2021 PriorityMedicare IdealSM (PPO)

This plan is one of our best for helping you manage chronic conditions, you’ll get the care you need, at a price you can afford. Plus, PriorityMedicare Ideal includes free companion care, giving you help with chores and transportation.

Our Medicare Advantage plans include the benefits you need, plus the extras you want. Like preventive dental services and routine vision and hearing coverage, including hearing aids and a $100 eyewear allowance. Plus, a free gym membership or home workout options. And if you’re headed south or get care in another state, our plans cover you at in-network prices anywhere in the U.S. outside of Michigan.

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In-network benefits

Deductible

$0

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

Out-of-pocket maximum

$5,800

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

Inpatient hospital care

$300 copay per day
Days 1-6
$0 copay per day
Days 7 and beyond

There is no limit to the number of days covered by the plan each hospital stay.

Authorization rules may apply.

Doctor office visits

$15 copay
Each primary care visit
$45 copay
Each specialist visit

Authorization rules may apply.

Emergency & urgent care

$90 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.

Lab services

$15 copay
Medicare-covered lab services

Diagnostic tests and procedures

$15 copay
Medicare-covered diagnostic procedures and tests

Authorization rules may apply.

Outpatient X-rays

$40 copay
Medicare-covered outpatient X-rays

 

Diagnostic radiology services

$150 copay
Medicare-covered diagnostic radiology services

Diagnostic radiology includes services such as MRIs and CT scans. 

Authorization rules may apply.

Radiation therapy

$30 copay
Medicare-covered radiation therapy services, such as cancer treatment

 

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.

Preventive dental services (by Delta Dental®)

$0 copay
Two oral exams and two cleanings (regular or periodontal maintenance) per year
$0 copay

One set of bitewing X-rays per year

Routine vision (by EyeMed®)

$0 copay
One routine exam (including refraction with dilation as necessary) & one retinal imaging per year
$100 eyewear allowance


Each year

Routine hearing (by TruHearing™)

$0 copay

Routine exam
$295-$1,495 copay
Per year, per ear for hearing aids from top manufacturers 

Hearing aid cost includes three fitting and follow-up evaluations within the first year and 48 batteries per hearing aid.

Chiropractic services

$20 copay
Routine visit, up to 12 visits per year
$40 copay
Chiropractic X-ray services, performed once per year
$20 copay

Medicare-covered visit

Acupuncture services

$20 copay
Medicare-covered visit for chronic low back pain
$20 copay
Routine visit, up to six visits per year for other conditions

Out-of-state travel benefit (with MultiPlan)

You'll pay in-network prices when seeking care anywhere in the U.S. outside of Michigan, when you see Medicare-participating providers. Learn more.
 
You may stay enrolled in the plan when outside of the service area for up to 12 months, as long as your residency remains in the service area.

Over-the-counter (OTC) benefit allowance

$75
Per quarter allowance

For use on drugs and health related products that do not need a prescription, such as allergy medication and eye drops. Learn more.

Virtual care

$0 copay
Each primary care, specialist or behavioral health virtual visit

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

Companion care with Papa

8 hours
Per month

Connects college students ("Papa Pals") with Medicare Advantage members for assistance with things like:

  • Technology support
  • Household chores
  • Transportation
  • Meal prep
  • Companionship

Learn more.

SilverSneakers health and fitness program

$0 copay

Membership at participating SilverSneakers® fitness centers, plus access to online educational programs and SilverSneakers On-DemandTM workout videos. Learn more.

BrainHQ

$0 copay

A personal gym for the brain. You can access online exercises that improve memory, attention, brain speed and more. Learn more.


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
Tiers 1 and 2
$125
Tiers 3-5

This deductible applies to the cost of all drugs on the plan's list of approved drugs, or "formulary." Download the formulary to see approved drugs or view the Approved Drug List on this website.

Tier 1 (preferred generic drugs)

$4 copay
Preferred retail (30-day)
$9 copay
Standard retail (30-day)
$0 copay
Mail order (90-day)

You pay copays for drugs on this plan's formulary until your total yearly drug costs reach $4,130.

Tier 2 (generic drugs)

$13 copay
Preferred retail (30-day)
$18 copay
Standard retail (30-day)
$0 copay
Mail order (90-day)

You pay copays for drugs on this plan's formulary until your total yearly drug costs reach $4,130.

Tier 3 (preferred brand drugs)

$42 copay
Preferred retail (30-day)  
$47 copay
Standard retail (30-day)  
$105 copay
Mail order (90-day)

You pay copays for drugs on this plan's formulary until your total yearly drug costs reach $4,130.

Tier 4 (non-preferred drugs)

50% coinsurance
Preferred retail (30-day)  
50% coinsurance
Standard retail (30-day)  
50% coinsurance
Mail order (90-day)
You pay copays for drugs on this plan's formulary until your total yearly drug costs reach $4,130.

Tier 5 (specialty drugs)

30% coinsurance
(30-day supplies only)

You pay copays for drugs on this plan's formulary until your total yearly drug costs reach $4,130.

Part D prescription drugs, while in the coverage gap

25% 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 $4,130, you'll enter what is called a coverage gap. At this time, you'll pay 25% 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 $6,550.

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 $6,550, you pay the greater of either 5% of the cost OR a copay of $3.70 for generic and $9.20 for all other drugs.


Optional benefits

Enhanced Dental and Vision package

Optional benefit: Add additional dental and vision coverage to your plan for an extra $37 monthly premium, including additional dental coverage for things like crowns, root canals, extractions, fillings, implants and more with $1,500 to spend each calendar year and another $150 per year toward year eyewear allowance.
 

PriorityMedicare IdealSM

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