Medica Prime Solution Standard w/Rx (Cost)
Available to residents of Mountrail County, ND for 2027. Contract H2450, plan 049, segment 0.
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- Plan health benefits
- Benefits in plain text
- Rx cost-sharing for all pharmacies and tiers
- Other plans in Mountrail County
- Plan website
- Browse the Medica Prime Solution Standard w/Rx (Cost) formulary
2027 drug-by-drug coverage is not published by CMS yet. The drug lookup covers 2026, whose formulary is live.
Renewed, service area reduced for 2027. CMS carries this plan forward from 2026. Every ND plan’s 2026–2027 changes →
Plan details
| Monthly premium (Part C + D) | $90.60 |
|---|---|
| — medical (Part C) part | — |
| — drug (Part D) part | $90.60? |
| Monthly premium with full Extra Help (LIS) | $66.00? |
| Health plan deductible (in-network) | $200.00 |
| In-network out-of-pocket maximum | $7,150.00? |
| Drug deductible | $500.00Tier 1 exempt |
| Drug out-of-pocket threshold | $2,400.00 |
| Plan type | Cost? |
| Contract / plan | H2450-049-0 |
| Offered by | Medica |
| Parent organization | Medica Holding Company |
| Formulary tiers | 5 |
| Formulary exception tier | 4? |
| Pharmacy search | medica.com/Members |
| Member services | (800)906-5432TTY 711 |
CMS star ratings
- Overall
- 3 out of 5 stars for Overall
- Health plan (Part C)
- 3 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 H2450 shares this rating.
Plan health benefits
| Service | In-network |
|---|---|
| Doctor visits | |
| Primary care doctor | $15 copay |
| Specialist | $60 copay |
| Other health care professional | $15–$60 copay |
| Preventive care | |
| Medicare-covered preventive services | $0 copay |
| Annual physical exam | $0 copay |
| Kidney disease education | $0 copay |
| Glaucoma screening | $0 copay |
| Diabetes self-management training | $0 copay |
| Diagnostic tests, labs and imaging | |
| Diagnostic tests and procedures | $15–$60 copay |
| Lab services | $0 copay |
| Diagnostic radiology (e.g. MRI, CT) | $300 copay |
| Therapeutic radiology | $80 copay |
| Outpatient x-rays | $60 copay |
| Emergency and urgent care | |
| Emergency room | $130 copay |
| Urgent care | $50 copay |
| Worldwide emergency coverage | $130 copay |
| Worldwide urgent care | Not covered |
| Worldwide emergency transportation | Not covered |
| Hospital care | |
| Inpatient hospital stay | $425 per day for days 1–5; $0 per day for days 6–90 |
| Outpatient hospital services | $0–$500 copay |
| Outpatient observation | $500 copay |
| Ambulatory surgical center | $0–$400 copay |
| Outpatient blood services | $0 copay |
| Skilled nursing and home health | |
| Skilled nursing facility | $0 per day for days 1–20; $221 per day for days 21–100 |
| Home health care | $0 copay |
| Kidney dialysis | 20% coinsurance |
| Rehabilitation | |
| Occupational therapy | $45 copay |
| Physical therapy and speech-language therapy | $60 copay |
| Cardiac rehabilitation | $40 copay |
| Pulmonary rehabilitation | $15 copay |
| Mental health and substance use | |
| Inpatient psychiatric hospital stay | $425 per day for days 1–5; $0 per day for days 6–90 |
| Outpatient mental health, individual session | $35 copay |
| Outpatient mental health, group session | $35 copay |
| Psychiatrist, individual session | $60 copay |
| Psychiatrist, group session | $60 copay |
| Partial hospitalization | $40 copay |
| Intensive outpatient program | $40 copay |
| Outpatient substance use, individual session | $30 copay |
| Outpatient substance use, group session | $30 copay |
| Opioid treatment program | $30 copay |
| Ambulance and transportation | |
| Ground ambulance | $350 copay |
| Air ambulance | 20% coinsurance |
