Your 2018 PriorityMedicare Ideal plan information
Find out what our 2018 PriorityMedicare Ideal℠ (PPO) plan offers you. Review your benefits in the chart below or by downloading any of your coverage documents.
Your 2018 plan documents
Your coverage documents provide detailed explanations about how your plan works.
- 2018 Summary of Benefits
- 2018 Evidence of Coverage
The Evidence of Coverage is the legal, detailed description of your benefits and costs for 2018. It also explains your rights and rules you need to follow when using your coverage for medical care and prescription drugs. - 2018 Priority Health Medicare Advantage Formulary
2018 PriorityMedicare Ideal coverage summary
This chart shows what our 2018 PriorityMedicare Ideal plan offers plan members.
Deductible
The amount you pay for combined in- and out-of-network covered health care services before Priority Health begins to pay.
In-network benefits
Out-of-pocket maximum
Inpatient hospital care
Days 1-6
Days 7 and beyond
Doctor office visits
Each primary care doctor visit
Each specialist visit
Authorization rules may apply.
Emergency & urgent care
Each emergency room visit
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
Medicare-covered lab services
If you receive additional services, cost-sharing for these services may apply.
Authorization rules may apply.
Diagnostic tests and procedures
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
Medicare-covered outpatient X-rays
If you receive additional services, cost-sharing for these services may apply.
Authorization rules may apply.
Diagnostic radiology services
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
Medicare-covered radiation therapy services, such as cancer treatment
If you receive additional services, cost-sharing for these services may apply.
Authorization rules may apply.
Preventive care
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 drug deductible
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)
Preferred retail (30-day)
Standard retail (30-day)
Mail order (90-day)
You pay copays for drugs on this plan's formulary until your total yearly drug costs reach $3,750.
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.
Tier 2 (generic drugs)
Preferred retail (30-day)
Standard retail (30-day)
Mail order (90-day)
You pay copays for drugs on this plan's formulary until your total yearly drug costs reach $3,750.
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.
Tier 3 (preferred brand drugs)
Preferred retail (30-day)
Standard retail (30-day)
Mail order (90-day)
You pay copays for drugs on this plan's formulary until your total yearly drug costs reach $3,750.
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.
Tier 4 (non-preferred drugs)
Preferred retail (30-day)
Standard retail (30-day)
Mail order (90-day)
You pay coinsurance for drugs on this plan's formulary until your total yearly drug costs reach $3,750.
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.
Tier 5 (specialty drugs)
You pay coinsurance for drugs on this plan's formulary until your total yearly drug costs reach $3,750.
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, while in the coverage gap
Covered generic drugs
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.
Dental services
Limited to Medicare-covered dental services
This includes Medicare-covered dental services such as extraction of teeth to prepare the jaw for radiation treatments. It does not include preventive services such as treatment, filling, removal or replacement of teeth.
Enhanced vision, dental & hearing coverage
Optional benefit available to add vision, dental and hearing coverage to your MAPD plan for an extra $29 monthly premium.
Get details and learn how to add this coverage to your plan.
Virtual care
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
For a fitness membership at a participating Silver&Fit® facility or up to 2 home fitness kits.