Medica Prime Solution® Value w/Rx and Medica Prime Solution® Value w/Rx 2 (COST)
H2450-022, H2450-023
Summary of Benefits
January 1, 2017 - December 31, 2017
This booklet gives you a summary of what we cover and what you pay. It doesn't list every service that
we cover or list every limitation or exclusion. To get a complete list of services we cover, call us and ask
for the "Evidence of Coverage."
You have choices about how to get your Medicare benefits
One choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare).
Original Medicare is run directly by the Federal government.
Another choice is to get your Medicare benefits by joining a Cost plan (such as Medica Prime Solution
Value (Cost)).
Tips for comparing your Medicare choices
This Summary of Benefits booklet gives you a summary of what Medica Prime Solution Value (Cost)
covers and what you pay. If you want to compare our plan with other Medicare health plans, ask the other
plans for their Summary of Benefits booklets. Or, use the Medicare Plan Finder on
http://www.medicare.gov.
If you want to know more about the coverage and costs of Original Medicare, look in your current
"Medicare & You" handbook. View it online at http://www.medicare.gov or get a copy by calling
1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call
1-877-486-2048.
Sections in this booklet
• Things to Know About Medica Prime Solution Value (Cost)
• Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services
• Covered Medical and Hospital Benefits
• Prescription Drug Benefits
• Optional Benefits (you must pay an extra premium for these benefits)
This document is available in other formats such as Braille and large print.
This document may be available in a non-English language. For additional information, call us toll-free at (800) 906-5432; (TTY/TDD 711).
Y0088_4438 CMS Accepted WI PRI-SB17-100-005
CHA52073-701016A
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2
Things to Know About Medica Prime Solution Value (Cost)
Hours of Operation
• From October 1 to February 14, you can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Central time.
• From February 15 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m.
Central time.
Medica Prime Solution Value (Cost) Phone Numbers and Website
• If you are a member of this plan, call toll-free (800) 234-8755; (TTY/TDD 711).
• If you are not a member of this plan, call toll-free (800) 906-5432; (TTY/TDD 711).
• Our website: medica.com/Medicare
Who can join?
To join Medica Prime Solution Value (Cost), you must be enrolled in Medicare Part B (or have both Medicare Part A and Medicare Part B), and live in our service area.
Our service area includes the following counties in:
Minnesota: All counties;
North Dakota: Adams, Barnes, Benson, Billings, Bowman, Burleigh, Cass, Cavalier, Dickey, Dunn, Eddy, Emmons, Foster, Grand Forks, Grant, Griggs, Hettinger, Kidder, LaMoure, Logan, McHenry, McIntosh, McLean, Mercer, Morton, Nelson, Oliver, Pembina, Pierce, Ramsey, Ransom, Richland, Rolette, Sargent, Sheridan, Sioux, Slope, Stark, Steele, Stutsman, Towner , Traill, Walsh, Ward, Wells, and Williams; South Dakota: Aurora, Beadle, Bennett, Bon Homme, Brookings, Brown, Brule, Buffalo, Butte, Campbell, Charles Mix, Clark, Clay, Codington, Corson, Custer, Davison, Day, Deuel, Dewey, Douglas, Edmunds, Fall River, Faulk, Grant, Gregory, Haakon, Hamlin, Hand, Hanson, Harding, Hughes, Hutchinson, Jackson, Jerauld, Jones, Kingsbury, Lake, Lawrence, Lincoln, Lyman, Marshall, McCook, McPherson, Meade, Mellette, Miner, Minnehaha, Moody, Oglala Lakota, Pennington, Perkins, Potter, Roberts, Sanborn, Spink, Stanley, Sully, Todd, Tripp, Turner, Union, Walworth, Yankton, and Ziebach; Wisconsin: Ashland, Barron, Bayfield, Burnett, Chippewa, Douglas, Dunn, Eau Claire, Pierce, Polk, Sawyer, St. Croix, and Washburn.
Which doctors, hospitals, and pharmacies can I use?
Medica Prime Solution Value (Cost) has a network of doctors, hospitals, pharmacies, and other
providers. If you use the providers in our network, you may pay less for your covered services. But if you
want to, you can also use providers that are not in our network.
You must generally use network pharmacies to fill your prescriptions for covered Part D drugs.
You may search for network providers and pharmacies on our website at medica.com/members.
