Your 2021 PriorityMedicare Vital plan information

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

Your 2021 plan documents

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

2021 PriorityMedicareVital coverage summary

This chart shows what our PriorityMedicare Vital plan offers members.

In-network benefits

Deductible

$0

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

$400 copay per day
Days 1-4
$0 copay per day
Days 5 and beyond

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

Authorization rules may apply

Doctor office visits

20% coinsurance
Each primary care visit  
20% coinsurance
Each specialist visit 

Authorization rules may apply.

Emergency  & urgent care

20% coinsurance
Each emergency room visit (up to $90)
20% coinsurance
Each urgent care visit (up to $65)

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

Deductible does not apply.

Lab services

$0 copay
Medicare-covered lab services

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.

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 (regular or periodontal maintenance) per year
$0 copay

One set of bitewing X-rays per year

Routine Hearing (by TruHearing)

$0 copay


Routine exam
$0 copay
Up to two TruHearing-branded "Advanced" hearing aids
One per ear, per year

Hearing aid cost includes 3 fitting and follow-up evaluations within the first year. 48 batteries per hearing aid.

Chiropractic services

20% coinsurance

Routine visit, up to 12 visits per year
20% coinsurance
Chiropractic X-ray services, performed once per year

Acupuncture services

$20 copay
Medicare-covered visit for chronic low back pain
$20 copay
Routine visit, up to six visits per year for other conditions

Over-the-counter (OTC) benefit allowance

$40
Per quarter allowance

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

Out-of-state travel benefit (with MultiPlan)


Get care anywhere in the U.S. for the same cost as if you were in-network in Michigan. You can see any Medicare-participating provider outside of Michigan, including providers in the Multiplan Medicare network. 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.

Virtual care

20% coinsurance
Each primary care, specialist or behavioral health 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.

BrainHQ

$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

$0
Tiers 1 and 2
$350
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 Drugs List on this website.

Tier 1 (preferred generic drugs)

$1 copay
Preferred retail (30-day)
$6 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 $4,130.

Tier 2 (generic drugs)

$4 copay
Preferred retail (30-day)
$10 copay
Standard retail (30-day)
$0 copay
Mail order (90-day)

You pay copays or coinsurance for drugs on this plan's formulary until your total yearly drug costs reach $4,130.

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 $4,130.

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 $4,130.

Tier 5 (specialty drugs)

26% coinsurance
(30-day supplies only)

You pay copays or coinsurance for drugs on this plan's formulary until your total yearly drug costs reach $4,130.

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 $4,130, 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 $6,550.

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 $6,550, you pay the greater of either 5% of the cost OR a copay of $3.70 for generic and $9.20 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 $37 monthly premium, including additional dental coverage for things like crowns, root canals, extractions, fillings, implants and more with $1,500 to spend each calendar year and another $150 per year toward your eyewear allowance.