| Transportation to plan-approved locations | Not covered |
| Medical equipment and supplies | |
| Durable medical equipment (e.g. wheelchairs, oxygen) | 30% coinsurance |
| Prosthetics (e.g. braces, artificial limbs) | 30% coinsurance |
| Medical supplies | 0%–30% coinsurance |
| Diabetes supplies | 20% coinsurance |
| Diabetic therapeutic shoes or inserts | 30% coinsurance |
| Chiropractic, acupuncture and foot care | |
| Chiropractic (Medicare-covered) | $15 copay |
| Routine chiropractic care | Not covered |
| Acupuncture | Not covered |
| Foot exams and treatment (Medicare-covered) | $60 copay |
| Routine foot care | Not covered |
| Dental? | |
| Oral exams | $0 copay(limits apply) |
| Cleanings | $0 copay(limits apply) |
| Fluoride treatment | Not covered |
| Dental x-rays | $0 copay(limits apply) |
| Other diagnostic dental services | Not covered |
| Other preventive dental services | $0 copay(limits apply) |
| Restorative services (fillings, crowns) | Not covered |
| Endodontics (root canals) | Not covered |
| Periodontics (gum disease) | Not covered |
| Dentures and other removable prosthodontics | Not covered |
| Maxillofacial prosthetics | Not covered |
| Implants | Not covered |
| Bridges and other fixed prosthodontics | Not covered |
| Oral and maxillofacial surgery | Not covered |
| Orthodontics | Not covered |
| Adjunctive general services | Not covered |
| Vision? | |
| Eye exam (Medicare-covered) | $15–$60 copay |
| Routine eye exam | $0 copay(limits apply) |
| Eyewear after cataract surgery (Medicare-covered) | $45 copay |
| Contact lenses | Not covered |
| Eyeglasses (frames and lenses) | Not covered |
| Eyeglass lenses | Not covered |
| Eyeglass frames | Not covered |
| Eyewear upgrades | Not covered |
| Hearing? | |
| Hearing exam (Medicare-covered) | $60 copay |
| Routine hearing exam | $0 copay(limits apply) |
| Hearing aid fitting and evaluation | $0 copay |
| Hearing aids (all types) | $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 |
| Chemotherapy and radiation drugs | 0%–20% coinsurance |
| Other Part B drugs | 0%–20% coinsurance |
| Other extra benefits? | |
| Over-the-counter (OTC) allowance | $25 allowance every six months |
| Meals after a hospital stay or for a chronic condition | Not covered |
| Fitness benefit | $0 copay |
| Health education | $0 copay |
| 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 |
| 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, CY2027). A range means the cost depends on the service or setting. Rows the filing does not state are left out rather than guessed. Contact the plan for the full Evidence of Coverage.
Drug tiers — preferred pharmacy, initial coverage
| Tier | Cost-sharing |
|---|---|
| Tier 1 · Preferred Generic | $0.00 |
| Tier 2 · Generic | $15.00 |
| Tier 3 · Preferred Brand | 15% |
| Tier 4 · Non-Preferred Drug | 25% |
| Tier 5 · Specialty Tier | 28% |
Rx cost-sharing by coverage phase
| Tier | 30-day supply | 90-day supply | ||||
|---|---|---|---|---|---|---|
| Preferred | Standard | Mail Order | Preferred | Standard | Mail Order | |
| Initial coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $15.00 | $15.00 | $15.00 | $45.00 | $45.00 | $45.00 |
| Tier 3: Preferred Brand | 15% | 15% | 15% | 15% | 15% | 15% |
| Tier 4: Non-Preferred Drug | 25% | 25% | 25% | 25% | 25% | 25% |
| Tier 5: Specialty Tier | 28% | 28% | 28% | n/a | n/a | n/a |
These are the initial coverage phase amounts, as the plan filed them in its benefit package. The deductible and post-threshold phases are not stated per tier in that filing, so they are not shown here rather than being inferred; the plan's annual out-of-pocket threshold is $2,400.00.
