2027 Medicare Advantage plan

Medica Advantage Select (PPO): 2027 benefits and costs

Medica PPO

CMS plan ID: H8889-028-1 · Plan year: 2027

Medica Advantage Select (PPO) is a 2027 Medicare Advantage plan offered by Medica. It is listed in South Dakota.

2027 plan costs at a glance

Monthly plan premium$80.00

Drug deductible$455.00

In-network medical out-of-pocket maximum$7,150.00

Organization: Medica
Plan organization: MEDICA HEALTH PLANS
Parent company: Medica Holding Company
Plan type: PPO
Part C premium: $71.30
Part D premium: $8.70
Prescription drug coverage: Yes
2027 CMS Star Rating

Standard monthly Medicare Part B premium: $209.50 (estimated)

You must continue to pay your Medicare Part B premium.

Annual medical deductible: None
In-network medical maximum: $7,150.00
Combined in/out-of-network medical maximum: $10,750.00
Out-of-network medical maximum: Not applicable

2027 benefit summary

Doctor visits and medical care

Common medical services and member costs
Service	In-network	Out-of-network	What to know
Primary care doctor	$0 Service-specific deductible No	$15.00 copay Deductible applies No
Specialist visit	$0.00 to $60.00 copay Service-specific deductible No	$15.00 to $75.00 copay Deductible applies No	Approval required No Referral required No
Telehealth	$0.00 to $60.00 copay Service-specific deductible No	Not summarized. Check coverage with the plan.	Approval required No Referral required No
Emergency care	$130.00 copay	Not summarized. Check coverage with the plan.
Urgent care	$45.00 copay	Not summarized. Check coverage with the plan.
Home health	$0 Service-specific deductible No	20% coinsurance Deductible applies No	Approval required No Referral required No
Dialysis	20% coinsurance Service-specific deductible No	20% coinsurance Deductible applies No	Approval required No Referral required No
Part B chemotherapy and radiation drugs	0% to 20% coinsurance Deductible applies No	0% to 20% coinsurance Deductible applies No	Approval required Yes
Other Part B drugs	0% to 20% coinsurance Deductible applies No	0% to 20% coinsurance Deductible applies No	Approval required Yes
Kidney disease education services	$0 Service-specific deductible No	$0 Deductible applies No	Approval required No Referral required No
Medicare-covered chiropractic	$15.00 copay Service-specific deductible No	$30.00 copay Deductible applies No	Approval required No Referral required No
Medicare-covered foot care	$60.00 copay Service-specific deductible No	$75.00 copay Deductible applies No	Approval required No Referral required No
Other health professionals	$0.00 to $60.00 copay Service-specific deductible No	$15.00 to $75.00 copay Deductible applies No	Approval required No Referral required No

Hospital, outpatient surgery and observation care

Inpatient stays and skilled nursing care

In-network stays. Charges can depend on the number of days and the benefit period.
Care	Your share of the cost	What to know
Inpatient hospital stay	$0.00 copay per stay Days 1–6: $350.00 copay per day Days 7–90: $0.00 copay per day	Approval required Yes Referral required No Benefit period Per Admission or Per Stay
Inpatient mental health care	$0.00 copay per stay Days 1–6: $350.00 copay per day Days 7–90: $0.00 copay per day	Approval required Yes Referral required No Benefit period Per Admission or Per Stay
Skilled nursing facility	Days 1–20: $0.00 copay per day Days 21–54: $221.00 copay per day Days 55–100: $0.00 copay per day	Approval required Yes Referral required No Benefit period Original Medicare

See plan documents for out-of-network hospital and skilled nursing costs.

Hospital, outpatient surgery and observation care and member costs
Service	In-network	Out-of-network	What to know
Outpatient hospital care	$0.00 to $450.00 copay Service-specific deductible No	$0.00 to $500.00 copay Deductible applies No
Hospital observation services	$350.00 copay Service-specific deductible No	$435.00 copay Deductible applies No
Ambulatory surgical center	$0.00 to $350.00 copay Service-specific deductible No	$0.00 to $435.00 copay Deductible applies No	Approval required Yes Referral required No
Outpatient blood	$0 Service-specific deductible No	$40.00 copay Deductible applies No	Approval required No Referral required No

Tests, imaging and laboratory services

Tests, imaging and laboratory services and member costs
Service	In-network	Out-of-network	What to know
Diagnostic procedures and tests	$0.00 to $250.00 copay Service-specific deductible No	$0.00 to $250.00 copay Deductible applies No	Approval required Yes Referral required No
Laboratory services	$0 Service-specific deductible No	$0 Deductible applies No	Approval required Yes Referral required No
Diagnostic radiology (CT, MRI)	$0.00 to $100.00 copay Service-specific deductible No	$0.00 to $100.00 copay Deductible applies No	Approval required Yes Referral required No
Therapeutic radiology	$85.00 copay Service-specific deductible No	$85.00 copay Deductible applies No	Approval required Yes Referral required No
X-rays	$25.00 copay Service-specific deductible No	$25.00 copay Deductible applies No	Approval required Yes Referral required No

