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Medica Advantage with SSM Value (HMO-POS)

Illinois Medicare Advantage Plan (2025 Plan)

Monthly Premium

Your Cost
$0
by Medica

Additional Coverage

HearingVisionDental

Overall Government Star Rating

(coming soon)

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Plan Overview

Plan Name
Medica Advantage with SSM Value (HMO-POS)
Insurance Carrier
Medica
Plan Type
Medicare Advantage Plan With Part D Prescription Drug Coverage
Network Type
HMO

Medica Advantage with SSM Value (HMO-POS) is a Medicare Advantage Plan With Part D Prescription Drug Coverage, which is available in Illinois and offered by the health insurance company Medica. This plan’s network type is HMO which determines in-network doctors who accept the health plan and whether a referral is needed.

Cost Summary

Monthly Premium
$0
Annual Deductible
$0
Max Out-of-Pocket
$4,000
Primary doctor visit
$0 copay
Specialist visit
$0-35 copay per visit
ER visit
$140 copay per visit (always covered)
Ambulance
$300 copay

Medica Advantage with SSM Value (HMO-POS) has a monthly premium cost of $0 per month, with an annual deductible of $0 and a maximum out of pocket cost sharing of $8,000 In and Out-of-network $4,000 In-network. The most common benefit costs which people evaluate when choosing a plan are costs for a primary doctor visit, specialist doctor visit, emergency room visit, and ambulance. These costs are listed in this summary section and a full list of benefit costs for Medica Advantage with SSM Value (HMO-POS) are defined below.

Additional Benefits and Coverage

Yes
Part D Prescription Drug Coverage
Yes
Dental
Yes
Vision
Yes
Hearing

Medica Advantage with SSM Value (HMO-POS) is a Medicare Advantage plan which does include Medicare Part D Prescription Drug coverage. Other common benefits included with Medicare Advantage plans are coverage for dental, vision, and hearing. Medica Advantage with SSM Value (HMO-POS) includes coverage for hearing, vision, dental.

Medicare Advantage health plans can offer even more additional benefits. Medica Advantage with SSM Value (HMO-POS) includes coverage for the following additional benefits:

Other benefits

Fitness benefit
Limited coverage
Over the counter drug benefits
Limited coverage
In-home support services
Not covered
Home and bathroom safety devices
Not covered
Meals for short duration
Limited coverage
Annual physical exams
Limited coverage
Telehealth
Limited coverage

Plan Benefits and Coverage Details

Monthly Premium
$0
Health Portion of Premium
$0
Drug Portion of Premium
$0
Health Plan Deductible
$0
Health Plan Max Out-of-Pocket
$8,000 In and Out-of-network
$4,000 In-network
Nationwide Coverage included
No
Hearing Coverage included
Yes
Vision Coverage included
Yes
Dental Coverage included
Yes
Doctor Lookup Link
http://central.medica.com/doctors
Plan Link
http://central.medica.com/medicare

Medical Benefits

Doctor Services

Primary doctor visit
In-network: $0 copay
Out-of-network: 50% coinsurance per visit
Specialist visit
In-network: $0-35 copay per visit
Out-of-network: 50% coinsurance per visit

Tests, labs, & imaging

Diagnostic tests & procedures
In-network: $10-20 copay
Out-of-network: 50% coinsurance
Lab services
In-network: $0-20 copay
Out-of-network: 50% coinsurance
Diagnostic radiology services (like MRI)
In-network: $0-200 copay
Out-of-network: 50% coinsurance
Outpatient x-rays
In-network: $20-25 copay
Out-of-network: 50% coinsurance
Emergency care
$140 copay per visit (always covered)
Urgent care
$0-40 copay per visit (always covered)

Hospital Services

Inpatient hospital coverage
In-network: $325 per day for days 1 through 7
$0 per day for days 8 through 90
Out-of-network: 50% per day for days 1 through 7
0% per day for days 8 through 90
Outpatient hospital coverage
In-network: $0-300 copay per visit
Out-of-network: 50% coinsurance per visit

