2018 PriorityMedicare SelectSM (PPO)

Want a little more?

This plan gives you the most coverage, with the lowest out-of-pocket costs. You'll be free to go to doctors and hospitals that are outside our network. You won't need to get prior authorizations for services you need, as long as they're covered by your plan.

  • No deductible when you see doctors in our network
  • Includes drug coverage with no deductible
  • See specialists in our network without a referral
  • Coverage in the United States and around the world

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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

$3,750

This is the most you pay during a policy period (usually a year) before Priority Health begins to pay 100% of the allowed amount. This includes your copayments, deductibles and coinsurance payments. This limit does not include your monthly premium, Part D drug costs or services from out-of-network providers.

Inpatient hospital care

$140 copay per day
Days 1-5
$0 copay per day
Days 6 and beyond

Copay is the same whether you go to in-network or out-of-network providers.

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

Doctor office visits

$15 copay
Each primary care doctor visit
$40 copay
Each specialist visit

Copay is the same for in-network and out-of-network.

Authorization rules may apply.

Emergency & urgent care

$80 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

$30 copay
Medicare-covered lab services

Copay is the same whether you go to in-network or out-of-network providers.

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

Authorization rules may apply.

Diagnostic tests and procedures

$30 copay
Medicare-covered diagnostic procedures and tests

Copay is the same whether you go to in-network or out-of-network providers.

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

Authorization rules may apply.

Outpatient X-rays

$30 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

$ 25 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.

Dental services

$0 copay
1 oral exam and 1 cleaning per year
50% of costs
1 set of bitewing X-rays per year

$15-$125 copay for limited non-routine Medicare-covered dental services such as extraction of teeth to prepare the jaw for radiation treatments. This copay does not apply to preventive or routine care (cleanings, fillings, etc.).

Virtual care

$15 copay
Per visit

Also referred to as "remote access technologies," which is visiting with a health care professional over the phone or using online video.

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." Download the formulary to see approved drugs or view the Approved Drug List on this website.

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 for drugs on this plan's formulary until your total yearly drug costs reach $3,750.

Tier 2 (generic drugs)

$7 copay
Preferred retail (30-day)
$12 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 $3,750.

Tier 3 (preferred drugs)

$37 copay
Preferred retail (30-day)
$42 copay
Standard retail (30-day)
$92.50 copay
Mail order (90-day)

You pay copays for drugs on this plan's formulary until your total yearly drug costs reach $3,750.

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 coinsurance for drugs on this plan's formulary until your total yearly drug costs reach $3,750.

Tier 5 (specialty drugs)

33% coinsurance

You pay coinsurance for drugs on this plan's formulary until your total yearly drug costs reach $3,750.

Part D prescription drugs, while in the coverage gap

44% coinsurance
Covered generic drugs
35% coinsurance
Covered brand drugs

When you reach your total yearly drug cost (includes what our plan has paid and what you've paid) of $3,750, you'll enter what is called a coverage gap. At this time, you'll pay 44% of the plan's cost for covered generic drugs and 35% of the plan's cost for covered brand drugs, plus dispensing fee, until your total costs reach $5,000.

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 $5,000, you pay the greater of either: 5% of the cost OR a copay of $3.35 for generic and $8.35 for all other drugs.


Optional benefits

Enhanced vision, dental & hearing coverage

Optional benefit available to add vision, dental and hearing coverage to your MAPD plan for an extra $20.50 monthly premium.

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