Or, call us and we will send you a copy of the provider and pharmacy directories.
3
What do we cover?
Our plan members get all of the benefits covered by Original Medicare. For some of these benefits, you
may pay more in our plan than you would in Original Medicare. For others, you may pay less.
We cover Part D drugs. In addition, we cover Part B drugs such as chemotherapy and some drugs
administered by your provider.
You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our
website, medica.com/Members.
Or, call us and we will send you a copy of the formulary.
How will I determine my drug costs?
Our plan groups each medication into one of five "tiers." You will need to use your formulary to locate
what tier your drug is on to determine how much it will cost you. The amount you pay depends on the
drug's tier and what stage of the benefit you have reached. Later in this document we discuss the benefit
stages that occur after you meet your deductible: Initial Coverage, Coverage Gap, and Catastrophic
Coverage.
4
SUMMARY OF BENEFITS
January 1, 2017 - December 31, 2017
Medica Prime Solution Value
w/Rx (Cost)
Medica Prime Solution Value
w/Rx 2 (Cost)
MONTHLY PREMIUM, DEDUCTIBLE, AND LIMITS ON HOW MUCH YOU PAY FOR COVERED SERVICES
How much is the monthly
premium?
$85.00 per month. In addition,
you must keep paying your
Medicare Part B premium.
$113.20 per month. In addition,
you must keep paying your
Medicare Part B premium.
How much is the deductible?
$315 per year for Part D
prescription drugs.
This plan does not have a
deductible.
Is there any limit on how much I Yes. Our plan protects you by
will pay for my covered services? having yearly limits on your outof-pocket costs for medical and
hospital care.
Yes. Our plan protects you by
having yearly limits on your outof-pocket costs for medical and
hospital care.
Your yearly limit(s) in this plan:
Your yearly limit(s) in this plan:
$4,000 for services you receive
from in-network providers.
$4,000 for services you receive
from in-network providers.
If you reach the limit on out-of­
pocket costs, you keep getting
covered hospital and medical
services and we will pay the full
cost for the rest of the year.
If you reach the limit on out-of­
pocket costs, you keep getting
covered hospital and medical
services and we will pay the full
cost for the rest of the year.
Please note that you will still need
to pay your monthly premiums
and cost-sharing for your Part D
prescription drugs.
Please note that you will still need
to pay your monthly premiums
and cost-sharing for your Part D
prescription drugs.
No. There are no limits on how
much our plan will pay.
No. There are no limits on how
much our plan will pay.
Is there a limit on how much the
plan will pay?
5
Medica Prime Solution Value
w/Rx (Cost)
Medica Prime Solution Value
w/Rx 2 (Cost)
COVERED MEDICAL AND HOSPITAL BENEFITS
OUTPATIENT CARE AND SERVICES
Acupuncture
Not covered
Not covered
Ambulance
$50 copay
$50 copay
Chiropractic Care
Manipulation of the spine to
correct a subluxation (when 1 or
more of the bones of your spine
move out of position): $20 copay
Manipulation of the spine to
correct a subluxation (when 1 or
more of the bones of your spine
move out of position): $20 copay
Dental Services
Limited dental services (this does
not include services in connection
with care, treatment, filling,
removal, or replacement of
teeth): 20% of the cost
Limited dental services (this does
not include services in connection
with care, treatment, filling,
removal, or replacement of
teeth): 20% of the cost
Diabetes Supplies and Services
Diabetes monitoring
supplies: 20% of the cost
Diabetes monitoring
supplies: 20% of the cost
Diabetes self-management
training: You pay nothing
Diabetes self-management
training: You pay nothing
Therapeutic shoes or inserts:
20% of the cost
Therapeutic shoes or inserts:
20% of the cost
Diagnostic Tests, Lab and
Diagnostic radiology services
Radiology Services, and X-Rays (such as MRIs, CT scans):
(Costs for these services may vary 10% of the cost
based on place of service)
Diagnostic tests and procedures:
10% of the cost
Diagnostic radiology services
(such as MRIs, CT scans):
10% of the cost
Diagnostic tests and procedures:
10% of the cost
Lab services: You pay nothing
Lab services: You pay nothing
Outpatient x-rays:
10% of the cost
Outpatient x-rays:
10% of the cost
Therapeutic radiology services
(such as radiation treatment for
cancer): 10% of the cost
Therapeutic radiology services
(such as radiation treatment for
cancer): 10% of the cost
6
Medica Prime Solution Value
w/Rx (Cost)
Medica Prime Solution Value
w/Rx 2 (Cost)
Primary care physician visit:
$10 copay
Primary care physician visit:
$10 copay
Specialist visit: $30 copay
Specialist visit: $30 copay
Durable Medical Equipment
(wheelchairs, oxygen, etc.)
