Your 2022 PriorityMedicare Value plan information

Find out what our PriorityMedicare ValueSM (HMO-POS) plan offers you. Review your benefits in the chart below or by downloading any of your coverage documents.

Your 2022 plan documents

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

2022 PriorityMedicare Value coverage summary

This chart shows what our PriorityMedicare Value plan offers members.

In-network benefits



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


This is the most you pay during a calendar year for in-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, Part D drug costs or services from out-of-network providers.

Inpatient hospital care

$325 copay per day
Days 1-5
$0 copay per day
Days 6 and beyond

There is no limit to the number of days covered by the plan each hospital stay.

Authorization rules may apply.

Doctor office visits

$5 copay
Each primary care visit
$45 copay
Each specialist visit
$0 copay
Each palliative care physician visit
Authorization rules may apply.

Emergency & urgent care

$90 copay
Each emergency room visit
$55 copay
Each urgent care visit

Get emergency or urgent care services wherever you are in the United States or all over the world.

Lab services

$10 copay
Medicare-covered lab services
$0 copay
Anticoagulant lab services (if on blood thinners)


Diagnostic tests and procedures

$10 copay
Medicare-covered diagnostic procedures and tests
Authorization rules may apply.

Outpatient X-rays

$35 copay
Medicare-covered outpatient X-rays

Diagnostic radiology services

$225 copay
Medicare-covered diagnostic radiology services

Diagnostic radiology includes services such as MRIs and CT scans. 

Authorization rules may apply.

Radiation therapy

$25 copay
Medicare-covered radiation therapy services, such as cancer treatment

Preventive services

$0 copay
Annual wellness visit 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.

Routine vision (by EyeMed®)

$0 copay
One routine exam (including refraction with dilation as necessary) & one retinal imaging per year
$100 eyewear allowance

Each year

Preventive dental services (by Delta Dental®)

$0 copay
Two oral exams and two cleanings per year (regular or periodontal maintenance)
$0 copay
One set of bitewing x-rays and one brush biopsy per year, all other x-rays one every two years

Routine hearing (by TruHearing™)

$0 copay

Routine exam
$295-$1,495 copay
Per year, per ear for hearing aids from top manufacturers 

Hearing aid cost includes three fitting and follow-up evaluations within the first year and 48 batteries per hearing aid.

Chiropractic services

$20 copay
Medicare-covered visit

Priority Health Travel Pass

Priority Health Travel Pass has you covered for out-of-state care at in-network prices, access to MultiPlan® Medicare Advantage providers, unlimited worldwide emergency and urgent care and Assist America® for global travel assistance. Learn more.

You may stay enrolled in the plan when outside of the service area for up to 12 months, as long as your residency remains in the service area.

Over-the-counter (OTC) benefit allowance

Per quarter

For use on drugs and health related products that do not need a prescription, such as allergy medication and eye drops. Learn more.

Virtual care

$0 copay
Each primary care, specialist or behavioral health provider virtual visit

Also referred to as "evisits" or "telehealth," virtual care is a cost-effective and convenient way to visit with a health care professional via phone or video for non-emergencies.

SilverSneakers health and fitness program

$0 copay

Free SilverSneakers® fitness membership gives you the freedom to access online workout videos, join LIVE classes, choose home fitness kits or visit any participating locations. Learn more.


$0 copay

A personal gym for the brain. You can access online exercises that improve memory, attention, brain speed and more. Learn more.

Prescription drug benefits

Have questions on drug tiers and costs? 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

Tiers 1 and 2
Tiers 3-5

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)

$2 copay
Preferred retail (30-day)
$7 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 $4,430.

Tier 2 (generic drugs)

$10 copay
Preferred retail (30-day)
$15 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 $4,430.

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 $4,430.

Tier 4 (non-preferred drugs)

50% coinsurance
Preferred retail (30-day)  
50% coinsurance
Standard retail (30-day)  
50% coinsurance
Mail order (90-day)
You pay copays for drugs on this plan's formulary until your total yearly drug costs reach $4,430.

Tier 5 (specialty drugs)

33% coinsurance
(30-day supplies only)

You pay copays for drugs on this plan's formulary until your total yearly drug costs reach $4,430.

Part D senior savings program for insulin

$35 copay or less
30-day supply of Lantus, Toujeo, Humalog, Humulin 100 ML or Lyumjev (preferred or standard retail pharmacy)
$0 copay
90-day supply of Humalog, Humulin 100 ML or Lyumjev (through Express Scripts mail order only)

Save on select insulins before you reach the coverage gap (“donut hole”) to help you manage your diabetes. You’ll pay no more than $35 for a month’s supply at the pharmacy.

Once you reach the coverage gap, your copays for the select insulins will range from $10-$35 depending on the insulin and pharmacy for a 30-day supply. 

Part D prescription drugs, while in the coverage gap

25% 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 $4,430, you'll enter what is called a coverage gap. At this time, you'll pay 25% 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 $7,050.

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 $7,050, you pay the greater of either 5% of the cost OR a copay of $3.95 for generic and $9.85 for all other drugs.

Optional benefits

Enhanced Dental and Vision package

Optional benefit: Add additional dental and vision coverage to your plan for an extra $29 monthly premium, including additional dental coverage for things like crowns, root canals, extractions, fillings and more with $2,500 to spend each calendar year and another $150 per year toward your eyewear allowance.

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