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PriorityMedicare RxSM(PDP) plan
Need just prescription drug coverage?
PriorityMedicare Rx is a Medicare Part D prescription plan offered by Priority Health under contract with the federal government.
There's no deductible, so the plan begins paying for your prescriptions right away.
It's a great option when you have Original Medicare, with or without a Medigap (Medicare Supplement insurance) plan.
Your monthly premium is just $56.80 anywhere in Michigan.
This prescription drug plan is available to any resident of Michigan who is eligible for Medicare.
General information
PriorityMedicare Rx plan
The benefit information in this chart is a brief summary, not a complete description of plan benefits. You can get more information about this plan's benefits to help you make a decision about your coverage. Please check the Evidence of Coverage, or call a Priority Health Medicare Representative toll-free at 888 389-6676 from 8:30 a.m. – 5:00 p.m., Monday through Friday.
1. Premium
Premium: $56.80 a month. You must also continue to pay your Medicare Part B premium.
Different out-of-pocket costs may apply for people who have limited incomes, live in long term care facilities, or have access to Indian/Tribal/Urban (Indian Health Service).
The plan offers national in-network prescription coverage (i.e., this would include 50 states and DC). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan's service area (for instance when you travel). See a list of national pharmacy chains.
Total yearly drug costs are the total drug costs paid by both you and the plan.
The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition (step therapy).
Some drugs have quantity limits.
Your doctor or other health care provider must get prior authorization from this plan to prescribe certain drugs for you.
The plan will pay for certain over-the-counter drugs as part of its utilization management program. Some over-the-counter drugs are less expensive than prescription drugs and work just as well. Contact the plan for details.
You must go to certain pharmacies for a very limited number of drugs, due to special handling, provider coordination, or patient education requirements for these drugs that cannot be met by most pharmacies in your network. These "limited availability" (LA) drugs are listed here on the plan's website and in printed materials, as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov.
If the actual cost of a drug is less than the normal cost-sharing amount for that drug, you will pay the actual cost, not the higher cost-sharing amount.
If you request a formulary exception for a drug and Priority Health approves the exception, you will pay Non-Preferred Brand cost-sharing for that drug.
3. Prescription deductible
$0 deductible for Part D drugs
4. Initial coverage (what you pay in 2010 until your total drug costs reach $2,830)
Generally, the plan covers prescriptions filled at out-of-network pharmacies only under special circumstances, for instance, illness while traveling outside of the plan's service area where there is no network pharmacy.
You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy.
You will likely have to pay the pharmacy's full charge for the drug and submit a claim to Priority Health to receive reimbursement for the drug.
You will be reimbursed up to the full cost of the drug minus the in-network retail pharmacy copays above.
5. Prescription coverage during the coverage gap After you reach $2,830 in total drug costs and until you reach $4,550 in yearly out-of-pocket drug costs
In-network: You pay 100% of the cost of drugs, minus your Priority Health discount (averaging 16% for brand-name drugs and 58% for generic drugs)
Out-of-network: You will pay 100% of the pharmacy's full charge for drugs purchased out-of-network. You will not be reimbursed by this plan for out-of-network purchases when you are in the coverage gap. However, you should still submit documentation to Priority Health so we can add the amounts you spent out-of-network to your total out-of-pocket costs for the year.
6. Catastrophic prescription coverage This coverage begins after you reach $4,550 in out-of-pocket prescription costs
In-network: You pay the greater of:
A $2.50 copay for generic (including brand drugs treated as generic)and a $6.30 copay for all other drugs, or
5% coinsurance (you pay 5%, Priority Health pays 95%)
Out-of-network: You will be reimbursed for drugs purchased out-of-network up to the full cost of the drug minus the greater of:
A $2.50 copay for generic (including brand drugs treated as generic)and a $6.30 copay for all other drugs, or
5% coinsurance (you pay 5%, Priority Health pays 95%)
7. Coverage guarantee
All Medicare Part D prescription drug plans agree to stay in the program for a full year at a time. Each year, the plans decide whether to continue for another year. In addition, Medicare must approve our contract each year.
Even if a plan leaves the program, you won't lose Medicare prescription drug coverage. If a plan decides not to continue, it must send you a letter at least 90 days before your coverage ends. The letter will explain your options for Medicare Part D coverage in your area.
Plans may change from year to year.
We review our plans annually at Priority Health. We may make adjustments to ensure that we're providing the coverage you need at an affordable price.
Effective January 1 of each year there may be changes to plan benefits, our approved drug list, our pharmacy network, the counties where we offer plans and/or our monthly premiums, copays and coinsurance.
We'll send you information about upcoming changes in October of each year to give you time to review them before the annual enrollment period November 15 - December 31.
Summary of Benefits brochure
The Summary of Benefits gives you the chart that appears above, plus more information about the basics of this plan.
People with limited incomes may qualify for extra help to pay for their prescription drug costs. If you are eligible, Medicare could pay for 75% of your drug costs, including your monthly prescription drug premiums, annual deductibles, and coinsurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don't even know it. Learn more about extra help.
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