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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 ND. 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) plan has an annual drug deductible of $615. For Tier 1 preferred generic drugs, members enjoy no copay at standard pharmacies and through preferred mail order, while standard mail order copays range from $10 to $30. Tier 2 generic prescriptions require a $6 to $18 copay at standard pharmacies and preferred mail order, or a $20 to $60 copay via standard mail order. For higher-tier medications, costs are based on coinsurance rather than flat copays. Tier 3 preferred brand drugs require a 16% coinsurance, and Tier 4 non-preferred drugs require a 50% coinsurance across all fulfillment methods. Tier 5 specialty drugs carry a 25% coinsurance for a one-month supply at standard pharmacies and mail order services.
Additional Benefits
The Medica Advantage Value (PPO) plan offers comprehensive medical coverage with predictable costs, featuring no coinsurance for many key services including inpatient hospital stays, outpatient care, and emergency visits. For primary care, preventive care, and home health services, members pay no copay and no coinsurance, while specialist visits and emergency room services require set copays. Inpatient hospital stays require a daily copay for the first six days, after which there is no copay for the remainder of your stay. This plan also includes valuable supplemental benefits such as dental, vision, and hearing coverage, often with no copay options up to specified annual limits. Routine hearing and vision exams feature no copay, and there are annual allowances for eyewear and dental care to help minimize out-of-pocket expenses. Additionally, medical equipment and diabetic supplies are covered with no copay, though some specialized services may require coinsurance or prior authorization.
Inpatient Hospital See details
Medica Advantage Value (PPO) inpatient hospital benefits are partially covered with no coinsurance, excluding upgrades, non-Medicare-covered stays, and additional psychiatric days. Covered acute stays require a $450 daily copay for days 1 through 6 and no copay for days 7 and beyond, while psychiatric stays require a $390 daily copay for days 1 through 6 and no copay for days 7 through 90.
Outpatient Services See details
Medica Advantage Value (PPO) outpatient services are covered with no coinsurance, featuring a copay of $0 to $475 for outpatient hospital services and $450 daily 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 copay of $40 for group or $50 for individual sessions.
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 ambulance services with no coinsurance, requiring a $375 copay for ground ambulance and a $475 copay for air ambulance. Some transportation services are covered, but transportation to plan-approved or any health-related locations is not covered.
Emergency Services See details
Medica Advantage Value (PPO) covers emergency services with a $130 copay (waived if admitted within one day) and no coinsurance, and urgently needed services with a $0 to $50 copay and no coinsurance. Worldwide emergency services are partially covered, offering worldwide emergency care and transportation with no copay and 20% coinsurance, while worldwide urgent coverage is not covered.
Primary Care See details
Medica Advantage Value (PPO) offers primary care physician services and select telehealth benefits with no copay and no coinsurance, though the overall benefit is only partially covered as podiatry services, routine chiropractic care, and other chiropractic services are not covered. Other covered services, such as specialist visits, physical therapy, and mental health services, require no coinsurance and copays ranging from $15 to $60.
Preventive Services See details
Preventive services under the Medica Advantage Value (PPO) are covered with no copay and no coinsurance, including annual physical exams, kidney disease education, and various screenings. While fitness benefits and remote access technologies are covered, multiple additional preventive services such as health education, personal emergency response systems, and nutritional/dietary benefits are not covered.
Hearing Services See details
Medica Advantage Value (PPO) covers annual routine hearing 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. Over-the-counter hearing aids are also covered with a $499.50 copay and no coinsurance.
Vision Services See details
Vision services are covered by Medica Advantage Value (PPO) with no deductibles, featuring annual eye exams for a $0 to $60 copay and no coinsurance. Eyewear is also covered with no copay and no coinsurance up to a $100 annual combined limit for contacts, lenses, frames, and upgrades.
Dental Services See details
Medica Advantage Value (PPO) covers Medicare-covered dental services with a $0 to $60 copay and no coinsurance, and other dental services with no copay and no coinsurance up to a $500 annual limit. This benefit is partially covered, offering comprehensive coverage for services like cleanings, exams, and implants, while orthodontics is not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by Medica Advantage Value (PPO) with no copay, though prior authorization is required. Under this benefit, Medicare Part B insulin drugs require a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs have a coinsurance of 0% to 20%.
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
Medica Advantage Value (PPO) covers medical equipment, including durable medical equipment (DME), prosthetics, and diabetic supplies, with no copay. Depending on the specific item, you will pay between no coinsurance and 20% coinsurance, and prior authorization may be required.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are partially covered under the Medica Advantage Value (PPO) plan with no coinsurance, though prior authorization is required and outpatient lab services are not covered. Covered diagnostic procedures and tests have a copay ranging from no copay to $125, while outpatient X-rays carry a $50 copay, therapeutic radiological services require at least an $85 copay, and diagnostic radiological services have no copay.
Home Health Services See details
Medica Advantage Value (PPO) provides coverage for home health services with no copay and no coinsurance.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by Medica Advantage Value (PPO) with no copay and no coinsurance, but only some services are covered; standard cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Medica Advantage Value (PPO) with no coinsurance, requiring prior authorization but no prior three-day hospital stay. There is no copay for days 1 to 20 and 53 to 100, a $218 daily copay for days 21 to 52, and additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Medica Advantage Value (PPO) provides partial coverage for other services, which includes over-the-counter (OTC) items with no copay and no coinsurance up to a maximum benefit of $45 every six months via reimbursement. Acupuncture, meal benefits, and other additional services under this category are not covered.
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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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