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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 2026 to people living in Select counties in SD. 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 $25.00. 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 has a $300.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
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) prescription drug plan features an annual drug deductible of $615. For Tier 1 preferred generic drugs, you will pay no copay at standard pharmacies and through preferred mail order. Tier 2 generic drugs are also highly affordable, costing a $5 copay for a one-month supply at standard pharmacies and preferred mail order. For higher-tier medications, Tier 3 preferred brand drugs require an 18% coinsurance across standard pharmacies and mail-order options. Tier 4 non-preferred drugs carry a 50% coinsurance, and Tier 5 specialty medications require a 25% coinsurance for a one-month supply. Understanding these copay and coinsurance tiers helps you estimate your out-of-pocket prescription costs with this Medica PPO plan.
Additional Benefits
The Medica Advantage Value (PPO) plan provides strong cost-saving benefits, featuring no copays and no coinsurance for primary care doctor visits, routine hearing exams, and home health services. When specialized care is required, members pay a $60 copay for specialist visits and a $500 copay for the first five days of acute inpatient hospital stays. Emergency room visits carry a $130 copay, while ground ambulance services require a $370 copay, with no coinsurance required for either service. For routine wellness, the plan covers dental services with copays up to $60 and no coinsurance, up to a $400 annual limit, alongside a $75 yearly allowance for eyewear. Essential medical supplies and durable medical equipment are covered with no copays, featuring coinsurance ranging from 0% to 20% depending on the item. Members also benefit from a $30 over-the-counter allowance every six months with no copay or coinsurance.
Inpatient Hospital See details
Medica Advantage Value (PPO) covers inpatient acute and psychiatric hospital services with no coinsurance, requiring a $500 copay for acute days 1 through 5 (and no copay for days 6 and beyond) and a $290 copay for psychiatric days 1 through 8 (and no copay for days 9 through 90). Prior authorization is required, and upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Medica Advantage Value (PPO) covers outpatient services with no coinsurance, offering no copay for ambulatory surgical center and blood services. Outpatient hospital services have a copay ranging from $0 to $550, observation services require a $500 daily copay, and outpatient substance abuse sessions cost a $45 to $55 copay.
Partial Hospitalization See details
Medica Advantage Value (PPO) covers partial hospitalization services with a copay of $140.00 and no coinsurance.
Ambulance and Transportation Services See details
Medica Advantage Value (PPO) covers ground ambulance services with a $370 copay and air ambulance services with a $475 copay, with no coinsurance required for either service. Transportation services to health-related locations are not covered under this plan.
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 with no copay and a 20% coinsurance for emergency care and transportation, but worldwide urgent coverage is not covered.
Primary Care See details
Medica Advantage Value (PPO) covers primary care physician services with no copay and no coinsurance, while specialist visits require a $60 copay and no coinsurance. Other services are partially covered with no coinsurance and copays ranging from $0 to $60, though podiatry and routine chiropractic care are not covered.
Preventive Services See details
Medica Advantage Value (PPO) preventive services are covered with no copay and no coinsurance for annual physical exams, kidney disease education, and various screenings. Additional preventive services are partially covered, offering fitness benefits and remote access technologies, while sub-services such as health education, weight management, and in-home safety assessments are not covered.
Hearing Services See details
Medica Advantage Value (PPO) covers routine hearing exams and fitting evaluations annually with no copay and no coinsurance. Hearing aids are partially covered with no coinsurance, featuring a copay of $499.50 for over-the-counter models and a copay of $549.00 to $1,299.00 for prescription models, though inner ear, outer ear, and over the ear prescription hearing aids are not covered.
Vision Services See details
Vision services are covered by the Medica Advantage Value (PPO) plan, featuring eye exams with a $0 to $60 copay and no coinsurance. Eyewear is also covered with no copay or coinsurance, up to a combined maximum benefit of $75 per year for contacts, frames, lenses, and upgrades.
Dental Services See details
Medica Advantage Value (PPO) provides partially covered dental services, featuring a copay ranging from no copay up to $60 and no coinsurance for covered services, up to a $400 combined annual maximum for in-network and out-of-network care. While most preventive and comprehensive dental services are covered with no copay and no coinsurance, orthodontics are not covered.
Home Infusion bundled Services See details
Medica Advantage Value (PPO) covers home infusion bundled services with no copay, although prior authorization and step therapy may be required. Under this benefit, Medicare Part B insulin drugs have a $35 copay and no coinsurance, while chemotherapy and other Part B drugs have no copay and a coinsurance ranging from 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 with no copayments, though prior authorization and coinsurance apply to certain items. Durable medical equipment features a 0% to 17% coinsurance, diabetic supplies range from 0% to 20% coinsurance, and medical supplies, prosthetics, and diabetic footwear require a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are partially covered by Medica Advantage Value (PPO) with no coinsurance, though prior authorization is required and lab services are not covered. Covered diagnostic procedures and tests carry a copay of $0 to $125, while radiological services range from no copay for diagnostic imaging to a $50 copay for outpatient X-rays and a minimum $85 copay for therapeutic radiology.
Home Health Services See details
Home Health Services are covered by the Medica Advantage Value (PPO) plan 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, though only some services are covered in practice. Standard cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) are not covered.
Skilled Nursing Facility (SNF) See details
Medica Advantage Value (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, featuring no copay for days 1 to 20 and 53 to 100, and a $218 daily copay for days 21 to 52. Prior authorization is required, and additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Medica Advantage Value (PPO) offers partial coverage for other services, featuring a $30 reimbursement every six months with no copay and no coinsurance for over-the-counter (OTC) items. Acupuncture, meal benefits, nicotine replacement therapy, and naloxone 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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