| General information | PriorityMedicare Value plan |
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| 1. Premium and other important information |
Premium
You must have Medicare Parts A and B to enroll, and you must continue to pay your monthly Part B premium in addition to your Medicare Advantage plan premium. In-network limits - $0 yearly deductible
- $3,400 out-of-pocket limit for Medicare-covered services and select non-Medicare supplemental services
Out-of-network limits - $750 yearly deductible
- $3,400 out-of-pocket limit for Medicare-covered services and select non-Medicare supplemental services
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2. Doctor and hospital choice
For more information, see line 15, Emergency care, and line 16, Urgently needed care |
No referral required for network doctors, specialists, and hospitals |
| Inpatient care | PriorityMedicare Value plan |
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3. Inpatient hospital care
(includes substance abuse and rehabilitation services) |
In-network - $600 copay for each Medicare-covered hospital stay
- $0 copay for additional hospital days
Out-of-network - $700 copay for each Medicare-covered hospital stay
There is no limit to the number of days covered by the plan.
Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. |
| 4. Inpatient mental health care |
In-network - $600 copay for each Medicare-covered hospital stay
Out-of-network - $700 copay for each Medicare-covered hospital stay
Medicare covers up to 190 days in a psychiatric hospital in a person's lifetime. Inpatient psychiatric hospital services count toward the 190 day lifetime limitation only if certain conditions are met.
This limitation does not apply to inpatient psychiatric services furnished in a general hospital.
Except in an emergency, your doctor must tell Priority Health in advance that you are going to be admitted to the hospital. |
5. Skilled nursing facility care
(in a Medicare-certified skilled nursing facility) |
In-network
For Medicare-covered SNF stays: - Days 1-20: $0 copay per day
- Days 21-100: $120 copay per day
Out-of-network
For each SNF stay: - Days 1-20: $0 copay per day
- Days 21-100: $135 copay per day
The plan covers up to 100 days each benefit period.
No prior hospital stay is required.
Authorization rules may apply. |
6. Home health care
(includes medically necessary intermittent skilled nursing care, home health aide services, rehabilitation services, etc.) |
In-network
$0 copay for Medicare-covered home health visits
Out-of-network
$0 copay for Medicare-covered home health visits
Authorization rules may apply. |
| 7. Hospice care |
You must get care from a Medicare-certified hospice. Your plan will pay for a consultative visit before you select hospice. |
| Outpatient care | PriorityMedicare Value plan |
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| 8. Doctor office visits |
In-network doctors
- $15 copay for each primary care doctor visit for Medicare-covered benefits
- $40 copay for each specialist visit for Medicare-covered benefits
- $40 copay for each in-area, network urgent care Medicare-covered visit
Out-of-network doctors
$45 copay for each doctor visit (primary care or specialist)
Authorization rules may apply. |
| 9. Chiropractic services |
In-network
$20 copay for each Medicare-covered visit
Out-of-network
$45 copay for each Medicare-covered visit
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. |
| 10. Podiatry services |
In-network
$40 copay for each Medicare-covered visit
Out-of-network
$45 copay for each Medicare-covered visit
Medicare-covered podiatry benefits are for medically necessary foot care. |
| 11. Outpatient mental health care |
In-network - $40 copay for each Medicare-covered individual therapy visit
- $15 copay for each Medicare-covered group therapy visit
- $40 copay for each Medicare-covered individual therapy visit with a psychiatrist
- $15 copay for each Medicare-covered group therapy visit with a psychiatrist
- 40% of the cost for Medicare-covered partial hospitalization program services
Out-of-network - $50 copay for mental health specialty services
- 40% coinsurance (you pay 40%, plan pays 60%) for partial hospitalization
Authorization rules may apply. |
| 12. Outpatient substance abuse care |
In-network - $40 copay for Medicare-covered individual visits
- $15 copay for Medicare-covered group visits
Out-of-network
$50 copay for outpatient substance abuse
Authorization rules may apply. |
| 13. Outpatient services/surgery |
In-network - $75 copay for each Medicare-covered ambulatory surgical center visit
- $75 to $175 copay for each Medicare-covered outpatient hospital facility visit
Out-of-network - $100 copay for ambulatory surgical center visit
- $200 copay for outpatient hospital services
Authorization rules may apply. |
14. Ambulance service
(Medically necessary ambulance services) |
In-network
$75 copay for Medicare-covered ambulance services
Out-of-network
$75 copay for ambulance services
Authorization rules may apply. |
15. Emergency care
(You may go to any emergency room if you reasonably believe you need emergency care.) |
$65 copay for Medicare-covered emergency room visits - Worldwide coverage
- 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.
