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PriorityMedicare

Broad coverage. Predictable copays.

Choose your county

Do you use your medical benefits frequently? This plan may be a good choice. You pay a slightly higher premium than you would for the PriorityMedicare Value plan, but your copays and out-of-pocket costs are less.
  • This plan includes Medicare Part D prescription drug coverage with no deductible.
  • As with our other Medicare Advantage plans, you won't need a referral to see specialists.
  • Go to any doctor or hospital you want; you have a deductible and a slightly higher copay when using out-of-network services.
  • Our local Michigan customer service representatives answer 96% of our members' questions on the first phone call.

Enroll now



General information
PriorityMedicare 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, deductible, and other important information

Premium (in your area)
(Call for pricing and availability) $33.40 monthly plan premium, which is in addition to your monthly Medicare Part B premium. $56.20 monthly plan premium, which is in addition to your monthly Medicare Part B premium. $69.80 monthly plan premium, which is in addition to your monthly Medicare Part B premium. $89.90 monthly plan premium, which is in addition to your monthly Medicare Part B premium. $110.80 monthly plan premium, which is in addition to your monthly Medicare Part B premium. (This plan is not available in your county.) (This plan is not available in your county.)

In-network limits
$3,400 limit to out-of-pocket medical expenses

Out-of-network limits
2. Doctor and hospital choice

No referral required for doctors, specialists, and hospitals
Inpatient care coverage
PriorityMedicare plan

3. Inpatient hospital care
(includes substance abuse and rehabilitation services)

There is no limit to the number of days covered by the plan each benefit period.

Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital.


  • Days 1-5: $75 copay per day
  • $0 copay per day for additional days

Out-of-network

  • Days 1-5: $175 copay per day
  • $0 copay per day for additional days
4. Inpatient mental health care

Medicare covers up to 190 days in a psychiatric hospital in a person's lifetime.

Plan covers up to 60 lifetime reserve days at the copays shown.

Except in an emergency, your doctor must tell Priority Health in advance that you are going to be admitted to the hospital.

In-network

  • Days 1-5: $75 copay per day
  • $0 copay per day for additional days

Out-of-network

  • Days 1-5: $175 copay per day
  • $0 copay per day for additional days
5. Skilled nursing facility care
(in a Medicare-certified skilled nursing facility)

The plan covers up to 100 days each benefit period. Authorization rules may apply. No prior hospital stay is required.

  • $0 copay per day for days 1-20
  • $120 copay per day for days 21-100
Out-of-network
  • $0 copay per day for days 1-20
  • $135 copay per day for days 21-100

6. Home health care
(includes medically necessary intermittent skilled nursing care, home health aide services, rehabilitation services, etc., from in-network home health care agencies)
In-network
$0 copay for Medicare-covered home health visits
Out-of-network
$0 copay for Medicare-covered home health visits
7. Hospice care
You must get care from a Medicare-certified hospice. Your claims will be paid by Original Medicare.
In-network
$30 copay for each Medicare-covered hospice consultation
Out-of-network
$35 copay for each Medicare-covered hospice consultation
Outpatient care coverage
PriorityMedicare plan
8. Doctor office visits

Also see line 33, Physical exams, for more information.

In-network doctors

  • $10 copay for each visit to your primary care doctor for Medicare-covered services
  • $30 copay for each specialist visit for Medicare-covered services
  • $35 copay for each doctor visit (primary care or specialist)
9. Chiropractic services

Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers.

In-network
$30 copay for each Medicare-covered visit

Out-of-network
$35 copay for each Medicare-covered visit
10. Podiatry services

Medicare-covered podiatry benefits are for medically necessary foot care.

In-network
$30 copay for each Medicare-covered visit

Out-of-network
$35 copay for each Medicare-covered visit
11. Outpatient mental health care

In-network
$40 copay for each Medicare-covered individual or group therapy visit

Out-of-network
$50 copay for each Medicare-covered visit
12. Outpatient substance abuse care

Authorization rules may apply.