20% of the cost
20% of the cost
Emergency Care
$50 copay
$50 copay
If you are admitted to the hospital
within 24 hours, you do not have
to pay your share of the cost for
emergency care. See the "Inpatient
Hospital Care" section of this
booklet for other costs.
If you are admitted to the hospital
within 24 hours, you do not have
to pay your share of the cost for
emergency care. See the "Inpatient
Hospital Care" section of this
booklet for other costs.
Benefits are also provided for
emergency care received in a
hospital outside the United States.
Coverage is available world-wide.
Benefits are also provided for
emergency care received in a
hospital outside the United States.
Coverage is available world-wide.
Foot Care (podiatry services)
Foot exams and treatment if you
have diabetes-related nerve
damage and/or meet certain
conditions: $30 copay
Foot exams and treatment if you
have diabetes-related nerve
damage and/or meet certain
conditions: $30 copay
Hearing Services
Exam to diagnose and treat
hearing and balance issues:
$10-30 copay, depending on
the service
Exam to diagnose and treat
hearing and balance issues:
$10-30 copay, depending on
the service
Doctor's Office Visits
Routine hearing exam (for up to 1 Routine hearing exam (for up to 1
every year): $30 copay
every year): $30 copay
Home Health Care
You pay nothing
You pay nothing
7
Mental Health Care
Medica Prime Solution Value
w/Rx (Cost)
Medica Prime Solution Value
w/Rx 2 (Cost)
Inpatient visit:
Inpatient visit:
The copays for hospital and
skilled nursing facility (SNF)
benefits are based on benefit
periods. A benefit period begins
the day you're admitted as an
inpatient and ends when you
haven't received any inpatient care
(or skilled care in a SNF) for 60
days in a row. If you go into a
hospital or a SNF after one benefit
period has ended, a new benefit
period begins. You must pay the
inpatient hospital deductible for
each benefit period. There's no
limit to the number of benefit
periods.
The copays for hospital and
skilled nursing facility (SNF)
benefits are based on benefit
periods. A benefit period begins
the day you're admitted as an
inpatient and ends when you
haven't received any inpatient care
(or skilled care in a SNF) for 60
days in a row. If you go into a
hospital or a SNF after one benefit
period has ended, a new benefit
period begins. You must pay the
inpatient hospital deductible for
each benefit period. There's no
limit to the number of benefit
periods.
Our plan covers 265 days for an
inpatient hospital stay.
Our plan covers 265 days for an
inpatient hospital stay.
Our plan also covers 60 "lifetime
reserve days." These are "extra"
days that we cover. If your
hospital stay is longer than 265
days, you can use these extra days.
But once you have used up these
extra 60 days, your inpatient
hospital coverage will be limited
to 265 days.
• $150 copayment per day for days 1-27
• $0 copayment per day for days
28-90
• You pay nothing per day for days 91 through 265
Our plan also covers 60 "lifetime
reserve days." These are "extra"
days that we cover. If your
hospital stay is longer than 265
days, you can use these extra days.
But once you have used up these
extra 60 days, your inpatient
hospital coverage will be limited
to 265 days.
• $150 copayment per day for days 1-27
• $0 copayment per day for days
28-90
• You pay nothing per day for days 91 through 265
Outpatient group therapy
visit: $30 copay
Outpatient group therapy
visit: $30 copay
Outpatient individual therapy
visit: $30 copay
Outpatient individual therapy
visit: $30 copay
8
Outpatient Rehabilitation
Medica Prime Solution Value
w/Rx (Cost)
Medica Prime Solution Value
w/Rx 2 (Cost)
Cardiac (heart) rehab services (for
a maximum of 2 one-hour
sessions per day for up to 36
sessions up to 36 weeks):
$30 copay
Cardiac (heart) rehab services (for
a maximum of 2 one-hour
sessions per day for up to 36
sessions up to 36 weeks):
$30 copay
Occupational therapy visit:
$30 copay
Occupational therapy visit:
$30 copay
Physical therapy and speech and Physical therapy and speech and
language therapy visit: $30 copay language therapy visit: $30 copay
Outpatient Substance Abuse
Group therapy visit: $30 copay
Group therapy visit: $30 copay
Individual therapy visit:
$30 copay
Individual therapy visit:
$30 copay
Ambulatory surgical center:
$125 copay
Ambulatory surgical center:
$125 copay
Outpatient hospital: $125 copay
Outpatient hospital: $125 copay
Over-the-Counter Items
Not Covered
Not Covered
Prosthetic Devices (braces,
artificial limbs, etc.)