Mental health and substance use treatment

Mental health and substance use treatment and member costs
Service	In-network	Out-of-network	What to know
Partial hospitalization	$130.00 copay Service-specific deductible No	$160.00 copay Deductible applies No	Approval required No Referral required No
Intensive outpatient program	$130.00 copay Service-specific deductible No	$160.00 copay Deductible applies No	Approval required No Referral required No
Substance use treatment, individual sessions	$50.00 copay Service-specific deductible No	$65.00 copay Deductible applies No	Approval required No Referral required No
Substance use treatment, group sessions	$40.00 copay Service-specific deductible No	$55.00 copay Deductible applies No	Approval required No Referral required No
Opioid treatment program	$50.00 copay Service-specific deductible No	$65.00 copay Deductible applies No	Approval required No Referral required No
Mental health, individual sessions	$50.00 copay Service-specific deductible No	$65.00 copay Deductible applies No	Approval required No Referral required No
Mental health, group sessions	$40.00 copay Service-specific deductible No	$55.00 copay Deductible applies No	Approval required No Referral required No
Psychiatry, individual sessions	$50.00 copay Service-specific deductible No	$65.00 copay Deductible applies No	Approval required No Referral required No
Psychiatry, group sessions	$40.00 copay Service-specific deductible No	$55.00 copay Deductible applies No	Approval required No Referral required No

Therapy and rehabilitation

Therapy and rehabilitation and member costs
Service	In-network	Out-of-network	What to know
Occupational therapy	$50.00 copay Service-specific deductible No	$65.00 copay Deductible applies No	Approval required No Referral required No
Physical and speech therapy	$60.00 copay Service-specific deductible No	$75.00 copay Deductible applies No	Approval required No Referral required No
Cardiac rehabilitation	$35.00 copay Service-specific deductible No	$50.00 copay Deductible applies No	Approval required No Referral required No
Intensive cardiac rehabilitation	$50.00 copay Service-specific deductible No	$65.00 copay Deductible applies No	Approval required No Referral required No
Pulmonary rehabilitation	$35.00 copay Service-specific deductible No	$50.00 copay Deductible applies No	Approval required No Referral required No
Supervised exercise for peripheral artery disease	$25.00 copay Service-specific deductible No	$35.00 copay Deductible applies No	Approval required No Referral required No

Ambulance, medical equipment and supplies

Ambulance, medical equipment and supplies and member costs
Service	In-network	Out-of-network	What to know
Ground ambulance	$395.00 copay Service-specific deductible No	$395.00 copay Deductible applies No	Approval required No
Air ambulance	$515.00 copay Service-specific deductible No	$515.00 copay Deductible applies No	Approval required No
Durable medical equipment	20% coinsurance Service-specific deductible No	30% coinsurance Deductible applies No	Approval required Yes
Prosthetic devices	20% coinsurance Service-specific deductible No	30% coinsurance Deductible applies No	Approval required Yes
Medical supplies	20% coinsurance Service-specific deductible No	30% coinsurance Deductible applies No	Approval required Yes
Diabetic supplies	0% to 20% coinsurance Service-specific deductible No	0% to 30% coinsurance Deductible applies No	Approval required Yes
Diabetic shoes and inserts	20% coinsurance Service-specific deductible No	30% coinsurance Deductible applies No	Approval required Yes
Diabetic monitors	0% to 20% coinsurance Service-specific deductible No	0% to 30% coinsurance Deductible applies No	Approval required Yes

Dental benefits

Dental benefits and member costs
Service	In-network	Out-of-network
Medicare-covered dental	$0.00 to $60.00 copay	$0.00 to $60.00 copay Deductible applies No
Oral examsAdditional plan benefit	$0	50% coinsurance Deductible applies No
Dental X-raysAdditional plan benefit	$0	50% coinsurance Deductible applies No
Dental cleaningAdditional plan benefit	$0	50% coinsurance Deductible applies No
FluorideAdditional plan benefit	$0	50% coinsurance Deductible applies No
Other preventive dentalAdditional plan benefit	$0	50% coinsurance Deductible applies No
Restorative dental careAdditional plan benefit	50% coinsurance	50% coinsurance Deductible applies No
Root canal treatment (endodontics)Additional plan benefit	50% coinsurance	50% coinsurance Deductible applies No
Gum treatment (periodontics)Additional plan benefit	50% coinsurance	50% coinsurance Deductible applies No
Fixed dental restorations (prosthodontics)Additional plan benefit	50% coinsurance	50% coinsurance Deductible applies No
Oral surgeryAdditional plan benefit	50% coinsurance	50% coinsurance Deductible applies No
Other dental servicesAdditional plan benefit	50% coinsurance	50% coinsurance Deductible applies No

Additional network details

These costs apply to the listed service categories and networks.

