PriorityMedicare® Merit (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.

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.

$0

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.

Days 1-6

$275 copay per day

Days 7 and beyond

$0 copay per day

Each primary care visit

$0 copay

Each specialist visit

$45 copay

Each palliative care physician visit

$0 copay

Each emergency room visit

Each urgent care visit

$55 copay

Medicare-covered lab services

$20 copay

Anticoagulant lab services
(if on blood thinners)

$0 copay

Medicare-covered diagnostic procedures and tests

$20 copay

Medicare-covered outpatient X-rays

$35 copay

Medicare-covered diagnostic radiology services

$125 copay

Medicare-covered radiation therapy services, such as cancer treatment

$30 copay

Annual physical exam and preventive services covered under Original Medicare

$0 copay

One routine exam (including refraction with dilation as necessary) & one retinal imaging per year

$0 copay

Each year

$100 eyewear allowance

Two oral exams and two cleanings per year (regular or periodontal maintenance)

$0 copay

One brush biopsy, one fluoride treatment and one set of bitewing x-rays each year

$0 copay

Periapical radiographs as needed and all other radiographs (full-mouth series or panoramic x-rays) every 24 months

$0 copay

Routine exam

$0 copay

Per year, per ear for hearing aids from top manufacturers 

$295-$1,495 copay

Medicare-covered visit

Medicare-covered visit

$20 copay

Routine visit, up to six visits per year for other conditions

$20 copay

Each primary care, specialist or behavioral health provider virtual visit

$0 copay

Access to the largest nationwide network of gyms and fitness locations, live digital fitness classes, on-demand workouts, and home fitness kits. Learn more.

$0 copay

Get online brain training mode just for you to help improve your memory and focus all through your One Pass user account. Learn more.

$0 copay

Deductible

$0

Preferred retail (30-day)

$2 copay

Standard retail (30-day)

$7 copay

$0 copay

Preferred retail (30-day)

$10 copay

Standard retail (30-day)

$15 copay

$0 copay

Preferred retail (30-day)

25% coinsurance

Standard retail (30-day)

25% coinsurance

25% coinsurance

Preferred retail (30-day)

Standard retail (30-day)

(30-day supplies only)

33% coinsurance