Prosthetic devices:
20% of the cost
Prosthetic devices:
20% of the cost
Related medical supplies:
20% of the cost
Related medical supplies:
20% of the cost
Renal Dialysis
You pay nothing
You pay nothing
Transportation
Not covered
Not covered
Urgently Needed Services
$30 copayment for traditional
urgent care clinic
$10 copayment for convenience
care/retail clinic
$30 copayment for traditional
urgent care clinic
$10 copayment for convenience
care/retail clinic
Outpatient Surgery
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Vision Services
Medica Prime Solution Value
w/Rx (Cost)
Medica Prime Solution Value
w/Rx 2 (Cost)
Exam to diagnose and treat
diseases and conditions of the eye
(including yearly glaucoma
screening): $10-30 copayment,
depending on the service.
Routine eye exam (for up to 1
every year): $30 copay
Exam to diagnose and treat
diseases and conditions of the eye
(including yearly glaucoma
screening): $10-30 copayment,
depending on the service.
Routine eye exam (for up to 1
every year): $30 copay
Eyeglasses or contact lenses after Eyeglasses or contact lenses after
cataract surgery: $50 copay
cataract surgery: $50 copay
Preventive Care
You pay nothing
You pay nothing
Our plan covers many preventive
services, including:
• Abdominal aortic aneurysm
screening
• Alcohol misuse counseling
• Bone mass measurement
• Breast cancer screening
(mammogram)
• Cardiovascular disease
(behavioral therapy)
• Cardiovascular screenings
• Cervical and vaginal cancer
screening
• Colorectal cancer screenings
(Colonoscopy, Fecal occult blood
test, Flexible sigmoidoscopy)
• Depression screening
• Diabetes screenings
• HIV screening
• Medical nutrition therapy
services
• Obesity screening and
counseling
• Prostate cancer screenings
(PSA)
• Sexually transmitted infections
screening and counseling
Our plan covers many preventive
services, including:
• Abdominal aortic aneurysm
screening
• Alcohol misuse counseling
• Bone mass measurement
• Breast cancer screening
(mammogram)
• Cardiovascular disease
(behavioral therapy)
• Cardiovascular screenings
• Cervical and vaginal cancer
screening
• Colorectal cancer screenings
(Colonoscopy, Fecal occult blood
test, Flexible sigmoidoscopy)
• Depression screening
• Diabetes screenings
• HIV screening
• Medical nutrition therapy
services
• Obesity screening and
counseling
• Prostate cancer screenings
(PSA)
• Sexually transmitted infections
screening and counseling
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Hospice
Medica Prime Solution Value
w/Rx (Cost)
Medica Prime Solution Value
w/Rx 2 (Cost)
• Tobacco use cessation
counseling (counseling for people
with no sign of tobacco-related
disease)
• Vaccines, including Flu shots,
Hepatitis B shots, Pneumococcal
shots
• "Welcome to Medicare"
preventive visit (one-time)
• Yearly "Wellness" visit
• Any additional preventive
services approved by Medicare
during the contract year will be
covered.
• Supplemental Annual physical
exam
• Tobacco use cessation
counseling (counseling for people
with no sign of tobacco-related
disease)
• Vaccines, including Flu shots,
Hepatitis B shots, Pneumococcal
shots
• "Welcome to Medicare"
preventive visit (one-time)
• Yearly "Wellness" visit
• Any additional preventive
services approved by Medicare
during the contract year will be
covered.
• Supplemental Annual physical
exam
You pay nothing for hospice care
from a Medicare-certified hospice.
You may have to pay part of the
cost for drugs and respite care.
Hospice is covered outside of our
plan. Please contact us for more
details.
You pay nothing for hospice care
from a Medicare-certified hospice.