Dental benefits: additional out-of-network or point-of-service benefits
Service	Network	Your share of the cost	What to know
Diagnostic and preventive dental (category)Additional plan benefit	Out-of-network	Confirm with the plan (copay); Confirm with the plan (coinsurance)	Dollar benefit limit applies No
Comprehensive dental (category)Additional plan benefit	Out-of-network	Confirm with the plan (copay); Confirm with the plan (coinsurance)	Dollar benefit limit applies No

Vision benefits

Vision benefits and member costs
Service	In-network	Out-of-network	What to know
Medicare-covered eye exams	$0.00 to $60.00 copay Service-specific deductible No	$0.00 to $75.00 copay Deductible applies No	Approval required No Referral required No
Routine eye examsAdditional plan benefit	$0	$0 Deductible applies No	Approval required No Referral required No
Medicare-covered eyewear	$0 Service-specific deductible No	$0 Deductible applies No	Approval required No Referral required No

Additional network details

These costs apply to the listed service categories and networks.

Vision benefits: additional out-of-network or point-of-service benefits
Service	Network	Your share of the cost	What to know
Eye exams (category)Additional plan benefit	Out-of-network	Confirm with the plan (copay); Confirm with the plan (coinsurance)	Dollar benefit limit applies No
Other Eye Exam ServicesAdditional plan benefit	Out-of-network	$0 Deductible applies No

Hearing benefits

Hearing benefits and member costs
Service	In-network	Out-of-network	What to know
Medicare-covered hearing exams	$0.00 to $60.00 copay Service-specific deductible No	$0.00 to $75.00 copay Deductible applies No	Approval required No Referral required No
Routine hearing examsAdditional plan benefit	$0	$0 Deductible applies No	Approval required No Referral required No
Hearing aid fitting and evaluationAdditional plan benefit	$0	$0 Deductible applies No	Approval required No Referral required No
Prescription hearing aids (all types)Additional plan benefit	$549.00 to $1,299.00 copay Service-specific deductible No	$549.00 to $1,299.00 copay Deductible applies No	Approval required No Referral required No
Over-the-counter hearing aidsAdditional plan benefit	$999.00 copay Service-specific deductible No	$999.00 copay Deductible applies No Dollar benefit limit applies No	Approval required No Referral required No

Additional network details

These costs apply to the listed service categories and networks.

Hearing benefits: additional out-of-network or point-of-service benefits
Service	Network	Your share of the cost	What to know
Hearing exams (category)Additional plan benefit	Out-of-network	Confirm with the plan (copay); Confirm with the plan (coinsurance)	Dollar benefit limit applies No
Prescription hearing aids (category)Additional plan benefit	Out-of-network	Confirm with the plan (copay); Confirm with the plan (coinsurance)	Dollar benefit limit applies No

Extra benefits

Extra benefits and member costs
Service	In-network	Out-of-network	What to know
Over-the-counter health itemsAdditional plan benefit	$0 Service-specific deductible No	$0 Deductible applies No Dollar benefit limit applies Yes Benefit allowance $20.00 How often this limit applies Every six months
Annual physical examAdditional plan benefit	$0 Service-specific deductible No	$0 Deductible applies No Dollar benefit limit applies No	Approval required No Referral required No
Fitness benefitAdditional plan benefit	$0 Service-specific deductible No	$0 Deductible applies No Dollar benefit limit applies No	Approval required No Referral required No

Additional services and network costs

Additional network details

These costs apply to the listed service categories and networks.

Additional medical services: additional out-of-network or point-of-service benefits
Service	Network	Your share of the cost	What to know
Medicare-covered preventive servicesMedicare-covered care	Out-of-network	$0 Deductible applies No
Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline)Additional plan benefit	Out-of-network	$0 Deductible applies No	Dollar benefit limit applies No
Glaucoma ScreeningMedicare-covered care	Out-of-network	$0 Deductible applies No
Diabetes Self-Management TrainingMedicare-covered care	Out-of-network	$0 Deductible applies No
Digital Rectal ExamsMedicare-covered care	Out-of-network	$0 Deductible applies No
EKG after a Welcome to Medicare visitMedicare-covered care	Out-of-network	$0 Deductible applies No
Medicare Part B insulinMedicare-covered care	Out-of-network	$35.00 copay Deductible applies No

Allowances and optional benefits

Benefits for qualifying members

Additional benefits for qualifying members with chronic conditions

The plan must confirm eligibility, including any qualifying condition.

