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Medica Advantage Solution H8889-004 (PPO)

H8889 - 004 - 0
3.5 out of 5 stars (3.5 / 5)

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Medica Advantage Solution H8889-004 (PPO) is a Medicare Advantage Plan by Medica.

This page features plan details for 2025 Medica Advantage Solution H8889-004 (PPO) H8889 – 004 – 0 available in Southern Minnesota.

Locations

Medica Advantage Solution H8889-004 (PPO) is offered in the following locations.

Big Stone County, Minnesota
Blue Earth County, Minnesota
Brown County, Minnesota

Click to see more locations

Plan Overview

Medica Advantage Solution H8889-004 (PPO) offers the following coverage and cost-sharing.

Insurer:Medica
Health Plan Deductible:$0
MOOP:$4,900 In and Out-of-network
$4,900 In-network
Drugs Covered:Yes

Ready to sign up for Medica Advantage Solution H8889-004 (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Premium Breakdown

Medica Advantage Solution H8889-004 (PPO) has a monthly premium of $149.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.
Part B Part C Part D Part B Give Back Total
$185.00 $135.60 $13.40 $ $
Please Note:
  • Your Part B premium may differ based on factors including late enrollment, income, and disability status.
  • You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.

Drug Info

Medica Advantage Solution H8889-004 (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible: $395.00
Drug Out-Of-Pocket maximum: $2,000.00
Drug Benefit Type: Enhanced Alternative

Part D Premium Reduction

The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.

The table below shows how the LIS impacts the Part D premium of this plan.

Part DLIS Full
$13.40$13.40

Initial Coverage Phase

After you pay your $395.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $2,000.00. Once you reach that amount, you will enter the next coverage phase.

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.

Additional Benefits

Medica Advantage Solution H8889-004 (PPO) also provides the following benefits.

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)
    • Out-of-Network: No Coins – No Copay (Limits Apply)
  • Endodontics
    • In-Network: No Coins – No Co pay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)
  • Implant Services
    • In-Network: No Coins – No Co pay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)
  • Maxillofacial Prosthetics
    • Out-of-Network: No Coins – No Copay (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)
    • Out-of-Network: No Coins – No Copay (Limits Apply)
  • Periodontics
    • In-Network: No Coins – No Co pay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)
  • Prosthodontics, fixed
    • In-Network: No Coins – No Co pay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)
  • Prosthodontics, removable
    • In-Network: No Coins – No Co pay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)
  • Restorative Services
    • In-Network: No Coins – No Co pay (Limits Apply)
    • Out-of-Network: No Coins – No Copay (Limits Apply)

Diagnostic and Preventive Dental

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

Diagnostic procedures/lab services/imaging

  • Lab services
    • In-Network: $0 copay (Authorization Required)
    • Out-of-Network: $0 copay (Authorization Required)
  • Diagnostic tests and procedures
    • In-Network: $0-85 copay (Authorization Required)
    • Out-of-Network: $0-85 copay (Authorization Required)
  • Diagnostic radiology services (e.g., MRI)
    • In-Network: $0-85 copay (Authorization Required)
    • Out-of-Network: $0-85 copay (Authorization Required)
  • Outpatient x-rays
    • In-Network: $20 copay (Authorization Required)
    • Out-of-Network: $20 copay (Authorization Required)

Doctor visits

  • Primary
    • In-Network: $0 copay
  • Specialist
    • In-Network: $40 copay per visit
  • Primary
    • Out-of-Network: $20 copay per visit
  • Specialist
    • Out-of-Network: $50 copay per visit

Emergency care/Urgent care

  • Emergency
    • $125 copay per visit (always covered)
  • Urgent care
    • $0-45 copay per visit (always covered)

Foot care (podiatry services)

  • Foot exams and treatment
    • In-Network: $40 copay
    • Out-of-Network: $50 copay
  • Routine foot care
    • Not covered

Ground ambulance

    • Out-of-Network: $325 copay
    • In-Network: $325 copay

Health plan deductible

    • $0

Hearing

  • Fitting/evaluation
    • Out-of-Network: $0 copay (Limits Apply)
  • Hearing aids
    • In-Network: $549-1,299 copay
  • Fitting/evaluation
    • In-Network: $0 copay (Limits Apply)
  • Hearing aids
    • Out-of-Network: $549-1,299 copay
  • Hearing aids OTC
    • Not covered
  • Medicare-Covered Hearing Exam
    • Out-of-Network: $20-40 copay
    • In-Network: $0-25 copay