Star rating measures
| Measure | 2027 | 2026 |
|---|---|---|
| Staying Healthy: Screenings, Tests and Vaccines | ||
| Breast Cancer Screening · C01 | 3 out of 5 stars for Breast Cancer Screening | 4 out of 5 stars for Breast Cancer Screening |
| Colorectal Cancer Screening · C02 | 2 out of 5 stars for Colorectal Cancer Screening | 3 out of 5 stars for Colorectal Cancer Screening |
| Annual Flu Vaccine · C03 | 4 out of 5 stars for Annual Flu Vaccine | 4 out of 5 stars for Annual Flu Vaccine |
| Improving or Maintaining Physical Health · C04 | 3 out of 5 stars for Improving or Maintaining Physical Health | 3 out of 5 stars for Improving or Maintaining Physical Health |
| Improving or Maintaining Mental Health · C05 | 4 out of 5 stars for Improving or Maintaining Mental Health | 4 out of 5 stars for Improving or Maintaining Mental Health |
| Monitoring Physical Activity · C06 | 1 out of 5 stars for Monitoring Physical Activity | 2 out of 5 stars for Monitoring Physical Activity |
| Managing Chronic (Long Term) Conditions | ||
| Osteoporosis Management in Women who had a Fracture · C10 | 1 out of 5 stars for Osteoporosis Management in Women who had a Fracture | 1 out of 5 stars for Osteoporosis Management in Women who had a Fracture |
| Diabetes Care – Eye Exam · C11 | 2 out of 5 stars for Diabetes Care – Eye Exam | 3 out of 5 stars for Diabetes Care – Eye Exam |
| Diabetes Care – Blood Sugar Controlled · C12 | 3 out of 5 stars for Diabetes Care – Blood Sugar Controlled | 3 out of 5 stars for Diabetes Care – Blood Sugar Controlled |
| Kidney Health Evaluation for Patients with Diabetes · C13 | 1 out of 5 stars for Kidney Health Evaluation for Patients with Diabetes | 1 out of 5 stars for Kidney Health Evaluation for Patients with Diabetes |
| Controlling High Blood Pressure · C14 | 2 out of 5 stars for Controlling High Blood Pressure | 2 out of 5 stars for Controlling High Blood Pressure |
| Reducing the Risk of Falling · C15 | 1 out of 5 stars for Reducing the Risk of Falling | 1 out of 5 stars for Reducing the Risk of Falling |
| Improving Bladder Control · C16 | 3 out of 5 stars for Improving Bladder Control | 2 out of 5 stars for Improving Bladder Control |
| Follow-up after Emergency Department Visit for People with Multiple High-Risk Chronic Conditions · C20 | 1 out of 5 stars for Follow-up after Emergency Department Visit for People with Multiple High-Risk Chronic Conditions | 2 out of 5 stars for Follow-up after Emergency Department Visit for People with Multiple High-Risk Chronic Conditions |
| Member Experience with Health Plan | ||
| Getting Needed Care · C21 | 3 out of 5 stars for Getting Needed Care | 4 out of 5 stars for Getting Needed Care |
| Getting Appointments and Care Quickly · C22 | 3 out of 5 stars for Getting Appointments and Care Quickly | 3 out of 5 stars for Getting Appointments and Care Quickly |
| Customer Service · C23 | 4 out of 5 stars for Customer Service | 5 out of 5 stars for Customer Service |
| Rating of Health Care Quality · C24 | 4 out of 5 stars for Rating of Health Care Quality | 5 out of 5 stars for Rating of Health Care Quality |
| Rating of Health Plan · C25 | 4 out of 5 stars for Rating of Health Plan | 4 out of 5 stars for Rating of Health Plan |
| Care Coordination · C26 | 3 out of 5 stars for Care Coordination | 5 out of 5 stars for Care Coordination |
| Member Complaints and Changes in the Health Plan's Performance | ||
| Complaints about the Health Plan · C27 | 5 out of 5 stars for Complaints about the Health Plan | 5 out of 5 stars for Complaints about the Health Plan |
| Members Choosing to Leave the Plan · C28 | 5 out of 5 stars for Members Choosing to Leave the Plan | 5 out of 5 stars for Members Choosing to Leave the Plan |
| Health Plan Quality Improvement · C29 | 1 out of 5 stars for Health Plan Quality Improvement | 3 out of 5 stars for Health Plan Quality Improvement |
| Health Plan Customer Service | ||
