Medica Prime Solution Total (Cost)

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

• • In-Network: No

Comprehensive Dental

• Adjunctive General Services
  • In-Network: No Coins – No Co pay (Limits Apply)
• Endodontics
  • In-Network: No Coins – No Co pay (Limits Apply)
• Implant Services
  • In-Network: No Coins – No Co pay (Limits Apply)
• Maxillofacial Prosthetics
  • In-Network: No Coins – No Co pay (Limits Apply)
• Oral and Maxillofacial Surgery
  • In-Network: No Coins – No Co pay (Limits Apply)
• Orthodontics
  • In-Network: No Coins – No Co pay (Limits Apply)
• Periodontics
  • In-Network: No Coins – No Co pay (Limits Apply)
• Prosthodontics, fixed
  • In-Network: No Coins – No Co pay (Limits Apply)
• Prosthodontics, removable
  • In-Network: No Coins – No Co pay (Limits Apply)
• Restorative Services
  • In-Network: No Coins – No Co pay (Limits Apply)

Diagnostic and Preventive Dental

• Dental X-Rays
  • In-Network: No Coins – No Copay (Limits Apply)
• Fluoride Treatment
  • In-Network: No Coins – No Copay (Limits Apply)
• Oral Exams
  • In-Network: No Coins – No Copay (Limits Apply)
• Other Diagnostic Dental Services
  • In-Network: No Coins – No Copay (Limits Apply)
• Other Preventive Dental Services
  • In-Network: No Coins – No Copay (Limits Apply)
• Prophylaxis (cleaning)
  • In-Network: No Coins – No Copay (Limits Apply)

Diagnostic procedures/lab services/imaging

• Diagnostic radiology services (e.g., MRI)
  • $100 copay
• Diagnostic tests and procedures
  • $0-10 copay
• Lab services
  • $0 copay
• Outpatient x-rays
  • $25 copay

Doctor visits

• Specialist
  • $10 copay per visit
• Primary
  • $0 copay

Emergency care/Urgent care

• Emergency
  • $100 copay per visit (always covered)
• Urgent care
  • $0-10 copay per visit (always covered)

Foot care (podiatry services)

• Foot exams and treatment
  • $10 copay
• Routine foot care
  • Not covered

Ground ambulance

• • $75 copay

Health plan deductible

• • $0

Hearing

• Fitting/evaluation
  • $0 copay
• Hearing aids
  • $0 copay (Limits Apply)
• Hearing aids OTC
  • $0 copay
• Medicare-Covered Hearing Exam
  • $0-10 copay

Inpatient hospital coverage

• • $350 per day for days 1 through 4
    $0 per day for days 5 through 90

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

• • $3,000 In-network

Medical equipment/supplies

• Prosthetics (e.g., braces, artificial limbs)
  • 15% coinsurance per item
• Durable medical equipment (e.g., wheelchairs, oxygen)
  • 15% coinsurance per item
• Diabetes supplies
  • 0-20% coinsurance per item

Medicare Part B drugs

• Chemotherapy
  • 0-20% coinsurance
• Other Part B drugs
  • 0-20% coinsurance

Mental health services

• Outpatient group therapy visit
  • $0 copay
• Outpatient individual therapy visit with a psychiatrist
  • $10 copay
• Outpatient group therapy visit with a psychiatrist
  • $10 copay
• Inpatient hospital – psychiatric
  • $350 per day for days 1 through 4
    $0 per day for days 5 through 90
• Outpatient individual therapy visit
  • $0 copay

Optional supplemental benefits

• • Yes

Other health plan deductibles?

• • In-Network: No

Outpatient hospital coverage

• • $300 copay per visit

Preventive care

• • $0 copay

Rehabilitation services

• Physical therapy and speech and language therapy visit
  • $10 copay
• Occupational therapy visit
  • $10 copay

Skilled Nursing Facility

• • $0 per day for days 1 through 20
    $214 per day for days 21 through 100

Transportation

• • Not covered

Vision

• Eyeglass frames
  • Not covered
• Eyeglass lenses
  • Not covered
• Eyeglasses (frames and lenses)
  • Not covered
• Other
  • $0 copay (Limits Apply)
• Upgrades
  • Not covered
• Contact lenses
  • Not covered
• Routine eye exam
  • $0 copay (Limits Apply)

Wellness programs (e.g., fitness, nursing hotline)

• • Covered

WI Rider Includes: $0 for Medicare-covered skilled nursing facility days plus 30 days of skilled nursing care not covered by Medicare per Medicare benefit period. Up to 365 home care visits per year. This is a combined benefit of Medicare and non-Medicare-covered services. The Rider picks up visits and services not covered by Medicare.

Other Benefit Services

• Other 1
  • Monthly Premium: $39.00

Skilled Nursing Facility (SNF)

• 2-Additional Days beyond Medicare-covered for Skilled Nursing Facility (SNF)
  • Monthly Premium: $39.00