In-network
$40 copay for Medicare-covered individual or group therapy visits

Out-of-network
$50 copay for each Medicare-covered visit
13. Outpatient services/surgery

In-network

  • $50 copay for each Medicare-covered ambulatory surgical center visit
  • $50 copay for each Medicare-covered outpatient hospital visit

Out-of-network

  • $75 copay for each Medicare-covered ambulatory surgical center visit
  • $75 copay for each Medicare-covered outpatient facility visit
14. Ambulance service

$50 copay for Medicare-covered ambulance services. Out-of-network deductible does not apply. Authorization rules may apply.
15. Emergency care

$50 copay for Medicare-covered emergency room visits

  • Covered worldwide
  • If you are admitted to the hospital within 24 hours for the same condition that brought you to the emergency room, you pay $0 for the emergency room visit.
  • Out-of-network deductible does not apply.
16. Urgently needed care
This is not emergency care, and in most cases, is out of the service area.

$40 copay for Medicare-covered urgently needed care visits

  • Covered worldwide
  • If you are admitted to the hospital within 24 hours for the same condition that brought you to the urgent care center, you pay $0 for the urgent-care center visit.
  • Out-of-network deductible does not apply.
17. Outpatient rehabilitation services

In-network

  • $0 copay for cardiac rehabilitation visits
  • $20 copay for Medicare-covered occupational therapy visits
  • $20 copay for Medicare-covered physical and/or speech/language therapy visits

Out-of-network

  • $10 copay for cardiac rehabilitation visits
  • $25 copay for Medicare-covered occupational therapy visits
  • $25 copay for Medicare-covered visits to a comprehensive outpatient rehabilitation therapy facility
Outpatient medical services and supplies
PriorityMedicare plan
18. Durable medical equipment

Authorization rules may apply.

In-network
20% coinsurance (you pay 20%, plan pays 80%) of the cost of Medicare-covered items

Out-of-network
30% coinsurance (you pay 30%, plan pays 70%) of the cost of Medicare-covered items
19. Prosthetic devices
(includes braces, artificial limbs and eyes, etc.)

Authorization rules may apply.

In-network
20% coinsurance (you pay 20%, plan pays 80%) of the cost of Medicare-covered items

Out-of-network
30% coinsurance (you pay 30%, plan pays 70%) of the cost of Medicare-covered items
20. Diabetes self-monitoring training, nutrition therapy, and supplies
(includes coverage for glucose monitors, test strips, lancets, screening tests, and self-management training)

Separate office visit copay may also apply.

In-network
$0 copay

Out-of-network
$10 copay per service or supply
21. Diagnostic tests, x-rays, lab services, and radiology services

Separate office visit copay may apply. Authorization rules may apply.

In-network

  • $10 copay for Medicare-covered lab services
  • $15 copay for Medicare-covered x-rays
  • $15 copay for Medicare-covered therapeutic radiology services
  • $20 copay for Medicare-covered diagnostic radiology services

Out-of-network

  • $20 copay for Medicare-covered lab services
  • $20 copay for Medicare-covered x-rays
  • $20 copay for Medicare-covered therapeutic radiology services
  • $25 copay for Medicare-covered diagnostic radiology services
Preventive services coverage
PriorityMedicare plan
22. Bone mass measurement

A separate office visit copay may apply in addition to the copay for this service.

In-network
$0 copay for Medicare-covered service

Out-of-network
$10 copay for Medicare-covered service
23. Colorectal screening exams
(for people with Medicare age 50 and older)

A separate office visit copay may apply in addition to the copay for this service.

In-network
$0 copay for Medicare-covered service

Out-of-network
$10 copay for Medicare-covered service
24. Immunizations

In-network

  • $0 copay for flu and pneumonia vaccines, no referral needed
  • $0 copay for hepatitis B vaccine
$10 copay

25. Mammograms
(annual screening, for women with Medicare age 40 and older)
In-network
$0 copay for Medicare-covered screening mammograms
$10 copay for Medicare-covered screening mammograms

26. Pap smears and pelvic exams
(for women with Medicare coverage)

A separate office visit copay may apply in addition to the copay for this service.

In-network
$0 copay for Medicare-covered services

Out-of-network:
$10 copay for Medicare-covered services
27. Prostate cancer screening exams

A separate office visit copay may apply in addition to the copay for this service.

In-network
$0 copay for Medicare-covered services

Out-of-network
$10 copay for Medicare-covered services
28. End stage renal disease

In-network

  • $10 copay for renal dialysis
  • $0 copay for nutrition therapy for end stage renal disease
  • $10 copay for renal dialysis
  • $10 copay for nutrition therapy for end stage renal disease
Prescription drug coverage
PriorityMedicare plan
29. Prescription drugs

For drugs covered under Medicare Part B
20% coinsurance for Part B-covered chemotherapy drugs and other Part B-covered drugs

For drugs covered under Medicare Part C
$0 copay for home infusion drugs that would normally be covered under Part D. This cost-sharing amount will also cover the supplies and services associated with home infusion of these drugs.