| Plan Makes Timely Decisions about Appeals · C30 | 4 out of 5 stars for Plan Makes Timely Decisions about Appeals | 3 out of 5 stars for Plan Makes Timely Decisions about Appeals |
| Reviewing Appeals Decisions · C31 | 5 out of 5 stars for Reviewing Appeals Decisions | 3 out of 5 stars for Reviewing Appeals Decisions |
| DD2: Member Complaints and Changes in the Drug Plan’s Performance | ||
| Complaints about the Drug Plan · D02 | 5 out of 5 stars for Complaints about the Drug Plan | 5 out of 5 stars for Complaints about the Drug Plan |
| Members Choosing to Leave the Plan · D03 | 5 out of 5 stars for Members Choosing to Leave the Plan | 5 out of 5 stars for Members Choosing to Leave the Plan |
| Drug Plan Quality Improvement · D04 | 2 out of 5 stars for Drug Plan Quality Improvement | 3 out of 5 stars for Drug Plan Quality Improvement |
| DD3: Member Experience with the Drug Plan | ||
| Rating of Drug Plan · D05 | 3 out of 5 stars for Rating of Drug Plan | 2 out of 5 stars for Rating of Drug Plan |
| DD4: Drug Safety and Accuracy of Drug Pricing | ||
| MPF Price Accuracy · D07 | 4 out of 5 stars for MPF Price Accuracy | 5 out of 5 stars for MPF Price Accuracy |
| Medication Adherence for Diabetes Medications · D08 | 2 out of 5 stars for Medication Adherence for Diabetes Medications | 4 out of 5 stars for Medication Adherence for Diabetes Medications |
| Medication Adherence for Hypertension (RAS antagonists) · D09 | 4 out of 5 stars for Medication Adherence for Hypertension (RAS antagonists) | 4 out of 5 stars for Medication Adherence for Hypertension (RAS antagonists) |
| Medication Adherence for Cholesterol (Statins) · D10 | 4 out of 5 stars for Medication Adherence for Cholesterol (Statins) | 4 out of 5 stars for Medication Adherence for Cholesterol (Statins) |
| Statin Use in Persons with Diabetes (SUPD) · D11 | 2 out of 5 stars for Statin Use in Persons with Diabetes (SUPD) | 2 out of 5 stars for Statin Use in Persons with Diabetes (SUPD) |
| Concurrent Use of Opioids and Benzodiazepines (COB) · D12 | 4 out of 5 stars for Concurrent Use of Opioids and Benzodiazepines (COB) | new measure |
| Polypharmacy: Use of Multiple Anticholinergic Medications in Older Adults (Poly-ACH) · D13 | 5 out of 5 stars for Polypharmacy: Use of Multiple Anticholinergic Medications in Older Adults (Poly-ACH) | new measure |
Measures are paired between the two years by name, not by the C/D number: CMS reuses those numbers, and in 2027 nineteen of them refer to a different measure than they did in 2026. A measure introduced for 2027 has no 2026 score to show. Published per contract — every plan under H2450 shares it.
Also available in 48 other ND counties
- Adams
- Barnes
- Benson
- Billings
- Bottineau
- Bowman
- Burke
- Cass
- Cavalier
- Dickey
- Divide
- Dunn
- Eddy
- Emmons
- Foster
- Golden Valley
- Grant
- Griggs
- Hettinger
- Kidder
- LaMoure
- Logan
- McHenry
- McIntosh
- McKenzie
- McLean
- Mercer
- Nelson
- Oliver
- Pembina
- Pierce
- Ramsey
- Ransom
- Renville
- Richland
- Rolette
- Sargent
- Sheridan
- Sioux
- Slope
- Stark
- Steele
- Towner
- Traill
- Walsh
- Ward
- Wells
- Williams
Benefits in plain text
Medica Prime Solution Standard w/Rx (Cost) (H2450-049-0) is a 2027 Cost Medicare Advantage plan offered by Medica, available to residents of Mountrail County, ND.
The monthly premium is $90.60.
With full Extra Help (the Low-Income Subsidy), the total monthly premium is $66.00.
The in-network deductible for health services is $200.00.
Its in-network out-of-pocket maximum is $7,150.00.
The drug deductible is $500.00. Tier 1 exempt.
At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1 (Preferred Generic): $0.00; tier 2 (Generic): $15.00; tier 3 (Preferred Brand): 15%; tier 4 (Non-Preferred Drug): 25%; tier 5 (Specialty Tier): 28%.
CMS gives the plan's contract (H2450) an overall rating of 3 out of 5 stars.
Email a copy of the plan benefit details
Plan facts come from the CMS plan Landscape file and the CMS plan benefit package (PBP) files.