Your 2026 plan documents
Find out what our PriorityMedicareSM Dual Eligible Special Needs Plan (D-SNP) (HMO) offers you. Review your benefits in the chart below or by downloading your coverage documents.
Your coverage documents provide detailed explanations about how your plan works.
- 2026 Evidence of Coverage
The Evidence of Coverage is the legal, detailed description of your benefits and costs. It also explains your rights and rules you need to follow when using your coverage for medical care and prescription drugs. - 2026 Annual Notice of Change
For existing members who have a 2024 Priority Health Medicare Advantage plan, the Annual Notice of Change outlines the year-over-year changes to the plan, including basic benefits and embedded extras. - 2026 PriorityMedicare D-SNP formulary
2026 PriorityMedicare D-SNP coverage summary
This chart shows what the PriorityMedicare D-SNP offers to our members. If you have Medicaid, you will owe the $0 cost-share we indicate below in each benefit. If you lose Medicaid eligibility, your cost-share will vary depending on the service you receive.
| Deductible | |
|---|---|
| The amount you'll pay for most covered medical services, in-network, before you start paying only copayments or coinsurance and Priority Health pays the balance. | $0 |
D-SNPs do not include a deductible.
| 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 Part D drug costs. If you are receiving full Medicaid benefits, you are not responsible for paying any out-of-pocket costs toward the maximum out-of-pocket amount for covered Part A and Part B services. | $9,250 |
| Inpatient hospital care | |
|---|---|
| Unlimited days | $0 copay per day |
No limit to the number of days covered by the plan each hospital stay.
Authorization rules may apply.
| Doctor office visits | |
|---|---|
| Each primary care doctor visit | $0 copay |
| Each specialist visit | $0 copay |
Authorization rules may apply for certain specialist visits.
| Emergency and urgent care | |
|---|---|
| Each emergency room visit | $0 copay |
| Each urgent care visit | $0 copay |
Get emergency or urgent care services wherever you are in the United States or all over the world.
| Lab services | |
|---|---|
| Medicare-covered lab services | $0 copay |
| Preventive care | |
|---|---|
| Annual physical exam and preventive services covered under Original Medicare | $0 copay |
See a list of preventive services.
| Dental services (by Delta Dental®) | |
|---|---|
$1,500 annual maximum on all covered dental services | $0 copay |
| Routine vision (by EyeMed) | |
|---|---|
| One routine exam (including refraction) & one retinal imaging per year | $0 copay |
| Each year | $200 for eyewear |
| Routine hearing (by TruHearing) | |
|---|---|
| Per hearing exam | $0 copay |
| Per hearing aid exam each year. $0 for Advanced Aids, per ear, every two years. | $0 copay |
| Virtual care | |
|---|---|
| Per visit | $0 copay |
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.
Prescription drug benefits
Curious about which pharmacies are in your network? Learn more.
| Part D prescription drug deductible | |
|---|---|
| Deductible | $615 (T3-5) - if you do not receive 'Extra Help' $0 (T3-5) - if you do receive 'Extra Help' |
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 digital Approved Drug List.
| All tiers | |
|---|---|
| Tiers 1 and 2 | $0 |
| Tiers 3-5 | 25% if you do not receive 'Extra Help' $0-$12.65 if you do receive 'Extra Help' |
| Transportation services | |
|---|---|
| Up to 30 one-way trips every year to or from health related locations. Trips are limited to 100 miles, members may also be reimbursed for mileage, up to 100 miles each way. | $0 |
Additional benefits
| Diabetes management | |
|---|---|
| Supplies and services | $0 |
Includes diabetes monitoring supplies, self-management training, and shoes or inserts.
Authorization rules may apply.
| Home health care | |
|---|---|
| Per visit | $0 |
| PriorityFlex allowance | |
|---|---|
| Per month (no rollover) | $70 |
Use your PriorityFlex benefit to purchase over-the-counter (OTC) items, bathroom modifications and safety devices, and if eligible, healthy food and produce, pest control services, personal care items, household supplies, meal delivery and select utilities.
Learn more about how to use your PriorityFlex benefit.
Benefit mentioned is part of a special supplemental benefit for chronically ill members with one of the following conditions: diabetes, chronic obstructive pulmonary disease (COPD), arrhythmias, depression, heart failure, prostate/breast/other cancers, and bipolar disorder. This is not a complete list of qualifying conditions. Even if you have a qualifying condition, you will not necessarily qualify to receive the benefit because coverage of the item or service depends on if you are chronically ill as defined by CMS and meet all applicable eligibility requirements. To see if you qualify, contact our Customer Care team by calling 833.939.0983 (TTY 711). From Oct. 1 – Mar. 31, we’re available seven days a week from 8 a.m. – 8 p.m. ET. From Apr. 1 – Sept. 30, we’re available Mon. – Fri. from 8 a.m. – 8 p.m. and Sat. 8 a.m. – noon ET.
Caregiver Support through Carallel
Unlimited caregiver support through caregiver advocates that can assist with:
- Health insurance
- Emotional support
- Stress management
- Housing and transportation
- Financial and legal guidance
Learn more about Caregiver Support.
One Pass®
Fitness membership and well-being network that provides access to an extensive network of gym locations and online workout classes.
Learn more about One Pass.