Your 2019 PriorityMedicare Ideal plan information

Find out what our 2019 PriorityMedicare Ideal℠ (PPO) plan offers you. Review your benefits in the chart below or by downloading any of your coverage documents.

Your 2019 plan documents

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

2019 PriorityMedicare Ideal coverage summary

This chart shows what our 2019 PriorityMedicare Ideal plan offers members.

In-network benefits

Deductible

$80

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

$6,000

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

$260 copay per day
Days 1-6
$0 copay per day
Days 7 and beyond

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

Authorization rules may apply.

Doctor office visits

$20 copay
Each primary care doctor visit
$50 copay
Each specialist visit

New for 2019: Deductible does not apply to primary care visits, you'll pay your copay right away.

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

$40 copay
Medicare-covered lab services

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

Authorization rules may apply.

Diagnostic tests and procedures

$40 copay
Medicare-covered diagnostic procedures and tests

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

Authorization rules may apply.

Outpatient X-rays

$40 copay
Medicare-covered outpatient X-rays

 

Diagnostic radiology services

$125 copay
Medicare-covered diagnostic radiology services

Diagnostic radiology includes services such as MRIs and CT scans.

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

Authorization rules may apply.

Radiation therapy

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

 

Preventive care

$0 copay
Annual physical exam and preventive services covered under Original Medicare

See a list of preventive services covered at $0 copay, regardless of what's discussed with your provider. 

Services may require a referral from your doctor.

Preventive dental services

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

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

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 drug deductible

$125

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 $3,820.

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 $3,820.

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 $3,820.

Tier 4 (non-preferred drugs)

45% coinsurance
Preferred retail (30-day)
50% coinsurance
Standard retail (30-day)
45% coinsurance
Mail order (90-day)

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

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 $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 $32 monthly premium.

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