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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
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. |
17. Outpatient rehabilitation services
(Occupational therapy, physical therapy, speech and language therapy) |
In-network - $30 copay for Medicare-covered occupational therapy visits
- $30 copay for Medicare-covered physical and/or speech and language therapy visits
Out-of-network - $35 copay for occupational therapy services
- $35 copay for physical and/or speech and language therapy services
There may be limits on physical therapy, occupational therapy, and speech and language pathology services. If so, there may be exceptions to these limits. |
| Outpatient medical services and supplies | PriorityMedicare Value plan |
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18. Durable medical equipment
(Includes wheelchairs, oxygen, etc.) |
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
Authorization rules may apply. |
19. Prosthetic devices
(Includes braces, artificial limbs and eyes, etc.) |
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
Authorization rules may apply. |
| 20. Diabetes programs and supplies |
In-network - $0 copay for diabetes self-management training
- $0 copay for diabetes monitoring supplies
- $0 copay for therapeutic shoes or inserts
- If the doctor provides you services in addition to diabetes self-management training, separate cost sharing of $15 to $40 may apply.
Out-of-network - $10 copay for diabetes self-management training
- $10 copay for diabetic supplies and services
- $10 copay for Medicare-covered zero cost-sharing preventive services
- $10 copay for kidney disease education services
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| 21. Diagnostic tests, x-rays, lab services, and radiology services |
In-network - $0 to $10 copay for Medicare-covered lab services
- $0 to $125 copay for Medicare-covered diagnostic procedures and tests
- $15 copay for Medicare-covered x-rays
- $125 copay for Medicare-covered diagnostic radiology services (not including x-rays)
- $15 copay for Medicare-covered therapeutic radiology services
- If the doctor provides you services in addition to outpatient diagnostic procedures, tests and lab services, separate cost sharing of $15 to $40 may apply.
- If the doctor provides you services in addition to outpatient diagnostic and therapeutic radiology services, separate cost sharing of $15 to $40 may apply.
Out-of-network - $20 copay for outpatient diagnostic procedures/tests/lab services
- $25 copay for therapeutic radiological services
- $25 copay for outpatient x-rays
- $175 copay for diagnostic radiological services
- If the doctor provides you services in addition to outpatient diagnostic procedures/tests/lab services, therapeutic radiological services, outpatient x-rays, separate cost sharing of $45 may apply.
Authorization rules may apply. |
| 22. Cardiac and pulmonary rehabilitation services |
In-network - $15 copay for Medicare-covered cardiac rehabilitation services
- $15 copay for Medicare-covered intensive cardiac rehabilitation services
- $15 copay for Medicare-covered pulmonary rehabilitation services
Out-of-network - $35 copay for cardiac rehabilitation services
- $35 copay for intensive cardiac rehabilitation services
- $35 copay for pulmonary rehabilitation services
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| Preventive services coverage | PriorityMedicare Value plan |
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| 23. Preventive services and wellness/education programs |
$0 copay for all preventive services covered under Original Medicare at zero cost sharing: - Abdominal aortic aneurysm screening
- Alcohol misuse screening and behavioral counseling interventions in the primary care setting
- Behavioral therapy for cardiovascular disease, intensive, in the primary care setting
- Behavioral therapy for obesity, intensive, in the primary care setting
- Breast cancer screening (mammogram)
- Bone mass measurement
- Cardiovascular screening
- Cervical and vaginal cancer screening (Pap test and pelvic exam)
- Colorectal cancer screening
- Depression screening, annual, for adults in the primary care setting
- Diabetes screening
- Influenza vaccine
- Hepatitis B vaccine
- HIV screening
HIV screening is covered for people with Medicare who are pregnant and people at increased risk for the infection, including anyone who asks for the test. Medicare covers this test once every 12 months or up to three times during a pregnancy. Please contact plan for details. - Medical nutrition therapy services
- Personalized prevention plan services (annual wellness visits)
- Pneumococcal vaccine
- Prostate cancer screening (prostate specific antigen (PSA) test only)
- Sexually transmitted diseases (STIs): Screening for, and counseling to prevent
- Smoking cessation (counseling to stop smoking)
- Welcome to Medicare physical exam (initial preventive physical exam)
In-network
The plan covers the following supplemental education/wellness programs: - Written health education materials, including newsletters
- Nutritional benefit
- Additional smoking cessation
- Health club membership/fitness classes
Authorization rules may apply. |
| 24. Kidney disease and conditions |
In-network - $0 copay for kidney disease education services
- $10 copay for renal dialysis
Out-of-network
$10 copay for kidney disease education services |
| Prescription drug coverage | PriorityMedicare Value plan |
|---|
| 25. Prescription drugs |
For drugs covered under Medicare Part B
20% coinsurance (you pay 20%, plan pays 80%) for Part B-covered chemotherapy drugs and other Part B-covered drugs
Home infusion drugs, supplies and services
$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) providers
- The plan offers national in-network prescription coverage (i.e., this would include 50 states and the District of Columbia). 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 a Part D 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 provider must get prior authorization from Priority Health Medicare for certain drugs.
- You must go to certain pharmacies for a very limited number of drugs, due to special handling, provider coordination, or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan's website, formulary, 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.