You may have to pay part of the
cost for drugs and respite care.
Hospice is covered outside of our
plan. Please contact us for more
details.
The copays for hospital and
skilled nursing facility (SNF)
benefits are based on benefit
periods. A benefit period begins
the day you're admitted as an
inpatient and ends when you
haven't received any inpatient care
(or skilled care in a SNF) for 60
days in a row. If you go into a
hospital or a SNF after one benefit
period has ended, a new benefit
period begins. You must pay the
inpatient hospital deductible for
each benefit period. There's no
limit to the number of benefit
periods.
The copays for hospital and
skilled nursing facility (SNF)
benefits are based on benefit
periods. A benefit period begins
the day you're admitted as an
inpatient and ends when you
haven't received any inpatient care
(or skilled care in a SNF) for 60
days in a row. If you go into a
hospital or a SNF after one benefit
period has ended, a new benefit
period begins. You must pay the
inpatient hospital deductible for
each benefit period. There's no
limit to the number of benefit
periods.
INPATIENT CARE
Inpatient Hospital Care
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Inpatient Mental Health Care
Medica Prime Solution Value
w/Rx (Cost)
Medica Prime Solution Value
w/Rx 2 (Cost)
Our plan covers an unlimited
number of days for an inpatient
hospital stay.
Our plan covers an unlimited
number of days for an inpatient
hospital stay.
• $150 copayment per day for
days 1-27
• $150 copayment per day for
days 1-27
• $0 copayment per day for days
28-90
• $0 copayment per day for days
28-90
• You pay nothing per day for
days 91 and beyond
• You pay nothing per day for
days 91 and beyond
For inpatient mental health care,
see the "Mental Health Care"
section of this booklet.
For inpatient mental health care,
see the "Mental Health Care"
section of this booklet.
Contact the plan for details about Contact the plan for details about
coverage in a psychiatric hospital coverage in a psychiatric hospital
beyond 190 days.
beyond 190 days.
Skilled Nursing Facility (SNF)
Our plan covers up to 100 days in Our plan covers up to 100 days in
a SNF.
a SNF.
• You pay nothing for days 1 • You pay nothing for days 1 through 20
through 20
• $80 copayment per day for • $80 copayment per day for days 21 through 100
days 21 through 100
PRESCRIPTION DRUG BENEFITS
How much do I pay?
For Part B drugs such as
chemotherapy drugs*:
20% of the cost
For Part B drugs such as
chemotherapy drugs*:
20% of the cost
Other Part B drugs*:
20% of the cost
*Prior authorization may be
required.
Other Part B drugs*:
20% of the cost
*Prior authorization may be
required.
12
Initial Coverage
Medica Prime Solution Value
w/Rx (Cost)
Medica Prime Solution Value
w/Rx 2 (Cost)
After you pay your yearly
deductible, you pay the following
until your total yearly drug costs
reach $3,700. Total yearly drug
costs are the total drug costs paid
by both you and our Part D plan.
You pay the following until your
total yearly drug costs reach
$3,700. Total yearly drug costs are
the total drug costs paid by both
you and our Part D plan.
You may get your drugs at
network retail pharmacies and
mail order pharmacies.
You may get your drugs at
network retail pharmacies and
mail order pharmacies.
Tier
Tier 1 (Preferred Generic)
Tier 2 (Generic)
Tier 3 (Preferred Brand)
Tier 4 (Non‐Preferred Drug)
Tier 5 (Specialty Tier)
Standard Retail Cost-Sharing
One‐month supply
One‐month supply
$4 copay
$2 copay
$10 copay
$8 copay
$45 copay
$35 copay
50% of the cost
50% of the cost
26% of the cost
33% of the cost
Tier
Tier 1 (Preferred Generic)
Tier 2 (Generic)
Tier 3 (Preferred Brand)
Tier 4 (Non‐Preferred Drug)
Tier 5 (Specialty Tier)
Standard Retail Cost-Sharing
Three‐month supply
Three‐month supply
$12 copay
$6 copay
$30 copay
$24 copay
$135 copay
$105 copay
50% of the cost
50% of the cost
26% of the cost
33% of the cost
Tier
Tier 1 (Preferred Generic)
Tier 2 (Generic)
Tier 3 (Preferred Brand)
Tier 4 (Non‐Preferred Drug)
Tier 5 (Specialty Tier)
Standard Mail Order Cost-Sharing
Three‐month supply
Three‐month supply
$8 copay
$4 copay
$20 copay
$16 copay
$90 copay
$70 copay
50% of the cost
50% of the cost
26% of the cost
33% of the cost
If you reside in a long-term care
facility, you pay the same as at a
retail pharmacy.
