Medica Advantage Value (PPO)

South Dakota Medicare Advantage Plan (2025 Plan)


Monthly Premium

Your Cost
$0
by Medica

Additional Coverage

HearingVisionDental

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Plan Name
Medica Advantage Value (PPO)
Insurance Carrier
Medica
Plan Type
Medicare Advantage Plan With Part D Prescription Drug Coverage
Network Type
PPO

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

Monthly Premium
$0
Annual Deductible
$0
Max Out-of-Pocket
$3,900
Primary doctor visit
$0 copay
Specialist visit
$45 copay per visit
ER visit
$125 copay per visit (always covered)
Ambulance
$295 copay

Medica Advantage Value (PPO) has a monthly premium cost of $0 per month, with an annual deductible of $0 and a maximum out of pocket cost sharing of $3,900 In and Out-of-network $3,900 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 Value (PPO) are defined below.

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

Medica Advantage Value (PPO) 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 Value (PPO) includes coverage for hearing, vision, dental.

Medicare Advantage health plans can offer even more additional benefits. Medica Advantage Value (PPO) 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
Not covered
Annual physical exams
Limited coverage
Telehealth
Limited coverage

Monthly Premium
$0
Health Portion of Premium
$0
Drug Portion of Premium
$0
Health Plan Deductible
$0
Health Plan Max Out-of-Pocket
$3,900 In and Out-of-network
$3,900 In-network
Nationwide Coverage included
No
Hearing Coverage included
Yes
Vision Coverage included
Yes
Dental Coverage included
Yes
Doctor Lookup Link

Doctor Services

Primary doctor visit
In-network: $0 copay
Out-of-network: $25 copay per visit
Specialist visit
In-network: $45 copay per visit
Out-of-network: $55 copay per visit

Tests, labs, & imaging

Diagnostic tests & procedures
In-network: $0-125 copay
Out-of-network: $0-125 copay
Lab services
In-network: $0 copay
Out-of-network: $0 copay
Diagnostic radiology services (like MRI)
In-network: $0-125 copay
Out-of-network: $0-125 copay
Outpatient x-rays
In-network: $20 copay
Out-of-network: $20 copay
Emergency care
$125 copay per visit (always covered)
Urgent care
$0-50 copay per visit (always covered)

Hospital Services

Inpatient hospital coverage
In-network: $350 per day for days 1 through 5
$0 per day for days 6 through 90
Out-of-network: $500 per day for days 1 through 5
$0 per day for days 6 through 90
Outpatient hospital coverage
In-network: $0-495 copay per visit
Out-of-network: $0-545 copay per visit

Skilled nursing facility

Skilled nursing facility
In-network: $0 per day for days 1 through 20
$214 per day for days 21 through 38
$0 per day for days 39 through 100
Out-of-network: $100 per day for days 1 through 20
$214 per day for days 21 through 38
$0 per day for days 39 through 100

Preventive services

Preventive services
In-network: $0 copay
Out-of-network: $0 copay

Ambulance

Ground ambulance
In-network: $295 copay
Out-of-network: $295 copay

Therapy services

Occupational therapy visit
In-network: $45 copay
Out-of-network: $55 copay
Physical therapy & speech & language therapy visit
In-network: $45 copay
Out-of-network: $55 copay

Mental health services

Outpatient group therapy with a psychiatrist
In-network: $35 copay
Out-of-network: $55 copay
Outpatient individual therapy with a psychiatrist
In-network: $45 copay
Out-of-network: $55 copay
Outpatient group therapy visit
In-network: $35 copay
Out-of-network: $55 copay
Outpatient individual therapy visit
In-network: $45 copay
Out-of-network: $55 copay

Opioid treatment services

Opioid treatment services
Covered

Other services

Durable medical equipment (like wheelchairs & oxygen)
In-network: 20% coinsurance per item
Out-of-network: 30% coinsurance per item
Prosthetics (like braces, artificial limbs)
In-network: 20% coinsurance per item
Out-of-network: 30% coinsurance per item
Diabetes supplies
In-network: 0-20% coinsurance per item
Out-of-network: 0-20% coinsurance per item

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

TiersInitial coverage phaseCatastrophic coverage phase
Preferred Generic$0.00 copay$0 copay
Generic$15.00 copay$0 copay
Preferred Brand18% coinsurance$0 copay
Non-Preferred Drug50% coinsurance$0 copay
Specialty Tier27% coinsurance$0 copay

Part B Drugs

Chemotherapy drugs
In-network: 0-20% coinsurance
Out-of-network: 0-30% coinsurance
Other Part B drugs
In-network: 0-20% coinsurance
Out-of-network: 0-30% coinsurance

Hearing

Hearing exam
In-network: $0-35 copay
Out-of-network: $25-40 copay
Fitting/evaluation
In-network: $0 copay
Out-of-network: $0 copay
Hearing aids - All types
In-network: $549-1,299 copay
Out-of-network: $549-1,299 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: $0 copay
Out-of-network: $0 copay
Endodontics
In-network: $0 copay
Out-of-network: $0 copay
Periodontics
In-network: $0 copay
Out-of-network: $0 copay
Prosthodontics, removable
In-network: $0 copay
Out-of-network: $0 copay
Prosthodontics, fixed
In-network: $0 copay
Out-of-network: $0 copay
Maxillofacial prosthetics
In-network: $0 copay
Out-of-network: $0 copay
Implant services
In-network: $0 copay
Out-of-network: $0 copay
Oral and maxillofacial surgery
In-network: $0 copay
Out-of-network: $0 copay
Orthodontics
Not covered
Adjunctive general services
In-network: $0 copay
Out-of-network: $0 copay

Vision

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

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