2027 Medicare Cost plan

Medica Prime Solution Core (Cost): 2027 benefits and costs

Medica Cost

CMS plan ID: H2450-034-0 · Plan year: 2027

Medica Prime Solution Core (Cost) is a 2027 Medicare Cost plan offered by Medica. It is listed in North Dakota, South Dakota.

2027 plan costs at a glance

Monthly plan premium$103.00
In-network medical out-of-pocket maximum$4,900.00
Organization
Medica
Plan organization
MEDICA INSURANCE COMPANY
Parent company
Medica Holding Company
Plan type
Cost
Part C premium
$103.00
Prescription drug coverage
No
2027 CMS Star Rating
Standard monthly Medicare Part B premium
$209.50 (estimated)

You must continue to pay your Medicare Part B premium.

In-network medical deductible
None
In-network medical maximum
$4,900.00

Applies to certain in-network supplemental services.

2027 benefit summary

Doctor visits and medical care

Common medical services and member costs
ServiceIn-networkWhat to know
Primary care doctor

$0

Service-specific deductible
No
Specialist visit

$15.00 copay

Service-specific deductible
No
Approval required
No
Referral required
No
Emergency care

$130.00 copay

Urgent care

$20.00 copay

Home health

$0

Service-specific deductible
No
Approval required
No
Referral required
No
Dialysis

20% coinsurance

Service-specific deductible
No
Approval required
No
Referral required
No
Part B chemotherapy and radiation drugs

0% to 20% coinsurance

Deductible applies
No
Approval required
No
Other Part B drugs

0% to 20% coinsurance

Deductible applies
No
Approval required
No
Kidney disease education services

$0

Service-specific deductible
No
Approval required
No
Referral required
No
Medicare-covered chiropractic

$15.00 copay

Service-specific deductible
No
Approval required
No
Referral required
No
Medicare-covered foot care

$15.00 copay

Service-specific deductible
No
Approval required
No
Referral required
No
Other health professionals

$0.00 to $15.00 copay

Service-specific deductible
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.
CareYour share of the costWhat to know
Inpatient hospital stay

$0.00 copay per stay

Days 1–5: $200.00 copay per day

Days 6–90: $0.00 copay per day

Approval required
No
Referral required
No
Benefit period
Original Medicare
Inpatient mental health care

$0.00 copay per stay

Days 1–5: $200.00 copay per day

Days 6–90: $0.00 copay per day

Approval required
No
Referral required
No
Benefit period
Original Medicare
Skilled nursing facility

Days 1–20: $0.00 copay per day

Days 21–100: $100.00 copay per day

Approval required
No
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
ServiceIn-networkWhat to know
Outpatient hospital care

$0.00 to $300.00 copay

Service-specific deductible
No
Hospital observation services

$300.00 copay

Service-specific deductible
No
Ambulatory surgical center

$0.00 to $200.00 copay

Service-specific deductible
No
Approval required
No
Referral required
No
Outpatient blood

$0

Service-specific deductible
No
Approval required
No
Referral required
No

Tests, imaging and laboratory services

Tests, imaging and laboratory services and member costs
ServiceIn-networkWhat to know
Diagnostic procedures and tests

$0.00 to $15.00 copay

Service-specific deductible
No
Approval required
No
Referral required
No
Laboratory services

$0

Service-specific deductible
No
Approval required
No
Referral required
No
Diagnostic radiology (CT, MRI)

$125.00 copay

Service-specific deductible
No
Approval required
No
Referral required
No
Therapeutic radiology

$30.00 copay

Service-specific deductible
No
Approval required
No
Referral required
No
X-rays

$10.00 copay

Service-specific deductible
No
Approval required
No
Referral required
No

Mental health and substance use treatment

Mental health and substance use treatment and member costs
ServiceIn-networkWhat to know
Partial hospitalization

$20.00 copay

Service-specific deductible
No
Approval required
No
Referral required
No
Intensive outpatient program

$20.00 copay

Service-specific deductible
No
Approval required
No
Referral required
No
Substance use treatment, individual sessions

$15.00 copay

Service-specific deductible
No
Approval required
No
Referral required
No
Substance use treatment, group sessions

$15.00 copay

Service-specific deductible
No
Approval required
No
Referral required
No
Opioid treatment program

$15.00 copay

Service-specific deductible
No
Approval required
No
Referral required
No
Mental health, individual sessions

