home is not covered; Prosthetics/Medical Supplies and Diabetic Equipment have a 20% coinsurance for some services, and Diabetic Supplies have a coinsurance between 0% and 20%.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the Medica Advantage Preferred (PPO) plan. Diagnostic Procedures/Tests have a copay between $0 and $50, and Diagnostic Radiological Services have a copay of at most $50; however, Lab Services, Therapeutic Radiological Services, and Outpatient X-Ray Services are not covered.
Home Health Services See details
Home Health Services are covered by the Medica Advantage Preferred (PPO) plan with no copay and no coinsurance. However, 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 Preferred (PPO) plan. The plan does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the Medica Advantage Preferred (PPO) plan, but require prior authorization. For days 1-20, there is no copay, for days 21-40, the copay is $150, and for days 41-100, there is no copay. Additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
The Medica Advantage Preferred (PPO) plan covers Over-the-Counter (OTC) Items, with a maximum benefit coverage amount of $75.00 every six months. Other services like acupuncture, meal benefits, and more are not covered.
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1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
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