PriorityMedicare® Latitude (PPO) plan details and documents

Region 1

Allegan, Barry, Kent, Lenawee, Ottawa

• Evidence of Coverage
• Annual Notice of Change

Region 2

Berrien, Calhoun, Cass, Ionia, Isabella, Kalamazoo, Mason, Midland, Missaukee, Montcalm, Muskegon, Newaygo, Oceana, Osceola, Otsego, St. Clair, Can Buren, Wexford

• Evidence of Coverage
• Annual Notice of Change

Region 3

Alcona, Antrim, Benzie, Charlevoix, Clare, Crawford, Grand Traverse, Hillsdale, Lake, Lapeer, Leelanau, Manistee, Mecosta, Monroe

• Evidence of Coverage
• Annual Notice of Change

Region 4

Alpena, Cheboygen, Eaton, Emmet, Gladwin, Gratiot, Presque Isle, Roscommon, Sanilac, Shiawassee, St. Joseph

• Evidence of Coverage
• Annual Notice of Change

Region 5

Arenac, Bay, Branch, Clinton, Genesee, Huron, Ingham, Livingston, Macomb, Oakland, Ogema, Saginaw, Tuscola, Washtenaw, Wayne

• Evidence of Coverage
• Annual Notice of Change

Deductible

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.

Doctor office visits

Authorization rules may apply.

Each primary care visit: $0 copay

Each palliative care physician visit: $0 copay

Inpatient hospital care

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

Authorization rules may apply.

Days 1-6: $225 copayper day

Days 7 and beyond: $0 copay per day

Preventive care

Annual wellness visit and preventive services covered under Original Medicare

Virtual care

Each primary care, specialist or behavioral health provider virtual visit

Important message about what you pay for vaccines: Our plan covers most Part D vaccines at no cost to you, even if you haven't paid your deductible (if your plan has a deductible). Call Customer Service for more information.

Important message about what you pay for insulin: You won't pay more than $35 for a one-month supply of each insulin product covered by our plan, no matter what cost-sharing tier it's on, even if you haven't paid your deductible (if your plan has a deductible).

Part D prescription drug, deductible

This deductible applies to the cost of all drugs on the plan's list of approved drugs or "formulary". View the Approved Drug List

Tier 1  (preferred generic drugs)

You pay copays/coinsurance for drugs on this plan's formulary until your total yearly drug costs reach $2,100.

Preferred retail (30-day): $2 copay

Standard retail (30-day): $7 copay

Preferred mail order (100-day): $0 copay

Tier 2 (generic drugs)

You pay copays/coinsurance for drugs on this plan's formulary until your total yearly drug costs reach $2,100.

Preferred retail (30-day): $8 copay

Standard retail (30-day): $15 copay

Preferred mail order (90-day): $0 copay

Tier 3 (preferred brand drugs)

You pay copays/coinsurance for drugs on this plan's formulary until your total yearly drug costs reach $2,100.

Preferred retail (30-day): 22% of the total cost

Standard retail (30-day): 25% of the total cost

Preferred mail order (90-day): 22% of the total cost

Tier 4 (non-preferred brand drugs)

You pay copays/coinsurance for drugs on this plan's formulary until your total yearly drug costs reach $2,100.

Preferred retail (30-day): 25% of the total cost

Standard retail (30-day): 30% of the total cost

Preferred mail order (90-day): 25% of the total cost

Tier 5 (specialty drugs)

30-day supply only

You pay copays/coinsurance for drugs on this plan's formulary until your total yearly drug costs reach $2,100.