Plan Basics
Contract Year 2021
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H2450-044-000
Plan Organization Medica
Plan Type Cost *
Plan Name Medica Prime Solution Standard (Cost)
Drugs Covered No
Doctors Choice Plan Doctors for Most Services
Overall Star Rating 4
Plan Cost Sharing
Premium $0.00
Total Premium (Includes Part B) $135.50
Monthly Part C Premium $0.00
Maximum Out-of-Pocket Limit for Parts A & B (MOOP) $4500.00

Medicare Advantage Plan Health Benefits


Additional Benefits And/or Reduced Cost-sharing For Enrollees With Certain Health Conditions?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Comprehensive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic services Yes - No No $0 copay
Endodontics Yes - No No $0 copay
Extractions Yes - No No $0 copay
Non-routine services Yes - No No $0 copay
Periodontics Yes - No No $0 copay
Prosthodontics, other oral/maxillofacial surgery, other services Yes - No No $0 copay
Restorative services Yes - No No $0 copay
Diagnostic Procedures/lab Services/imaging
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic radiology services (e.g., MRI) - - No No $35-150 copay
Diagnostic tests and procedures - - No No $0-35 copay
Lab services - - No No $0 copay
Outpatient x-rays - - No No $0-35 copay
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - - - - $0 copay
Specialist - - No No $35 copay per visit
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Emergency - - - - $90 copay per visit (always covered)
Urgent care - - - - $0-35 copay per visit (always covered)
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Foot exams and treatment - - No No $35 copay
Routine foot care - - - - Not covered
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $200 copay
Health Plan Deductible
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $0
Hearing
Service Cap Network Auth. Req. Ref. Req. Cost Share
Fitting/evaluation Yes - No No $0 copay
Hearing aids Yes - No No $0 copay
Hearing exam - - No No $35 copay
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No $280 per day for days 1 through 5$0 per day for days 6 through 90
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $4,500 In-network
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diabetes supplies - - No - 20% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen) - - No - 20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs) - - No - 20% coinsurance per item
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Inpatient hospital - psychiatric - - No No $280 per day for days 1 through 5$0 per day for days 6 through 90
Outpatient group therapy visit - - No No $30 copay
Outpatient group therapy visit with a psychiatrist - - No No $35 copay
Outpatient individual therapy visit - - No No $30 copay
Outpatient individual therapy visit with a psychiatrist - - No No $35 copay
Optional Supplemental Benefits
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - No
Other Health Plan Deductibles?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Outpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No $200 copay per visit
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No $0 copay
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Cleaning Yes - No No $0 copay
Dental x-ray(s) Yes - No No $0 copay
Fluoride treatment Yes - No No $0 copay
Oral exam Yes - No No $0 copay
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Occupational therapy visit - - No No $35 copay
Physical therapy and speech and language therapy visit - - No No $35 copay
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No Coming soon
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - Not covered
Vision
Service Cap Network Auth. Req. Ref. Req. Cost Share
Contact lenses Yes - No No $0 copay
Eyeglass frames Yes - No No $0 copay
Eyeglass lenses Yes - No No $0 copay
Eyeglasses (frames and lenses) Yes - No No $0 copay
Other No - - - Not covered
Routine eye exam Yes - No No $0 copay
Upgrades Yes - No No $0 copay
Wellness Programs (e.g., Fitness, Nursing Hotline)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No Covered
Plan Drug Info
Formulary Link Drug Formulary Directory
Official Medicare Contact
Medicare Phone 1-800-MEDICARE (1-800-633-4227)
Medicare TTY User 1-877-486-2048
Plan Available in these Counties
Adams County, North Dakota, Aitkin County, Minnesota, Aurora County, South Dakota, Barnes County, North Dakota, Beadle County, South Dakota, Bennett County, South Dakota, Benson County, North Dakota, Billings County, North Dakota, Bon Homme County, South Dakota, Bowman County, North Dakota, Brookings County, South Dakota, Brown County, South Dakota, Brule County, South Dakota, Buffalo County, South Dakota, Burleigh County, North Dakota, Butte County, South Dakota, Campbell County, South Dakota, Carlton County, Minnesota, Cass County, North Dakota, Cavalier County, North Dakota, Charles Mix County, South Dakota, Clark County, South Dakota, Clay County, South Dakota, Codington County, South Dakota, Cook County, Minnesota, Corson County, South Dakota, Custer County, South Dakota, Davison County, South Dakota, Day County, South Dakota, Deuel County, South Dakota, Dewey County, South Dakota, Dickey County, North Dakota, Douglas County, South Dakota, Dunn County, North Dakota, Eddy County, North Dakota, Edmunds County, South Dakota, Emmons County, North Dakota, Fall River County, South Dakota, Faulk County, South Dakota, Foster County, North Dakota, Goodhue County, Minnesota, Grand Forks County, North Dakota, Grant County, North Dakota, Grant County, South Dakota, Gregory County, South Dakota, Griggs County, North Dakota, Haakon County, South Dakota, Hamlin County, South Dakota, Hand County, South Dakota, Hanson County, South Dakota, Harding County, South Dakota, Hettinger County, North Dakota, Hughes County, South Dakota, Hutchinson County, South Dakota, Hyde County, South Dakota, Itasca County, Minnesota, Jackson County, South Dakota, Jerauld County, South Dakota, Jones County, South Dakota, Kanabec County, Minnesota, Kidder County, North Dakota, Kingsbury County, South Dakota, Koochiching County, Minnesota, Lake County, Minnesota, Lake County, South Dakota, Lamoure County, North Dakota, Lawrence County, South Dakota, Le Sueur County, Minnesota, Lincoln County, South Dakota, Logan County, North Dakota, Lyman County, South Dakota, Marshall County, South Dakota, Mccook County, South Dakota, Mchenry County, North Dakota, Mcintosh County, North Dakota, Mclean County, North Dakota, Mcleod County, Minnesota, Mcpherson County, South Dakota, Meade County, South Dakota, Meeker County, Minnesota, Mellette County, South Dakota, Mercer County, North Dakota, Mille Lacs County, Minnesota, Miner County, South Dakota, Minnehaha County, South Dakota, Moody County, South Dakota, Morton County, North Dakota, Nelson County, North Dakota, Oglala Lakota County, South Dakota, Oliver County, North Dakota, Pembina County, North Dakota, Pennington County, South Dakota, Perkins County, South Dakota, Pierce County, North Dakota, Pine County, Minnesota, Pipestone County, Minnesota, Potter County, South Dakota, Ramsey County, North Dakota, Ransom County, North Dakota, Rice County, Minnesota, Richland County, North Dakota, Roberts County, South Dakota, Rock County, Minnesota, Rolette County, North Dakota, Saint Louis County, Minnesota, Sanborn County, South Dakota, Sargent County, North Dakota, Sheridan County, North Dakota, Sibley County, Minnesota, Sioux County, North Dakota, Slope County, North Dakota, Spink County, South Dakota, Stanley County, South Dakota, Stark County, North Dakota, Steele County, North Dakota, Stevens County, Minnesota, Stutsman County, North Dakota, Sully County, South Dakota, Todd County, South Dakota, Towner County, North Dakota, Traill County, North Dakota, Traverse County, Minnesota, Tripp County, South Dakota, Turner County, South Dakota, Union County, South Dakota, Walsh County, North Dakota, Walworth County, South Dakota, Ward County, North Dakota, Wells County, North Dakota, Williams County, North Dakota, Yankton County, South Dakota, Yellow Medicine County, Minnesota, Ziebach County, South Dakota

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