Medica Advantage Value (PPO)

Available to residents of Gosper County, NE for 2026. Contract H8889, plan 010, segment 0.

Renewed, service area expanded for 2026. CMS carries this plan forward from 2025.

Plan details

Monthly premium (Part C + D)	$0.00
— medical (Part C) part	$0.00
— drug (Part D) part	$0.00?
Monthly premium with full Extra Help (LIS)	$0.00?
Part B premium reduction (giveback)	None
In-network out-of-pocket maximum	$6,750.00?
In- and out-of-network out-of-pocket maximum	$6,750.00
Drug deductible	$615.00Tier 1 and 2 exempt
Drug out-of-pocket threshold	$2,100.00
Plan type	PPO?
Contract / plan	H8889-010-0
Offered by	Medica
Parent organization	Medica Holding Company
Formulary drugs	3,520
Formulary exception tier	4?
Pharmacy search	medica.com/Members
Member services	(800)906-5432TTY 711

CMS star ratings

Overall: 3.5 out of 5 stars for Overall
Health plan (Part C): 3.5 out of 5 stars for Health plan (Part C)
Drug plan (Part D): 3.5 out of 5 stars for Drug plan (Part D)

Published per contract — every plan under contract H8889 shares this rating.

Plan health benefits

Service	In-network	Out-of-network?
Doctor visits
Primary care doctor	$0 copay	$25 copay
Specialist	$55 copay	$60 copay
Other health care professional	$0–$55 copay	$25–$60 copay
Additional telehealth services	$0–$55 copay	—
Preventive care
Medicare-covered preventive services	$0 copay	$0 copay
Annual physical exam	$0 copay	$0 copay
Kidney disease education	$0 copay	$0 copay
Glaucoma screening	$0 copay	$0 copay
Diabetes self-management training	$0 copay	$0 copay
Diagnostic tests, labs and imaging
Diagnostic tests and procedures	$0–$250 copay(authorization required)	$0–$250 copay
Lab services	$0 copay(authorization required)	$0 copay
Diagnostic radiology (e.g. MRI, CT)	$0–$250 copay(authorization required)	$0–$250 copay
Therapeutic radiology	$85 copay(authorization required)	$85 copay
Outpatient x-rays	$50 copay(authorization required)	$50 copay
Emergency and urgent care
Emergency room	$130 copay	—
Urgent care	$25–$50 copay	—
Worldwide emergency coverage	20% coinsurance	—
Worldwide urgent care	Not covered	—
Worldwide emergency transportation	20% coinsurance	—
Hospital care
Inpatient hospital stay	$550 per day for days 1–5; $0 per day for days 6–90(authorization required)	$625 per day for days 1–5; $0 per day for days 6–90
Outpatient hospital services	$0–$550 copay(authorization required)	$0–$600 copay
Outpatient observation	$550 copay	$625 copay
Ambulatory surgical center	$0–$450 copay(authorization required)	$0–$500 copay
Outpatient blood services	$0 copay	$50 copay
Skilled nursing and home health
Skilled nursing facility	$0 per day for days 1–20; $218 per day for days 21–52; $0 per day for days 53–100(authorization required)	$90 per day for days 1–20; $218 per day for days 21–44; $0 per day for days 45–100
Home health care	$0 copay	30% coinsurance
Kidney dialysis	20% coinsurance	30% coinsurance
Rehabilitation
Occupational therapy	$50 copay	$60 copay
Physical therapy and speech-language therapy	$55 copay	$60 copay
Cardiac rehabilitation	$40 copay	$60 copay
Pulmonary rehabilitation	$35 copay	$70 copay
Mental health and substance use
Inpatient psychiatric hospital stay	$450 per day for days 1–5; $0 per day for days 6–90(authorization required)	$525 per day for days 1–4; $0 per day for days 5–90
Outpatient mental health, individual session	$50 copay	$55 copay
Outpatient mental health, group session	$40 copay	$55 copay
Psychiatrist, individual session	$50 copay	$55 copay
Psychiatrist, group session	$40 copay	$55 copay
Partial hospitalization	$140 copay	$150 copay
Intensive outpatient program	$140 copay	$150 copay
Outpatient substance use, individual session	$50 copay	$55 copay
Outpatient substance use, group session	$40 copay	$55 copay
Opioid treatment program	$50 copay	$55 copay
Ambulance and transportation
Ground ambulance	$375 copay	$375 copay
Air ambulance	$475 copay	$475 copay
Transportation to plan-approved locations	Not covered	—
Medical equipment and supplies
Durable medical equipment (e.g. wheelchairs, oxygen)	0%–20% coinsurance(authorization required)	0%–30% coinsurance
Prosthetics (e.g. braces, artificial limbs)	20% coinsurance(authorization required)	30% coinsurance
Medical supplies	20% coinsurance(authorization required)	30% coinsurance
Diabetes supplies	0%–20% coinsurance	0%–20% coinsurance
Diabetic therapeutic shoes or inserts	20% coinsurance	30% coinsurance
Chiropractic, acupuncture and foot care
Chiropractic (Medicare-covered)	$15 copay	$35 copay
Routine chiropractic care	Not covered	—
Acupuncture	Not covered	—
Foot exams and treatment (Medicare-covered)	$55 copay	$60 copay
Routine foot care	Not covered	—
Dental?
Preventive dental plan limit	$450 plan limit every year	—
Oral exams	$0 copay	$0 copay
Cleanings	$0 copay	$0 copay
Fluoride treatment	$0 copay	$0 copay
Dental x-rays	$0 copay	$0 copay
Other diagnostic dental services	$0 copay	$0 copay
Other preventive dental services	$0 copay	$0 copay
Restorative services (fillings, crowns)	$0 copay	$0 copay
Endodontics (root canals)	$0 copay	$0 copay
Periodontics (gum disease)	$0 copay	$0 copay
Dentures and other removable prosthodontics	$0 copay	$0 copay
Maxillofacial prosthetics	$0 copay	$0 copay
Implants	$0 copay	$0 copay
Bridges and other fixed prosthodontics	$0 copay	$0 copay
Oral and maxillofacial surgery	$0 copay	$0 copay
Orthodontics	Not covered	—
Adjunctive general services	$0 copay	$0 copay
Vision?
Eye exam (Medicare-covered)	$0–$55 copay	$25–$60 copay
Routine eye exam	$0 copay(limits apply)	$0 copay
Eyewear after cataract surgery (Medicare-covered)	$0 copay(limits apply)	—
Eyewear plan limit	$75 plan limit every year	—
Contact lenses	$0 copay(limits apply)	$0 copay
Eyeglasses (frames and lenses)	$0 copay(limits apply)	$0 copay
Eyeglass lenses	$0 copay(limits apply)	$0 copay
Eyeglass frames	$0 copay(limits apply)	$0 copay
Eyewear upgrades	$0 copay(limits apply)	$0 copay
Hearing?
Hearing exam (Medicare-covered)	$0–$55 copay	$25–$60 copay
Routine hearing exam	$0 copay(limits apply)	$0 copay
Hearing aid fitting and evaluation	$0 copay(limits apply)	$0 copay
Hearing aids (all types)	$549–$1,299 copay	$549–$1,299 copay
Hearing aids, inner ear	Not covered	—
Hearing aids, outer ear	Not covered	—
Hearing aids, over the ear	Not covered	—
Medicare Part B drugs
Part B insulin	$35 copay(authorization required, step therapy may apply)	$35 copay
Chemotherapy and radiation drugs	0%–20% coinsurance(authorization required, step therapy may apply)	0%–30% coinsurance
Other Part B drugs	0%–20% coinsurance(authorization required, step therapy may apply)	0%–30% coinsurance
Other extra benefits?
Over-the-counter (OTC) allowance	$40 allowance every six months	—
Meals after a hospital stay or for a chronic condition	Not covered	—
Fitness benefit	$0 copay	$0 copay
Health education	Not covered	—
Nutritional / dietary benefit	Not covered	—
Extra smoking and tobacco cessation counseling	Not covered	—
Enhanced disease management	Not covered	—
Telemonitoring	Not covered	—
Remote access technologies (web/phone, nurse line)	$0 copay	$0 copay
Home and bathroom safety devices	Not covered	—
Counseling services	Not covered	—
In-home safety assessment	Not covered	—
Personal emergency response system (PERS)	Not covered	—
Medical nutrition therapy	Not covered	—
Post-discharge in-home medication reconciliation	Not covered	—
Re-admission prevention	Not covered	—
Wigs for hair loss from chemotherapy	Not covered	—
Weight management programs	Not covered	—
Alternative therapies	Not covered	—
Therapeutic massage	Not covered	—
Adult day health services	Not covered	—
Home-based palliative care	Not covered	—
In-home support services	Not covered	—
Support for caregivers	Not covered	—

