Medica Prime Solution Standard (Cost)
H2450 - 050 - 0
(4 / 5)
Medica Prime Solution Standard (Cost) is a Medicare Advantage (Part C) Plan by Medica.
This page features plan details for 2024 Medica Prime Solution Standard (Cost) H2450 – 050 – 0 available in Select counties in WI.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Locations
Medica Prime Solution Standard (Cost) is offered in the following locations.
Plan Overview
Medica Prime Solution Standard (Cost) offers the following coverage and cost-sharing.
| Insurer: | Medica |
| Health Plan Deductible: | $0.00 |
| MOOP: | $5,000 In-network |
| Drugs Covered: | No |
Ready to sign up for Medica Prime Solution Standard (Cost) ?
Premium Breakdown
Medica Prime Solution Standard (Cost) has a monthly premium of $10.00. This amount includes your Part C premium but does not include your Part B premium.| Part B | Part C | Part B Give Back | Total |
|---|---|---|---|
| $174.70 | $10.00 | $0.00 | $184.70 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
Additional Benefits
Medica Prime Solution Standard (Cost) also provides the following benefits.
| $0 |
| In-network | No |
| $5,000 In-network |
| No |
| In-network | No |
| $325 copay per visit (Authorization is not required.) (Referral is not required.) |
| Primary | $15 copay per visit (Not applicable.) (Not applicable.) |
| Specialist | $50 copay per visit (Authorization is not required.) (Referral is not required.) |
| $0 copay (Authorization is not required.) (Referral is not required.) |
| Emergency | $120 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $15-50 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Diagnostic tests and procedures | $15-50 copay (Authorization is not required.) (Referral is not required.) |
| Lab services | $0 copay (Authorization is not required.) (Referral is not required.) |
| Diagnostic radiology services (e.g., MRI) | $50-150 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient x-rays | $15-50 copay (Authorization is not required.) (Referral is not required.) |
| Hearing exam | $50 copay (Authorization is not required.) (Referral is not required.) |
| Fitting/evaluation | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Hearing aids – inner ear | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Hearing aids – outer ear | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Hearing aids – over the ear | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Cleaning | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Fluoride treatment | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Non-routine services | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Diagnostic services | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Restorative services | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Endodontics | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Periodontics | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Extractions | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Prosthodontics, other oral/maxillofacial surgery, other services | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Routine eye exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Other | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Contact lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglass frames | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglass lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Upgrades | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Occupational therapy visit | $45 copay (Authorization is not required.) (Referral is not required.) |
| Physical therapy and speech and language therapy visit | $50 copay (Authorization is not required.) (Referral is not required.) |
| $250 copay (Not applicable.) (Not applicable.) |
| Not covered (Not applicable.) (Not applicable.) |
| Foot exams and treatment | $50 copay (Authorization is not required.) (Referral is not required.) |
| Routine foot care | Not covered (Not applicable.) (Not applicable.) |
| Durable medical equipment (e.g., wheelchairs, oxygen) | 20% coinsurance per item (Authorization is not required.) (Not applicable.) |
| Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is not required.) (Not applicable.) |
| Diabetes supplies | $25 copay per item (Authorization is not required.) (Not applicable.) |
| Covered (Authorization is not required.) (Referral is not required.) |
| Chemotherapy | 0-20% coinsurance (Authorization is not required.) (Not applicable.) |
| Other Part B drugs | 0-20% coinsurance (Authorization is not required.) (Not applicable.) |
| Part B Insulin drugs | $35 copay (Authorization is not required.) (Not applicable.) |
| $325 per day for days 1 through 4 $0 per day for days 5 through 90 (Authorization is not required.) (Referral is not required.) |
| Inpatient hospital – psychiatric | $325 per day for days 1 through 4 $0 per day for days 5 through 90 (Authorization is not required.) (Referral is not required.) |
| Outpatient group therapy visit with a psychiatrist | $50 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient individual therapy visit with a psychiatrist | $50 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient group therapy visit | $30 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient individual therapy visit | $30 copay (Authorization is not required.) (Referral is not required.) |
| Coming soon (Authorization is not required.) (Referral is not required.) |
Ready to sign up for Medica Prime Solution Standard (Cost) ?
Table of Contents
SMID: MULTIPLAN_HCIHNDOGMED01_M
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