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 Summary of Benefits
- 2019 Evidence of Coverage
The Evidence of Coverage is the legal, detailed description of your benefits and costs for 2019. It also explains your rights and rules you need to follow when using your coverage for medical care and prescription drugs. - Delta Dental Certificate of Coverage
- 2019 Priority Health Medicare Advantage Formulary
2019 PriorityMedicare Ideal coverage summary
This chart shows what our 2019 PriorityMedicare Ideal plan offers members.
In-network benefits
Deductible
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
This is the most you pay for in-network services during a calendar year for in-network services 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
Days 1-6
Days 7 and beyond
Doctor office visits
Each primary care doctor visit
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
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.
Preventive dental services
1 oral exam and 1 cleaning per year
1 set of bitewing X-rays per year
If you receive additional services, cost-sharing for those services may apply.
Virtual care
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
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
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 $3,820.
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 $3,820.
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 $3,820.
Tier 4 (non-preferred 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 $3,820.
Tier 5 (specialty drugs)
(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
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 $3,820, 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.