13
If you reside in a long-term care
facility, you pay the same as at a
retail pharmacy.
Medica Prime Solution Value
w/Rx (Cost)
Medica Prime Solution Value
w/Rx 2 (Cost)
You may get drugs from an out-of­ You may get drugs from an out-of­
network pharmacy at the same
network pharmacy at the same
cost as an in-network pharmacy. cost as an in-network pharmacy.
Coverage Gap
Catastrophic Coverage
Most Medicare drug plans have a
coverage gap (also called the
"donut hole"). This means that
there's a temporary change in what
you will pay for your drugs. The
coverage gap begins after the total
yearly drug cost (including what
our plan has paid and what you
have paid) reaches $3,700.
Most Medicare drug plans have a
coverage gap (also called the
"donut hole"). This means that
there's a temporary change in what
you will pay for your drugs. The
coverage gap begins after the total
yearly drug cost (including what
our plan has paid and what you
have paid) reaches $3,700.
After you enter the coverage gap,
you pay 40% of the plan's cost for
covered brand name drugs and
51% of the plan's cost for covered
generic drugs until your costs total
$4,950, which is the end of the
coverage gap. Not everyone will
enter the coverage gap.
After you enter the coverage gap,
you pay 40% of the plan's cost for
covered brand name drugs and
51% of the plan's cost for covered
generic drugs until your costs total
$4,950, which is the end of the
coverage gap. Not everyone will
enter the coverage gap.
After your yearly out-of-pocket
drug costs (including drugs
purchased through your retail
pharmacy and through mail order)
reach $4,950, you pay the greater
of:
• 5% of the cost, or
• $3.30 copay for generic
(including brand drugs treated as
generic) and a $8.25 copayment
for all other drugs.
After your yearly out-of-pocket
drug costs (including drugs
purchased through your retail
pharmacy and through mail order)
reach $4,950, you pay the greater
of:
• 5% of the cost, or
• $3.30 copay for generic
(including brand drugs treated as
generic) and a $8.25 copayment
for all other drugs.
14
Medica Prime Solution Value
w/Rx (Cost)
Medica Prime Solution Value
w/Rx 2 (Cost)
OPTIONAL BENEFITS (you must pay an extra premium each month for these benefits)
Package 1: Medica SeniorDental®
Benefits include:
• Preventive Dental
• Comprehensive Dental
• Preventive Dental
• Comprehensive Dental
How much is the monthly
premium?
Additional $62.90 per month.
You must keep paying your
Medicare Part B premium and
your $85.00 monthly plan
premium.
Additional $62.90 per month.
You must keep paying your
Medicare Part B premium and
your $113.20 monthly plan
premium.
How much is the deductible?
$50 per year
$50 per year
Is there a limit on how much the Our plan pays up to $1,000 every
plan will pay?
year. Our plan has additional
coverage limits for certain
benefits.
15
Our plan pays up to $1,000 every
year. Our plan has additional
coverage limits for certain
benefits.
This information is not a complete description of benefits. Contact the plan for more information.
Limitations, copayments, and restrictions may apply. Benefits, premiums, and/or
copayments/coinsurance may change on January 1 of each year. The formulary, pharmacy network,
and/or provider network may change at any time. You will receive notice when necessary.
Medica is a Cost plan with a Medicare contract. Enrollment in Medica depends on contract renewal.
© 2016 Medica. Medica®, Medica Prime Solution®, and Medica SeniorDental® are registered service
marks of Medica Health Plans. “Medica” refers to the family of health plan businesses that includes
Medica Health Plans, Medica Health Plans of Wisconsin, Medica Insurance Company, Medica SelfInsured, and Medica Health Management, LLC.
