Your 2016 PriorityMedicare Select plan information

Find out what our 2016 PriorityMedicare Select℠ (PPO) plan offers you. Review your benefits in the chart below or by downloading any of your coverage documents.

Your 2016 plan documents

Your coverage documents provide detailed explanations about how your plan works. 

PriorityMedicare Select coverage summary

This chart shows what our 2016 PriorityMedicare Select plan offers plan members. 

In-network benefits

Deductible

$0
The amount you pay for in-network covered health care services before Priority Health begins to pay.

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.

Inpatient hospital care

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

$0 copay for additional non-Medicare covered hospital days.

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
Authorization rules may apply.

Lab services

$30 copay
Medicare-covered lab services

If the doctor provides you services in addition to outpatient lab services, separate cost sharing of $20 to $40 may apply. Copay is the same for in-network and out-of-network.

Authorization rules may apply.

Diagnostic tests and procedures

$30 copay
Medicare-covered diagnostic procedures and tests

If the doctor provides you services in addition to outpatient diagnostic procedures and tests, separate cost sharing of $20 to $40 may apply.

Authorization rules may apply.

Outpatient X-rays

$30 copay
Medicare-covered outpatient X-rays

If the doctor provides you services in addition to outpatient X-rays, separate cost sharing of $20 to $40 may apply.

Authorization rules may apply.

Diagnostic radiology services

$100 copay
Medicare-covered diagnostic radiology services

Diagnostic radiology services include services such as MRIs and CT scans.

If the doctor provides you with services in addition to outpatient diagnostic, separate cost sharing of $25 to $50 may apply.

Authorization rules may apply.

Therapeutic radiology services

$ 25 copay
Medicare-covered therapeutic radiology services

If the doctor provides you services in addition to outpatient therapeutic radiology services (such as radiation treatment for cancer), separate cost sharing of $25 to $45 may apply.

Authorization rules may apply.

Preventive care

$0 copay
Annual physical exam 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.

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.

Retail pharmacy Part D prescription drugs, initial coverage

$4 copay
Preferred generic drugs (tier 1) 30-day
$12 copay
Preferred generic drugs (tier 1) 90-day
You pay the following for drugs on this plan's formulary until your total yearly drug costs reach $3,310.

These are the rest of the drug tiers for this plan. For one-month (30-day) / three-month (90-day) supplies:

  • Generic drugs (tier 2): $9/$27
  • Preferred brand drugs (tier 3): $40/$100
  • Non-preferred brand drugs (tier 4): $85/$212.50
  • Specialty drugs (tier 5): 33% coinsurance for a one-month (30-day) supply
Have questions on drug tiers? Learn more.

This plan uses a list of approved drugs, or a "formulary." The plan will send you the formulary or you can view the Approved Drug List on this website.

Mail order pharmacy Part D prescription drugs, initial coverage

$4 copay
Preferred generic drugs (tier 1) 30-day
$0 copay
Preferred generic drugs (tier 1) 90-day
You pay the following for drugs on this plan's formulary until your total yearly drug costs reach $3,310.

These are the rest of the drug tiers for this plan. For one-month (30-day) / three-month (90-day) supplies:

  • Generic drugs (tier 2): $9/$0
  • Preferred brand drugs (tier 3): $40/$100
  • Non-preferred brand drugs (tier 4): $85/$212.50
  • Specialty drugs (tier 5): 33% coinsurance for a one-month (30-day) supply
Have questions on drug tiers? Learn more.

This plan uses a list of approved drugs, or a "formulary." The plan will send you the formulary or you can view the Approved Drug List on this website.

Part D prescription drugs, while in the coverage gap

51%
Coinsurance,
covered generic drugs
40%
Coinsurance,
covered brand name drugs

When you reach your total yearly drug cost (includes what our plan has paid and what you've paid) of $3,700, you'll enter what is called a coverage gap. At this time, you'll pay 51% of the plan's cost for covered generic drugs and 40% of the plan's cost for covered brand name drugs until your total costs reach $4,950.

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 $4,850, you pay the greater of either:

5% of the cost
OR
A copay of $2.95 for generic (including brand drugs treated as generic) and $7.40 for all other drugs

Dental services

$0 copay
1 oral exam and 1 cleaning per year
50% of costs
1 set of bitewing X-rays per year
$15-$100 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.).

Fitness membership


Included with this plan through Silver&Fit®:

$0 copay for a fitness membership at a participating Silver&Fit facility or a home fitness program.