For drugs covered under Medicare Part D

  • This plan uses a list of approved drugs, or "formulary." The plan will send you the formulary. You can also see the formulary on this website.
  • 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.
Prescription deductible
$0 deductible for Part D drugs
Initial coverage
(what you pay in 2010 until your total drug costs reach $2,830)

At in-network retail pharmacies:

Generic drugs (tier 1)

  • $8 copay for a for a 31-day supply
  • $24 copay for a 90-day supply

Preferred brand drugs (tier 2)

  • $30 copay for a for a 31-day supply
  • $90 copay for a 90-day supply

Non-preferred brand drugs (tier 3)

  • $60 copay for a for a 31-day supply
  • $180 copay for a 90-day supply

Specialty drugs (tier 4)

  • 25% coinsurance (you pay 25%, Priority Health pays 75%) for a for a 31-day supply

 

At in-network long term care pharmacies:

Generic drugs (tier 1)

  • $8 copay for a for a 31-day supply

Preferred brand drugs (tier 2)

  • $30 copay for a for a 31-day supply

Non-preferred brand drugs (tier 3)

  • $60 copay for a 31-day supply

Specialty drugs (tier 4)

  • 25% coinsurance (you pay 25%, Priority Health pays 75%) for a 31-day supply

From a network mail order pharmacy:

Generic drugs (tier 1)

  • $20 copay for a 90-day supply

Preferred brand drugs (tier 2)

  • $75 copay for a 90-day supply

Non-preferred brand drugs (tier 3)

  • $150 copay for a 90-day supply

Specialty drugs (tier 4)

  • 25% coinsurance (you pay 25%, Priority Health pays 75%) for a 31-day supply
At out-of-network pharmacies:
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.
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.
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%)
Preventive services, continued
PriorityMedicare plan

30. Dental services
In general, preventive dental benefits such as cleanings are not covered. For other services, authorization rules may apply.
In-network
$30 copay for Medicare-covered services
Out-of-network
$35 copay for Medicare-covered services

31. Hearing services
You are covered in- or out-of-network for $350 for hearing aids every 3 years
In-network
  • $30 copay for Medicare-covered diagnostic hearing exams
  • $30 copay for one routine hearing exam each year
Out-of-network
$35 copay for Medicare-covered diagnostic hearing exams

32. Vision services
You are covered in- or out-of-network for $100 for eye wear (glasses or contacts) every 2 years

In-network
  • $0 copay for one pair of eyeglasses or contact lenses after cataract surgery
  • $30 copay for exams to diagnose and treat diseases and conditions of the eye
  • $30 copay for one routine eye exam each year
  • $35 copay for exams to diagnose and treat diseases and conditions of the eye
  • $0 copay for one pair of eyeglasses or contact lenses after cataract surgery

33. Physical exams
Limited to one exam every year.
In-network
$10 copay for routine exams
Out-of-network
$15 copay for routine exams 

34. Health and wellness education
In-network
$0 copay for each Medicare-covered smoking cessation counseling session
This plan also covers:
  • Written health education materials, including newsletters
  • Nutritional training
  • Additional smoking cessation

Out-of-network
Not covered

35. Transportation
This plan does not cover routine transportation.

36. Acupuncture
This plan does not cover acupuncture.
Coverage guarantee

All Medicare Advantage 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 Medicare health 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 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.


Enroll now

Summary of Benefits brochure

The Summary of Benefits gives you the chart that appears above, plus more information about the basics of this plan.

Download, view and print the Summary of Benefits (887KB PDF)*  This link will open in a new window.

Evidence of Coverage booklet

This booklet contains all the details of what the plan covers and how to work with Priority Health, including:

  • Your rights and responsibilities under this plan
  • How you can leave or quit this plan ("disenrollment")
  • What protections you have under this plan

Download, view and print the Evidence of Coverage booklet (1.7MB PDF)*  This link will open in a new window.

Extra help with your premiums

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.

 


* You'll need Adobe® Reader software to view and print PDF files. Download it free now!


Updated: January 07, 2010

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