- You pay $0 the first time you fill a prescription for certain drugs. These drugs will be listed as "free first fill" on the plan’s website, formulary, printed materials, and on the Medicare Prescription Drug Plan Finder on Medicare.gov.
- If you request a formulary exception for a drug and Priority Heath Medicare approves the exception, you will pay Tier 3: Non-preferred brand drugs cost sharing for that drug.
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| Prescription deductible |
$0 deductible for Part D drugs |
Initial coverage
(What you pay in 2012 until your total drug costs reach $2,930) |
At in-network retail pharmacies:
Generic drugs (tier 1) - $9 copay for a for a 31-day supply
- $27 copay for a 90-day supply
Preferred brand drugs (tier 2) - $40 copay for a for a 31-day supply
- $120 copay for a 90-day supply
Non-preferred brand drugs (tier 3) - $81 copay for a for a 31-day supply
- $243 copay for a 90-day supply
Specialty drugs (tier 4) - 33% coinsurance (you pay 33%, Priority Health pays 67%) for a for a 31-day supply
At in-network long-term care pharmacies:
Generic drugs (tier 1) - $9 copay for a for a 31-day supply
Preferred brand drugs (tier 2) - $40 copay for a for a 31-day supply
Non-preferred brand drugs (tier 3) - $81 copay for a 31-day supply
Specialty drugs (tier 4) - 33% coinsurance (you pay 33%, Priority Health pays 67%) for a 31-day supply
From a network mail order pharmacy:
Generic drugs (tier 1) - $22.50 copay for a 90-day supply
Preferred brand drugs (tier 2) - $100 copay for a 90-day supply
Non-preferred brand drugs (tier 3) - $202.50 copay for a 90-day supply
Specialty drugs (tier 4) - 33% coinsurance (you pay 33%, Priority Health pays 67%) for a 31-day supply
At out-of-network pharmacies:
Plan drugs may be covered in 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. In addition, you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from Priority Health Medicare.
Generic drugs (tier 1) - $9 copay for a 31-day supply
Preferred brand drugs (tier 2) - $40 copay for a 31-day supply
Non-preferred brand drugs (tier 3) - $81 copay for a 31-day supply
Specialty drugs (tier 4) - 33% coinsurance (you pay 33%, Priority Health pays 67%) for a 31-day supply
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Prescription coverage during the coverage gap
(The "donut hole") After you reach $2,930 in total drug costs and until you reach $4,700 in yearly out-of-pocket drug costs |
In-network:
You receive a discount on brand name drugs and pay 86% of the plan's costs for all generic drugs.
Out-of-network:You will be reimbursed up to 14% of the plan allowable cost for generic drugs. |
Catastrophic prescription coverage
This coverage begins after you reach $4,700 in out-of-pocket prescription costs |
In-network:
You pay the greater of: - 5% coinsurance (you pay 5%, Priority Health pays 95%), or
- A $2.60 copay for generic (including brand drugs treated as generic) and $6.50 copay for all other drugs
Out-of-network:
You will be reimbursed for drugs purchased out-of-network up to the plan's cost of the drug minus your cost share, the greater of: - 5% coinsurance(you pay 5%, Priority Health pays 95%), or
- A $2.60 copay for generic (including brand drugs treated as generic) and $6.50 copay for all other drugs
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| Other services | PriorityMedicare Value plan |
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| 26. Dental services |
In-network - $40 copay for Medicare-covered services
- 0% of the cost for up to 1 oral exam(s) every year
- 0% of the cost for up to 1 cleaning(s) every year
- 50% of the cost for up to 1 dental x-ray(s) every year
Plan offers additional comprehensive dental benefits.
Out-of-network
0% to 50% of the cost for preventive dental
Authorization rules may apply. |
| 27. Hearing services |
In-network
$15 to $40 copay for Medicare-covered diagnostic hearing exams
Out-of-network
$45 copay for Medicare-covered diagnostic hearing exams
In general, supplemental routine hearing exams and hearing aids not covered. |
| 28. Vision services |
In-network - $0 copay for one pair of eyeglasses or contact lenses after cataract surgery
- $0 to $40 copay for exams to diagnose and treat diseases and conditions of the eye
- If the doctor provides you services in addition to eye exams, separate cost sharing of $40 may apply.
Out-of-network - $45 copay for exams to diagnose and treat diseases and conditions of the eye
Non-Medicare supplemental eye exams and glasses not covered. |
| 29. Over-the-counter items |
This plan does not cover over-the-counter items. |
| 30. Transportation |
This plan does not cover routine transportation. |
| 31. Acupuncture |
This plan does not cover acupuncture. |
| Optional suppplemental dental | PriorityMedicare Value plan |
|---|
| 32. Premium and other important information |
Optional enhanced dental benefit: - $12.79 monthly premium, in addition to your monthly plan premium and the monthly Medicare Part B premium.
- $1,000 plan coverage limit every year for these benefits
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| 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 including your Medicare prescription drug coverage.
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.
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