Medica Prime Solution Value w/Rx Roberts County, SD; Medica Prime Solution Value w/Rx Sanborn County, SD; Medica Prime
Solution Value w/Rx Spink County, SD; Medica Prime Solution Value w/Rx Ashland County, WI; Medica Prime Solution Value w/Rx
Potter County, SD; Medica Prime Solution Value w/Rx Sawyer County, WI; Medica Prime Solution Value w/Rx Moody County, SD;
Medica Prime Solution Value w/Rx Mcpherson County, SD; Medica Prime Solution Value w/Rx Meade County, SD; Medica Prime
Solution Value w/Rx Mellette County, SD; Medica Prime Solution Value w/Rx Miner County, SD; Medica Prime Solution Value w/Rx
Mccook County, SD; Medica Prime Solution Value w/Rx Jerauld County, SD; Medica Prime Solution Value w/Rx Jones County, SD;
Medica Prime Solution Value w/Rx Kingsbury County, SD; Medica Prime Solution Value w/Rx Lake County, SD; Medica Prime Solution
Value w/Rx Lawrence County, SD; Medica Prime Solution Value w/Rx Lincoln County, SD; Medica Prime Solution Value w/Rx Lyman
County, SD; Medica Prime Solution Value w/Rx Marshall County, SD; Medica Prime Solution Value w/Rx Perkins County, SD; Medica
Prime Solution Value w/Rx Wright County, MN; Medica Prime Solution Value w/Rx Pennington County, SD; Medica Prime Solution
Value w/Rx Wadena County, MN; Medica Prime Solution Value w/Rx Grant County, SD; Medica Prime Solution Value w/Rx Gregory
County, SD; Medica Prime Solution Value w/Rx Haakon County, SD; Medica Prime Solution Value w/Rx Winona County, MN; Medica
Prime Solution Value w/Rx Waseca County, MN; Medica Prime Solution Value w/Rx Washington County, MN; Medica Prime Solution
Value w/Rx Watonwan County, MN; Medica Prime Solution Value w/Rx Steele County, ND; Medica Prime Solution Value w/Rx
Stutsman County, ND; Medica Prime Solution Value w/Rx Towner County, ND; Medica Prime Solution Value w/Rx Traill County, ND;
Medica Prime Solution Value w/Rx Walsh County, ND; Medica Prime Solution Value w/Rx Ward County, ND; Medica Prime Solution
Value w/Rx Wells County, ND; Medica Prime Solution Value w/Rx Williams County, ND; Medica Prime Solution Value w/Rx Richland
County, ND; Medica Prime Solution Value w/Rx Rolette County, ND; Medica Prime Solution Value w/Rx Sargent County, ND; Medica
Prime Solution Value w/Rx Adams County, ND; Medica Prime Solution Value w/Rx Barnes County, ND; Medica Prime Solution Value
w/Rx Benson County, ND; Medica Prime Solution Value w/Rx Billings County, ND; Medica Prime Solution Value w/Rx Bowman County,
ND; Medica Prime Solution Value w/Rx Burleigh County, ND; Medica Prime Solution Value w/Rx Cass County, ND; Medica Prime
Solution Value w/Rx Cavalier County, ND; Medica Prime Solution Value w/Rx Dickey County, ND; Medica Prime Solution Value w/Rx
Dunn County, ND; Medica Prime Solution Value w/Rx Eddy County, ND; Medica Prime Solution Value w/Rx Emmons County, ND;
Medica Prime Solution Value w/Rx Foster County, ND; Medica Prime Solution Value w/Rx Grand Forks County, ND; Medica Prime
Solution Value w/Rx Grant County, ND; Medica Prime Solution Value w/Rx Griggs County, ND; Medica Prime Solution Value w/Rx
Hettinger County, ND; Medica Prime Solution Value w/Rx Kidder County, ND; Medica Prime Solution Value w/Rx Lamoure County, ND;
Medica Prime Solution Value w/Rx Logan County, ND; Medica Prime Solution Value w/Rx Mchenry County, ND; Medica Prime Solution
Value w/Rx Mcintosh County, ND; Medica Prime Solution Value w/Rx Mclean County, ND; Medica Prime Solution Value w/Rx Mercer
County, ND; Medica Prime Solution Value w/Rx Morton County, ND; Medica Prime Solution Value w/Rx Nelson County, ND; Medica
Prime Solution Value w/Rx Oliver County, ND; Medica Prime Solution Value w/Rx Pembina County, ND; Medica Prime Solution Value
w/Rx Pierce County, ND; Medica Prime Solution Value w/Rx Ramsey County, ND; Medica Prime Solution Value w/Rx Stark County,