Your 2027 plan documents
Find out what our PriorityMedicare® Thrive (PPO) plan offers you. Review your benefits in the chart below or by downloading any of your coverage documents.
Your coverage documents provide detailed explanations about how your plan works.
See your Certificate of Coverage for details.
Plan documents Select based on your county | |
|---|---|
Region 1 Allegan, Barry, Ionia, Kent, Montcalm, Muskegon, Ottawa | |
Region 2 Berrien, Branch, Calhoun, Cass, Clinton, Eaton, Gratiot, Hillsdale, Ingham, Jackson, Saint Joseph, Van Buren | |
Region 5 Genessee, Lapeer, Lenawee, Livingston, Macomb, Monroe, Oakland, Saginaw, Saint Clair, Shiawassee, Washtenaw, Wayne | |
| Coverage summary | |
|---|---|
Deductible The amount you'll pay for most covered medical services before you start paying only copayments or coinsurance and Priority Health pays the balance. | Region 1: $475 Region 2: $525 Region 5: $475 |
Out-of-pocket maximum This is the most you pay during a calendar year for 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. | $7,150 |
Doctor office visits Authorization rules may apply. | Each primary care visit: $0 copay Each palliative care physician visit: $0 copay |
| Specialist visits | One skin check: $0 All other specialists: $40 |
Inpatient hospital care No limit to the number of days covered by the plan each hospital stay. Authorization rules may apply. | Days 1-6: $450 copay per day Days 7 and beyond: $0 copay per day |
Preventive care Annual wellness visit and preventive services covered under Original Medicare | Each visit: $0 copay |
Virtual care Each primary care, urgent care, specialist or behavioral health provider virtual visit | $0 copay |
See a list of preventive services covered at $0 copay. Any additional preventive services approved by Medicare during the contract year will be covered.
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.
For existing members, the Annual Notice of Change outlines the year-over-year changes to the plan, including the basic benefits and embedded extras.
2027 Formulary & drug coverage
| Medicare Advantage Formulary | |
|---|---|
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 Care 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). | 2027 Priority Health Medicare Advantage formulary |
| Prescription drugs | Cost |
|---|---|
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 | $400 (tiers 3-5) |
Tier 1 (preferred generic drugs) You pay copays/coinsurance for drugs on this plan's formulary until your total yearly drug costs reach $2,400. | Preferred retail (30-day): $1 copay Standard retail (30-day): $6 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 $2,400. | Preferred retail (30-day): $7 copay Standard retail (30-day): $12 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 $2,400. | Preferred retail (30-day): 21% of the total cost Standard retail (30-day): 21% of the total cost Preferred mail order (90-day): 21% 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 $2,400. | Preferred retail (30-day): 25% of the total cost Standard retail (30-day): 25% 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 $2,400. | 29% of the total cost |
Visit the Approved Drug List to see if your prescriptions are covered.
Your 2026 plan documents
Find out what your PriorityMedicare Thrive (PPO) plan offers you. Review your benefits in the chart below or by downloading any of your coverage documents.
Your coverage documents provide detailed explanations about how your plan works.
- 2026 Evidence of Coverage (Regions 1, 2 and 5)
- 2026 Evidence of Coverage (Regions 3, 4)
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 (Regions 1, 2 and 5)
- 2026 Annual Notice of Change (Regions 3, 4)
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).
2026 PriorityMedicare Thrive coverage summary
This chart shows what our PriorityMedicare Thrive plan offers members.
| Deductible | |
|---|---|
| Regions 1, 2 and 5 | $270 |
| Regions 3 and 4 | $600 |
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 | |
|---|---|
| All Regions | $6,200 |
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 | |
|---|---|
| Days 1-7 | $375 copay per day |
| Days 8 and beyond | $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 visit | $0 copay |
| $0 copay for one skin check per plan year with a dermatologist and $40 copay for all other specialty copays | $0-$40 copay |
| Each palliative care physician visit | $0 copay |
Authorization rules may apply.
| Emergency and urgent care | |
|---|---|
| Each emergency room visit | $130 copay |
| Each urgent care visit | $50 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 |
| Anticoagulant lab services (if on blood thinners) | $0 copay |
| Diagnostic tests and procedures | |
|---|---|
| Medicare-covered diagnostic procedures and tests | $0 copay |
Authorization rules may apply.
| Outpatient X-rays | |
|---|---|
| One diagnostic mammogram, following a routine mammogram, per plan year | $0 copay |
| Medicare-covered outpatient X-rays | $20 copay |
| Diagnostic radiology services | |
|---|---|
| Medicare-covered diagnostic radiology services | $275 copay |
Diagnostic radiology includes services such as MRIs and CT scans.