$0

Service-specific deductible
No
Approval required
No
Referral required
No
Mental health, group sessions

$0

Service-specific deductible
No
Approval required
No
Referral required
No
Psychiatry, individual sessions

$15.00 copay

Service-specific deductible
No
Approval required
No
Referral required
No
Psychiatry, group sessions

$15.00 copay

Service-specific deductible
No
Approval required
No
Referral required
No

Therapy and rehabilitation

Therapy and rehabilitation and member costs
ServiceIn-networkWhat to know
Occupational therapy

$15.00 copay

Service-specific deductible
No
Approval required
No
Referral required
No
Physical and speech therapy

$15.00 copay

Service-specific deductible
No
Approval required
No
Referral required
No
Cardiac rehabilitation

$15.00 copay

Service-specific deductible
No
Approval required
No
Referral required
No
Intensive cardiac rehabilitation

$15.00 copay

Service-specific deductible
No
Approval required
No
Referral required
No
Pulmonary rehabilitation

$15.00 copay

Service-specific deductible
No
Approval required
No
Referral required
No
Supervised exercise for peripheral artery disease

$10.00 copay

Service-specific deductible
No
Approval required
No
Referral required
No

Ambulance, medical equipment and supplies

Ambulance, medical equipment and supplies and member costs
ServiceIn-networkWhat to know
Ground ambulance

$200.00 copay

Service-specific deductible
No
Approval required
No
Air ambulance

20% coinsurance

Service-specific deductible
No
Approval required
No
Durable medical equipment

20% coinsurance

Service-specific deductible
No
Approval required
No
Prosthetic devices

20% coinsurance

Service-specific deductible
No
Approval required
No
Medical supplies

0% to 20% coinsurance

Service-specific deductible
No
Approval required
No
Diabetic supplies

$0

Service-specific deductible
No
Approval required
No
Diabetic shoes and inserts

20% coinsurance

Service-specific deductible
No
Approval required
No
Diabetic monitors

0% to 20% coinsurance

Service-specific deductible
No
Approval required
No

Dental benefits

Dental benefits and member costs
ServiceIn-networkWhat to know
Medicare-covered dental

$0.00 to $15.00 copay

Oral examsAdditional plan benefit

$0

Dental X-raysAdditional plan benefit

$0

Dental cleaningAdditional plan benefit

$0

Other preventive dentalAdditional plan benefit

$0

Vision benefits

Vision benefits and member costs
ServiceIn-networkWhat to know
Medicare-covered eye exams

$0.00 to $15.00 copay

Service-specific deductible
No
Approval required
No
Referral required
No
Routine eye examsAdditional plan benefit

$0

Approval required
No
Referral required
No
Medicare-covered eyewear

$30.00 copay

Service-specific deductible
No
Approval required
No
Referral required
No
Contact lensesAdditional plan benefit

$0

Approval required
No
Referral required
No
Eyeglasses, lenses and framesAdditional plan benefit

$0

Approval required
No
Referral required
No
Eyeglass lensesAdditional plan benefit

$0

Approval required
No
Referral required
No
Eyeglass framesAdditional plan benefit

$0

Approval required
No
Referral required
No

Hearing benefits

Hearing benefits and member costs
ServiceIn-networkWhat to know
Medicare-covered hearing exams

$0.00 to $15.00 copay

Service-specific deductible
No
Approval required
No
Referral required
No
Routine hearing examsAdditional plan benefit

$0

Approval required
No
Referral required
No
Hearing aid fitting and evaluationAdditional plan benefit

$0

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
Approval required
No
Referral required
No
Over-the-counter hearing aidsAdditional plan benefit

$999.00 copay

Service-specific deductible
No
Approval required
No
Referral required
No

Extra benefits

Extra benefits and member costs
ServiceIn-networkWhat to know
Over-the-counter health itemsAdditional plan benefit

$0

Service-specific deductible
No
Annual physical examAdditional plan benefit

$0

Service-specific deductible
No
Approval required
No
Referral required
No
Fitness benefitAdditional plan benefit

$0

Service-specific deductible
No
Approval required
No
Referral required
No

Prescription drug coverage

This plan does not include a Part D prescription drug benefit.

Where this plan is offered

CMS lists this plan in 2 states or territories. Availability can vary by county and ZIP code.

View all locations 88 county listings across 2 states or territories

North Dakota

South Dakota