Qualifying conditions: Cancer; Cardiovascular disorders; Chronic heart failure; Dementia; Diabetes mellitus; Chronic gastrointestinal disease; Chronic kidney disease (CKD); Severe hematologic disorders; Chronic lung disorders; Neurologic disorders; Stroke
To qualify: Participation in a Care Management Program
Included services: Meal Benefit; Home and Bathroom Safety Devices and Modifications
Applies to out-of-network or point-of-service care: Yes
Some package benefits are exempt from the deductible: No

Prescription drug coverage

Costs shown are for initial coverage.

Drug deductible exceptions: Tier 1; Tier 2; Tier 6 are exempt from the deductible.

Standard retail costs

On a small screen, scroll the table sideways to compare all fill lengths.

Standard retail: initial-coverage cost per prescription fill
Drug tier	30 days	60 days	90 days
Tier 1Preferred Generic	$0.00	$0.00	$0.00
Tier 2Generic	$10.00	$20.00	$30.00
Tier 3Preferred Brand	18%	18%	18%
Tier 4Non-Preferred Drug	25%	25%	25%
Tier 5Specialty Tier	28%	Not listed	Not listed
Tier 6Select Care Drugs	$0.00	$0.00	$0.00

Mail-order and other pharmacies

Out-of-network pricing: You pay the standard retail copay or coinsurance, plus any difference between the pharmacy’s billed charge and the amount the plan allows at a standard retail pharmacy.

Preferred mail order costs

On a small screen, scroll the table sideways to compare all fill lengths.

Preferred mail order: initial-coverage cost per prescription fill
Drug tier	30 days	60 days	90 days
Tier 1Preferred Generic	$0.00	$0.00	$0.00
Tier 2Generic	$10.00	$20.00	$30.00
Tier 3Preferred Brand	18%	18%	18%
Tier 4Non-Preferred Drug	25%	25%	25%
Tier 5Specialty Tier	28%	Not listed	Not listed
Tier 6Select Care Drugs	$0.00	$0.00	$0.00

Standard mail order costs

On a small screen, scroll the table sideways to compare all fill lengths.

Standard mail order: initial-coverage cost per prescription fill
Drug tier	30 days	60 days	90 days
Tier 1Preferred Generic	$15.00	$30.00	$45.00
Tier 2Generic	$30.00	$60.00	$90.00
Tier 3Preferred Brand	18%	18%	18%
Tier 4Non-Preferred Drug	25%	25%	25%
Tier 5Specialty Tier	28%	Not listed	Not listed
Tier 6Select Care Drugs	$0.00	$0.00	$0.00

Long-term care pharmacy costs

Long-term care pharmacy: initial-coverage cost per prescription fill
Drug tier	31 days
Tier 1Preferred Generic	$0.00
Tier 2Generic	$10.00
Tier 3Preferred Brand	18%
Tier 4Non-Preferred Drug	25%
Tier 5Specialty Tier	28%
Tier 6Select Care Drugs	$0.00

Out-of-network pharmacy costs

Out-of-network pharmacy: initial-coverage cost per prescription fill
Drug tier	30 days
Tier 1Preferred Generic	$0.00
Tier 2Generic	$10.00
Tier 3Preferred Brand	18%
Tier 4Non-Preferred Drug	25%
Tier 5Specialty Tier	28%
Tier 6Select Care Drugs	$0.00

Drug coverage rules and exceptions

Tier 1: Preferred Generic

Drugs included in this tier: Part D Drugs Only
Longer fills available for every covered drug: Yes
Some longer-fill prescriptions require a one-month first fill: No

Tier 2: Generic

Drugs included in this tier: Part D Drugs Only
Longer fills available for every covered drug: Yes
Some longer-fill prescriptions require a one-month first fill: No

Tier 3: Preferred Brand

Drugs included in this tier: Part D Drugs Only
Longer fills available for every covered drug: Yes
Some longer-fill prescriptions require a one-month first fill: No

Tier 4: Non-Preferred Drug

Drugs included in this tier: Part D Drugs Only
Longer fills available for every covered drug: Yes
Some longer-fill prescriptions require a one-month first fill: No

Tier 5: Specialty Tier

Drugs included in this tier: Part D Drugs Only

Tier 6: Select Care Drugs

Drugs included in this tier: Part D Drugs Only
Longer fills available for every covered drug: Yes
Some longer-fill prescriptions require a one-month first fill: No

Initial-coverage prices also apply to drugs exempt from the deductible: Yes

Special cost protections apply to covered insulin and recommended adult vaccines.

Where this plan is offered

CMS lists this plan in 1 state or territory. Availability can vary by county and ZIP code.

View all locations 12 county listings across 1 state or territory