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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 ND and SD. 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 $205.00. 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 $240.00 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 $3300.00 (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 $3300.00 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 features an annual drug deductible of $240. Under this plan, Tier 1 preferred generic drugs have no copay when filled at a standard pharmacy or through preferred mail order, while standard mail order copays range from $10 to $30. Tier 2 generic drugs require a copay starting at $7 for a 1-month supply at standard pharmacies and preferred mail order, rising to up to $60 for a 3-month standard mail order. For higher-tier medications, costs are determined by coinsurance rather than flat copays. Tier 3 preferred brand drugs carry a 21% coinsurance, Tier 4 non-preferred drugs require 50% coinsurance, and Tier 5 specialty drugs require 30% coinsurance for a 1-month supply. These cost-sharing rates apply across standard pharmacies, preferred mail order, and standard mail order channels.
Additional Benefits
The Medica Advantage Preferred (PPO) plan offers comprehensive medical coverage with no coinsurance for many essential services, including inpatient hospital stays for a $95 copay per stay and no copay for primary care doctor visits. Outpatient services feature highly predictable costs, with no copay for ambulatory surgical centers and copays ranging from $0 to $75 for outpatient hospital care. Emergency care is covered with a $95 copay, which is waived if admitted, while urgent care visits require a low copay of $0 to $30. This PPO plan also provides valuable supplemental benefits, including preventive and comprehensive dental care with no copay up to an $800 annual limit, and a $200 yearly eyewear allowance with no copay. Annual hearing exams are available with no copay, while prescription hearing aids and skilled nursing facility stays are covered with defined copayments and no coinsurance. Additionally, members benefit from no copay on home health services and receive a $60 reimbursement every six months for over-the-counter items.
Inpatient Hospital See details
Medica Advantage Preferred (PPO) covers inpatient acute and psychiatric hospital services with a $95.00 copayment per stay and no coinsurance, though prior authorization is required. This benefit is partially covered because upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered, while unlimited additional acute care days are covered with no copayment.
Outpatient Services See details
Medica Advantage Preferred (PPO) covers outpatient services with no coinsurance, featuring no copay for ambulatory surgical center and outpatient blood services. Outpatient hospital services require a copay of $0 to $75, observation services require a $95 copay per stay, and outpatient substance abuse sessions have a $10 copay.
Partial Hospitalization See details
Partial hospitalization is covered by Medica Advantage Preferred (PPO) with a $50.00 copay and no coinsurance. This benefit ensures you have clear and predictable out-of-pocket costs for your care.
Ambulance and Transportation Services See details
Medica Advantage Preferred (PPO) partially covers ambulance services, offering air ambulance services with a $350 copay and no coinsurance, while ground ambulance services are not covered. Transportation services to health-related locations are not covered under this plan.
Emergency Services See details
Emergency services under the Medica Advantage Preferred (PPO) are covered with a $95 copay and no coinsurance, with the copay waived if admitted to the hospital within one day. Urgently needed services require a $0 to $30 copay and no coinsurance, and while worldwide emergency and transportation services are covered with no copay or coinsurance, worldwide urgent care is not covered.
Primary Care See details
Medica Advantage Preferred (PPO) provides partially covered primary care benefits with no coinsurance, featuring no copay for primary care doctor visits and copays between $10 and $20 for specialists, physical therapy, and mental health services. Podiatry and routine chiropractic services are not covered under this plan.
Preventive Services See details
Medica Advantage Preferred (PPO) covers preventive services, such as annual physical exams and kidney disease education, with no copay and no coinsurance. Additional preventive services are partially covered with no copay and no coinsurance, which includes fitness benefits and remote access technologies, but excludes health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, readmission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional/dietary benefits, home-based palliative care, in-home support, caregiver support, additional smoking cessation, enhanced disease management, telemonitoring, safety devices, and counseling.
Hearing Services See details
Hearing services are covered by Medica Advantage Preferred (PPO), featuring one annual routine exam and fitting with no copay and no coinsurance. Prescription hearing aids are partially covered with no coinsurance and copays between $549.00 and $1,299.00, excluding inner ear, outer ear, and over the ear models. OTC hearing aids are also covered with a $499.50 copay and no coinsurance.
Vision Services See details
Vision services are covered by Medica Advantage Preferred (PPO), featuring eye exams with a $0 to $15 copay and no coinsurance. Eyewear, including lenses, frames, and contact lenses, is available with no copay and no coinsurance up to a combined maximum plan benefit of $200 per year.
Dental Services See details
Medica Advantage Preferred (PPO) provides partially covered dental services up to an annual maximum benefit of $800 for both in-network and out-of-network care. Covered preventive and comprehensive dental services have no copay and no coinsurance, while Medicare-covered dental services require a $0 to $15 copay and no coinsurance; however, orthodontics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Medica Advantage Preferred (PPO) with no copay, though prior authorization is required. Covered Medicare Part B insulin drugs require a $35 copay and no coinsurance, while chemotherapy and other Part B drugs feature no copay and a coinsurance ranging from 0% to 20%.
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, offering no coinsurance to 20% coinsurance for durable medical equipment and diabetic supplies. Prosthetic devices, medical supplies, and diabetic therapeutic shoes or inserts are also covered with no copay and a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services under the Medica Advantage Preferred (PPO) plan are partially covered with no coinsurance, though prior authorization is required. Diagnostic procedures range from no copay to a $95 copay, diagnostic radiological services have no copay, and therapeutic radiological services start at a $50 copay, while lab services and outpatient X-ray services are not covered.
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
Cardiac Rehabilitation Services are partially covered under the Medica Advantage Preferred (PPO) plan with no coinsurance; however, 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
Skilled Nursing Facility (SNF) services are covered by Medica Advantage Preferred (PPO) with no coinsurance and prior authorization required, featuring no copay for days 1 through 20 and days 38 through 100, and a $218 daily copay for days 21 through 37. A prior three-day inpatient hospital stay is not required for admission, though additional days beyond the standard 100 Medicare-covered days are not covered.
Other Services See details
Medica Advantage Preferred (PPO) partially covers other services, offering a $60 reimbursement every six months with no copay and no coinsurance for over-the-counter (OTC) items. Acupuncture and meal benefits are not covered under this plan.
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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.
* 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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