2019 PriorityMedicareSM plan (HMO-POS)

This plan is ready to travel with you. Pay the same in- and out-of-network copays for many services, and the out-of-network deductible does not apply to PCP and specialist visits, labs, inpatient hospital stays, and more.

All Priority Health Medicare Advantage plans include:

  • Ways to save on prescription drugs, with Preferred Pharmacy pricing and $0 copay on 90-day mail order tier 1 and 2 drugs
  • Preventive dental services, including exams and cleanings
  • Free fitness center membership or at-home fitness kits

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In-network benefits

Deductible

$0

The amount you'll pay for most covered in-network medical services before you start paying only copayments or coinsurance and Priority Health pays the balance.

Out-of-pocket maximum

$3,400
This is the most you pay during a calendar year for in-network services before Priority Health begins to pay 100% of the allowed amount. This limit includes copayments, deductibles and coinsurance payments. It does not include monthly premiums, Part D drug costs or services from out-of-network providers.

Inpatient hospital care

$150 copay per day
Days 1-6
$0 copay per day
Days 7 and beyond

Copay is the same whether you go to in-network or out-of-network providers, and you don't have to meet the out-of-network deductible first - it doesn't apply.

No limit to the number of days covered by the plan each hospital stay.

Doctor office visits

$10 copay
Each primary care doctor visit
$40 copay
Each specialist visit

Copay is the same whether you go to in-network or out-of-network providers, and you don't have to meet the out-of-network deductible first - it doesn't apply.

Authorization rules may apply.

Emergency  & urgent care

$75 copay
Each emergency room visit
$50 copay
Each urgent care visit

Get emergency or urgent care services wherever you are in the United States or all over the world.

Deductible does not apply.

Lab services

$35 copay
Medicare-covered lab services

Copay is the same whether you go to in-network or out-of-network providers, and you don't have to meet the out-of-network deductible first - it doesn't apply.

If you receive additional services, cost-sharing for those services may apply.

Authorization rules may apply.

Diagnostic tests and procedures

$35 copay
Medicare-covered diagnostic procedures and tests

Copay is the same whether you go to in-network or out-of-network providers, and you don't have to meet the out-of-network deductible first - it doesn't apply.

If you receive additional services, cost-sharing for those services may apply.

Authorization rules may apply.

Outpatient X-rays

$35 copay
Medicare-covered outpatient X-rays

If you receive additional services, cost-sharing for those services may apply.

Authorization rules may apply.

Diagnostic radiology services

$100 copay
Medicare-covered diagnostic radiology services

Diagnostic radiology includes services such as MRIs and CT scans.

If you receive additional services, cost-sharing for those services may apply.

Authorization rules may apply.

Radiation therapy

$20 copay
Medicare-covered radiation therapy services, such as cancer treatment

If you receive additional services, cost-sharing for those services may apply.

Authorization rules may apply.

Preventive services

$0 copay
Annual wellness visit and preventive services covered under Original Medicare

See a list of preventive services covered at $0 copay. Any additional preventive services approved by Medicare during the contract year will be covered. 

Services may require a referral from your doctor.

Preventive dental services

$0 copay
2 oral exams and 2 cleanings per year
50% of costs
1 set of bitewing X-rays per year

Virtual care

$0 copay
Per visit

Also referred to as "evisits" or "remote access technologies," virtual care is a cost-effective and convenient way to visit with a health care professional via phone or video for non-emergencies.

Wellness (fitness) programs

$0 copay

For a fitness membership at a participating Silver&Fit® facility or up to 2 home fitness kits.


Prescription drug benefits

Have questions on drug tiers? Learn more.

You have lower copays when you use a preferred pharmacy. See if your pharmacy is on the "preferred" list.

Part D prescription drugs, deductible

$0

This deductible applies to the cost of all drugs on the plan's list of approved drugs, or "formulary." View the online Approved Drug List.

Tier 1 (preferred generic drugs)

$1 copay
Preferred retail (30-day)
$6 copay
Standard retail (30-day)
$0 copay
Mail order (90-day)

You pay copays or coinsurance for drugs on this plan's formulary until your total yearly drug costs reach $3,820.

Tier 2 (generic drugs)

$8 copay
Preferred retail (30-day)
$13 copay
Standard retail (30-day)
$0 copay
Mail order (90-day)

You pay copays or coinsurance for drugs on this plan's formulary until your total yearly drug costs reach $3,820.

Tier 3 (preferred brand drugs)

$38 copay
Preferred retail (30-day)
$43 copay
Standard retail (30-day)
$95 copay
Mail order (90-day)

You pay copays or coinsurance for drugs on this plan's formulary until your total yearly drug costs reach $3,820.

Tier 4 (non-preferred drugs)

40% coinsurance
Preferred retail (30-day)
45% coinsurance
Standard retail (30-day)
40% coinsurance
Mail order (90-day)

You pay copays or coinsurance for drugs on this plan's formulary until your total yearly drug costs reach $3,820.

Tier 5 (specialty drugs)

33% coinsurance
(30-day supplies only)

You pay copays or coinsurance for drugs on this plan's formulary until your total yearly drug costs reach $3,820.

Part D prescription drugs, while in the coverage gap

37% coinsurance
Covered generic drugs
25% coinsurance
Covered brand drugs

When you reach your total yearly drug cost (includes what our plan has paid and what you've paid) of $3,820, you'll enter what is called a coverage gap. At this time, you'll pay 37% of the plan's cost for covered generic drugs and 25% of the plan's cost for covered brand drugs, plus dispensing fee, until your total costs reach $5,100.

Most Medicare plans have this coverage gap (also called the "donut hole"), but not everyone will enter the coverage gap.

Part D prescription drugs, catastrophic coverage


After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $5,100, you pay the greater of either 5% of the cost OR a copay of $3.40 for generic and $8.50 for all other drugs.


Optional benefits

Enhanced Vision, Dental & Hearing Package


Optional benefit: Add vision, dental and hearing coverage to your MAPD plan for an extra $27.20 monthly premium.

Get details and learn how to add this coverage to your plan.

PriorityMedicareSM

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