Inpatient hospital coverage

    • In-Network: $325 per stay (Authorization Required)
    • Out-of-Network: $400 per stay (Authorization Required)

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

    • $4,900 In and Out-of-network
      $4,900 In-network

Medical equipment/supplies

  • Diabetes supplies
    • In-Network: 0-20% coinsurance per item
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • In-Network: 20% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • In-Network: 20% coinsurance per item (Authorization Required)
  • Diabetes supplies
    • Out-of-Network: 0-20% coinsurance per item
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • Out-of-Network: 30% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • Out-of-Network: 30% coinsurance per item (Authorization Required)

Medicare Part B drugs

  • Chemotherapy
    • In-Network: 0-20% coinsurance (Authorization Required)
    • Out-of-Network: 0-30% coinsurance (Authorization Required)
  • Other Part B drugs
    • In-Network: 0-20% coinsurance (Authorization Required)
    • Out-of-Network: 0-30% coinsurance (Authorization Required)

Mental health services

  • Outpatient individual therapy visit
    • Out-of-Network: $50 copay
  • Inpatient hospital – psychiatric
    • In-Network: $325 per stay (Authorization Required)
  • Outpatient group therapy visit
    • Out-of-Network: $50 copay
  • Outpatient individual therapy visit with a psychiatrist
    • In-Network: $40 copay
    • Out-of-Network: $50 copay
  • Inpatient hospital – psychiatric
    • Out-of-Network: $400 per stay (Authorization Required)
  • Outpatient group therapy visit
    • In-Network: $30 copay
  • Outpatient group therapy visit with a psychiatrist
    • In-Network: $30 copay
    • Out-of-Network: $50 copay
  • Outpatient individual therapy visit
    • In-Network: $40 copay

Optional supplemental benefits

    • No

Other health plan deductibles?

    • In-Network: No

Outpatient hospital coverage

    • Out-of-Network: $0-445 copay per visit (Authorization Required)
    • In-Network: $0-395 copay per visit (Authorization Required)

Preventive care

    • In-Network: $0 copay
    • Out-of-Network: $0 copay

Rehabilitation services

  • Physical therapy and speech and language therapy visit
    • In-Network: $40 copay
  • Occupational therapy visit
    • In-Network: $45 copay
    • Out-of-Network: $50 copay
  • Physical therapy and speech and language therapy visit
    • Out-of-Network: $50 copay

Skilled Nursing Facility

    • In-Network: $0 per day for days 1 through 20
      $214 per day for days 21 through 43
      $0 per day for days 44 through 100 (Authorization Required)
    • Out-of-Network: $100 per day for days 1 through 20
      $214 per day for days 21 through 43
      $0 per day for days 44 through 100 (Authorization Required)

Transportation

    • Not covered

Vision

  • Eyeglasses (frames and lenses)
    • In-Network: $0 copay (Limits Apply)
    • Out-of-Network: $0 copay (Limits Apply)
  • Upgrades
    • In-Network: $0 copay (Limits Apply)
  • Routine eye exam
    • Out-of-Network: $0 copay (Limits Apply)
  • Contact lenses
    • In-Network: $0 copay (Limits Apply)
  • Eyeglass frames
    • In-Network: $0 copay (Limits Apply)
  • Eyeglass lenses
    • In-Network: $0 copay (Limits Apply)
    • Out-of-Network: $0 copay (Limits Apply)
  • Other
    • In-Network: $0 copay (Limits Apply)
    • Out-of-Network: $0 copay (Limits Apply)
  • Routine eye exam
    • In-Network: $0 copay (Limits Apply)
  • Upgrades
    • Out-of-Network: $0 copay (Limits Apply)
  • Contact lenses
    • Out-of-Network: $0 copay (Limits Apply)
  • Eyeglass frames
    • Out-of-Network: $0 copay (Limits Apply)

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

    • Covered

Ready to sign up for Medica Advantage Solution H8889-004 (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Need more information on Medica Advantage Solution H8889-004 (PPO)? See 2025 Medica Advantage Solution H8889-004 (PPO) at MedicareAdvantageRX.com.

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Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Anthem Blue Cross, Aspire Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, GlobalHealth, Health Care Service Corporation, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Baylor Scott & White Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint

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