Authorization rules may apply.
| Radiation therapy | |
|---|---|
| Medicare-covered radiation therapy services, such as cancer treatment | $40 copay |
| Preventive care | |
|---|---|
| Annual physical exam and preventive services covered under Original Medicare | $0 copay |
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®) | |
|---|---|
| One routine exam (including refraction with dilation as necessary) & one retinal imaging per year | $0 copay |
| Each year | $100 eyewear allowance |
| Dental services (by Delta Dental®) | |
|---|---|
| Two exams, two cleanings, one set of bitewing X-rays & one brush biopsy each year | $0 copay |
| All other X-rays, including panoramic, once every two years | $0 copay |
$1,500 annual maximum that applies to the following services: $0 for fillings (includes composite resin and amalgam once per tooth per lifetime, $0 for simple extractions one per tooth per lifetime, $0 for crown repairs once per tooth every 12 months, $0 for anesthesia, no limit when used during any of the services above.
| Routine hearing (by TruHearingTM) | |
|---|---|
| Routine exam | $0 copay |
| Per year, per ear for hearing aids from top manufacturers | $295-$1,495 copay |
Hearing aid cost includes three fitting and follow-up evaluations within the first year and 48 batteries per hearing aid.
| Chiropractic services | |
|---|---|
| Routine visit, up to 12 visits per year | $15 copay |
| Chiropractic X-ray services, performed once per year | $20 copay |
| Medicare-covered visit | $15 copay |
| Acupuncture services | |
|---|---|
| Medicare-covered visit | $20 copay |
| Routine visit, up to six visits per year for other conditions | $20 copay |
| Galleri® | |
|---|---|
| Once every other year | $150 copay |
The Galleri multi-cancer early detection test from GRAIL is a proactive blood test that screens for many deadly cancers before symptoms appear*
| ThriveFlex | |
|---|---|
| For over-the-counter (OTC) items | $60 per quarter (no rollover) |
| To use on fitness equipment, fitness facilities and nutrition support | $285 per year (no rollover) |
Use your ThriveFlex card to purchase over-the-counter (OTC) items as well as fitness equipment, memberships at fitness facilities and nutrition support applications like myFitnessPal and Noom. Learn more.
Priority Health Travel Pass
Priority Health Travel Pass has you covered for out-of-area 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.
| Virtual care | |
|---|---|
| Each primary care, specialist or behavioral health provider virtual 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.
| One Pass® | |
|---|---|
| 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 |
| CogniFit® | |
|---|---|
| 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 |
| Part D prescription drug, deductible | |
|---|---|
| Deductible | $250 (3-5) |
This deductible applies to the cost of all drugs on tiers 3-5 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.
| Erectile dysfunction drugs | |
|---|---|
| Slidenafil | Follows Tier 2 pricing below |
| Tadalafil 10mg, 20mg; vardenafil | Follows Tier 3 pricing below |
*These prescription drugs are not normally covered in a Medicare Prescription Drug Plan. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage) or your Rx deductible. In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this drug.
| Tier 1 (preferred generic drugs) | |
|---|---|
| Preferred retail (30-day) | $2 copay |
| Standard retail (30-day) | $7 copay |
| Preferred Mail-order (100-day) | $0 copay |
You pay copays/coinsurance for drugs on this plan's formulary until your total yearly drug costs reach $2,100.
| Tier 2 (generic drugs) | |
|---|---|
| Preferred retail (30-day) | $8 copay |
| Standard retail (30-day) | $15 copay |
| Preferred Mail-order (90-day) | $0 copay |
You pay copays/coinsurance for drugs on this plan's formulary until your total yearly drug costs reach $2,100.
| Tier 3 (preferred brand drugs) | |
|---|---|
| Preferred retail (30-day) | 21% coinsurance |
| Standard retail (30-day) | 21% coinsurance |
| Mail order (90-day) | 21% coinsurance |
You pay copays/coinsurance for drugs on this plan's formulary until your total yearly drug costs reach $2,100.
| Tier 4 (non-preferred drugs) | |
|---|---|
| Preferred retail (30-day) | 25% coinsurance |
| Standard retail (30-day) | 25% coinsurance |
| Mail order (90-day) | 25% coinsurance |
You pay copays/coinsurance for drugs on this plan's formulary until your total yearly drug costs reach $2,100.
| Tier 5 (specialty drugs) | |
|---|---|
| (30-day supplies only) | 30% coinsurance |
You pay copays/coinsurance for drugs on this plan's formulary until your total yearly drug costs reach $2,100.
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 $2,100 you pay $0 for the remainder of the plan year.
Enhanced Dental and Vision package
Optional benefit: Add additional dental and vision coverage to your plan for an extra $43 monthly premium, including additional dental coverage for things like crowns, root canals, implants 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.