In-network cost-sharing as the plan filed it with CMS (CMS plan benefit package (PBP) files, CY2026). A range means the cost depends on the service or setting. Rows the filing does not state are left out rather than guessed; an out-of-network dash means the plan files no separate out-of-network cost for that service. Contact the plan for the full Evidence of Coverage.

Drug tiers — preferred pharmacy, initial coverage

Tier	Cost-sharing
Tier 1	$0.00
Tier 2	$5.00
Tier 3	18%
Tier 4	50%
Tier 5	25%

Rx cost-sharing by coverage phase

Tier	30-day supply			90-day supply
Tier	Preferred	Standard	Mail Order	Preferred	Standard	Mail Order
Initial deductible phase
Tier 1: Preferred Generic	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00
Tier 2: Generic	$5.00	$5.00	$5.00	$15.00	$15.00	$15.00
Initial coverage phase
Tier 1: Preferred Generic	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00
Tier 2: Generic	$5.00	$5.00	$5.00	$15.00	$15.00	$15.00
Tier 3: Preferred Brand	18%	18%	18%	18%	18%	18%
Tier 4: Non-Preferred Drug	50%	50%	50%	50%	50%	50%
Tier 5: Specialty Tier	25%	25%	25%	n/a	n/a	n/a
Catastrophic coverage phase
Tier 1: Preferred Generic	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00
Tier 2: Generic	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00
Tier 3: Preferred Brand	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00
Tier 4: Non-Preferred Drug	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00
Tier 5: Specialty Tier	$0.00	$0.00	$0.00	$0.00	$0.00	$0.00

Also available in 48 other NE counties

Benefits in plain text

Medica Advantage Value (PPO) (H8889-010-0) is a 2026 PPO Medicare Advantage plan offered by Medica, available to residents of Gosper County, NE.

The monthly premium is $0.00 (Part C and Part D together).

With full Extra Help (the Low-Income Subsidy), the total monthly premium is $0.00.

Its in-network out-of-pocket maximum is $6,750.00.

The combined in- and out-of-network out-of-pocket maximum is $6,750.00.

The drug deductible is $615.00. Tier 1 and 2 exempt.

The plan's formulary lists 3,520 drugs.

At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1: $0.00; tier 2: $5.00; tier 3: 18%; tier 4: 50%; tier 5: 25%.

CMS gives the plan's contract (H8889) an overall rating of 3.5 out of 5 stars.

Email a copy of the plan benefit details

Plan facts come from the CMS quarterly prescription drug plan public use files; the premium split, Extra Help premium, MOOP and plan type from the CMS Landscape file; the Part B giveback and health benefits from the CMS plan benefit package (PBP) files.