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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 ND and SD. 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 $201.00. 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 $3000.00 (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 $3000.00 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:
Sign up for Medica Advantage Preferred (PPO)
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Drug Coverage
The Medica Advantage Preferred (PPO) plan has a $0 deductible for prescription drugs. During the initial coverage phase, you will pay either a copay or coinsurance depending on the drug tier and pharmacy. For preferred generic drugs, you will pay an $11 copay at standard or mail order pharmacies. Standard generic drugs have a 25% coinsurance, while preferred brand drugs have a 50% coinsurance. Non-preferred drugs have a 33% coinsurance.
Additional Benefits
The Medica Advantage Preferred (PPO) plan offers a range of benefits with varying costs. Many services have no copay, including primary care, preventive services, emergency services, and home health services. However, some services like outpatient hospital services, hearing aids, and diagnostic procedures may have copays. This plan covers vision and dental services, with an annual maximum for dental. Hearing services include routine exams and hearing aid coverage. The plan also provides coverage for medical equipment and home infusion services, with specific copays or coinsurance amounts depending on the service.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for acute and psychiatric inpatient hospital stays, with additional days covered for acute stays, but not psychiatric stays. Non-Medicare-covered stays and upgrades are not covered.
Outpatient Services See details
Outpatient Services, including all outpatient hospital services and observation services, are covered under the Medica Advantage Preferred (PPO) plan. Outpatient Hospital Services have a copay between $0 and $50, and outpatient substance abuse services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the plan, but requires prior authorization.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are partially covered by the Medica Advantage Preferred (PPO) plan. Air Ambulance Services have a $50 copay, while Ground Ambulance Services and Transportation Services are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, Worldwide Emergency Services, and Worldwide Emergency Transportation are covered with no copay and no coinsurance. Worldwide Urgent Coverage is not covered.
Primary Care See details
Primary Care Physician Services, Occupational Therapy Services, Physician Specialist Services, Other Health Care Professional, Physical Therapy and Speech-Language Pathology Services, Additional Telehealth Benefits, and Opioid Treatment Program Services are covered with no copay and no coinsurance. Chiropractic Services are partially covered, as Routine Chiropractic Care is not covered. Mental Health Specialty Services and Psychiatric Services are partially covered, as Individual and Group sessions are not covered. Podiatry Services are not covered.
Preventive Services See details
The Medica Advantage Preferred (PPO) plan covers preventive services including annual physical exams, kidney disease education services, and other preventive services like glaucoma screenings, with no copay. Additional services such as health education, in-home safety assessments, and several others are not covered.
Hearing Services See details
Hearing services under the Medica Advantage Preferred (PPO) plan cover routine hearing exams and fitting/evaluation for hearing aids, each limited to one visit per year. Prescription hearing aids (all types) are covered with a copay between $549 and $1299. Prescription hearing aids for the inner, outer, and over the ear are not covered, nor are OTC hearing aids.
Vision Services See details
The Medcia Advantage Preferred (PPO) plan covers vision services, including routine eye exams once per year, and other eye exam services once per year. This plan also covers eyewear with a combined maximum of $250 per year for both in-network and out-of-network services, along with contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades.
Dental Services See details
The Medcia Advantage Preferred (PPO) plan covers a wide range of dental services, including oral exams, dental x-rays, and other diagnostic and preventive services, up to a maximum of $1000 per year. However, orthodontics is not covered by this plan.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the Medica Advantage Preferred (PPO) plan, 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 with this plan. There is no copay or coinsurance for this benefit.
Medical Equipment See details
Medical Equipment benefits are covered under the Medica Advantage Preferred (PPO) plan, including Durable Medical Equipment (DME) with no copay or coinsurance, but Durable Medical Equipment for use outside the home is not covered. Prosthetics/Medical Supplies - Non-Medicare benefits are covered with no copay or coinsurance, but Prosthetic Devices and Medical Supplies are not covered. Diabetic Equipment is covered, and Diabetic Supplies have a coinsurance between 0% and 20%, but Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered under the Medica Advantage Preferred (PPO) plan. Diagnostic Procedures/Tests have a copay between $0 and $50, while Diagnostic Radiological Services have a copay of up to $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. Additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are technically covered, but none of the sub-services, including Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services, are covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Medica Advantage Preferred (PPO) plan, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $25. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
The Medica Advantage Preferred (PPO) plan does not cover acupuncture, meal benefits, 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, or Self-Directed Personal Assistance Services. This plan does cover Over-the-Counter (OTC) Items, with a maximum benefit coverage of $75 every six months.
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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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