Skilled nursing facility

Skilled nursing facility
In-network: $10 per day for days 1 through 20
$214 per day for days 21 through 100
Out-of-network: 50% per day for days 1 through 100

Preventive services

Preventive services
In-network: $0 copay
Out-of-network: 50% coinsurance

Ambulance

Ground ambulance
In-network: $300 copay
Out-of-network: $300 copay

Therapy services

Occupational therapy visit
In-network: $35 copay
Out-of-network: 50% coinsurance
Physical therapy & speech & language therapy visit
In-network: $40 copay
Out-of-network: 50% coinsurance

Mental health services

Outpatient group therapy with a psychiatrist
In-network: $25 copay
Out-of-network: 50% coinsurance
Outpatient individual therapy with a psychiatrist
In-network: $35 copay
Out-of-network: 50% coinsurance
Outpatient group therapy visit
In-network: $25 copay
Out-of-network: 50% coinsurance
Outpatient individual therapy visit
In-network: $35 copay
Out-of-network: 50% coinsurance

Opioid treatment services

Opioid treatment services
Covered

Other services

Durable medical equipment (like wheelchairs & oxygen)
In-network: 0-20% coinsurance per item
Out-of-network: 50% coinsurance per item
Prosthetics (like braces, artificial limbs)
In-network: 20% coinsurance per item
Out-of-network: 50% coinsurance per item
Diabetes supplies
In-network: $0 copay
Out-of-network: 50% coinsurance per item

Prescription Drug Benefits

Tier drug costs for: Standard retail pharmacy drug cost for 1-month

TiersInitial coverage phaseCatastrophic coverage phase
Preferred Generic$7.00 copay$0 copay
Generic$13.00 copay$0 copay
Preferred Brand25% coinsurance$0 copay
Non-Preferred Drug50% coinsurance$0 copay
Specialty Tier33% coinsurance$0 copay

Part B Drugs

Chemotherapy drugs
In-network: 0-20% coinsurance
Out-of-network: 50% coinsurance
Other Part B drugs
In-network: 0-20% coinsurance
Out-of-network: 50% coinsurance

Extra Benefits

Hearing

Hearing exam
In-network: $35 copay
Out-of-network: 50% coinsurance
Fitting/evaluation
In-network: $0 copay
Hearing aids - All types
In-network: $0 copay

Preventive Dental

Oral exam
In-network: $0 copay
Out-of-network: $0 copay
Cleaning
In-network: $0 copay
Out-of-network: $0 copay
Fluoride treatment
In-network: $0 copay
Out-of-network: $0 copay
Dental x-rays
In-network: $0 copay
Out-of-network: $0 copay

Comprehensive dental

Restorative services
In-network: 50% coinsurance
Out-of-network: 50% coinsurance
Endodontics
In-network: 50% coinsurance
Out-of-network: 50% coinsurance
Periodontics
In-network: 50% coinsurance
Out-of-network: 50% coinsurance
Prosthodontics, removable
In-network: 50% coinsurance
Out-of-network: 50% coinsurance
Prosthodontics, fixed
In-network: 50% coinsurance
Out-of-network: 50% coinsurance
Maxillofacial prosthetics
Not covered
Implant services
In-network: 50% coinsurance
Out-of-network: 50% coinsurance
Oral and maxillofacial surgery
In-network: 50% coinsurance
Out-of-network: 50% coinsurance
Orthodontics
Not covered
Adjunctive general services
In-network: 50% coinsurance
Out-of-network: 50% coinsurance

Vision

Routine eye exam
In-network: $0 copay
Contact lenses
In-network: $0 copay
Eyeglasses (frames & lenses)
In-network: $0 copay
Eyeglass frames (only)
In-network: $0 copay
Eyeglass lenses (only)
In-network: $0 copay
Upgrades
In-network: $0 copay

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