PriorityMedicare D-SNP (HMO D-SNP)
PriorityMedicare D-SNP (HMO D-SNP) H8379-001 Plan Details
PriorityMedicare D-SNP (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Priority Health
Plan ID: H8379-001
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$0.00
Monthly Premium
PriorityMedicare D-SNP (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Priority Health
Plan ID: H8379-001
Have Medicare questions?
Talk to a licensed agent today to find a plan that fits your needs.
Michigan Counties Served
Gladwin
Wayne
Kalamazoo
Gratiot
Oscoda
Midland
Allegan
Ingham
Montmorency
Isabella
Cheboygan
Montcalm
Clinton
Calhoun
Kalkaska
Ottawa
Mason
Presque Isle
Iosco
Newaygo
Missaukee
Barry
Van Buren
Oakland
Lapeer
Branch
Macomb
Kent
Tuscola
Monroe
Osceola
Wexford
Alcona
Arenac
Mecosta
Hillsdale
Alpena
Cass
Muskegon
Antrim
Saint Joseph
Washtenaw
Bay
Lenawee
Clare
Berrien
Saginaw
Genesee
Sanilac
Roscommon
Ogemaw
Shiawassee
Eaton
Grand Traverse
Emmet
Crawford
Ionia
Benzie
Otsego
Huron
Oceana
Charlevoix
Saint Clair
Manistee
Leelanau
Livingston
Lake
Jackson
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $8500 Out-of-Network: N/A |
| Initial Coverage Limit | $5030 |
| Catastrophic Coverage Limit | $8,000 |
| Primary Care Doctor Visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0.00 |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $0.00 Prior Authorization may be required for Doctor Specialty Visit Prior authorization required |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: Copayment for Acute Hospital Services per Stay $0.00 Your plan covers an unlimited number of days for an inpatient stay. Prior Authorization may be required for Acute Hospital Services Prior authorization required |
| Urgent Care | Copayment for Urgent Care $0.00 Coinsurance for Medicare Covered Urgent Care waived if you are admitted to hospital within 24 hours Worldwide Coverage: Copayment for Worldwide Urgent Coverage $0.00 |
| Emergency Room Visit | Copayment for Emergency Care $0.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $0.00 Copayment for Worldwide Emergency Transportation $0.00 |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $0.00 Air Ambulance: Copayment for Air Ambulance Services $0.00 Please see Evidence of Coverage for Prior Authorization rules Prior authorization required |
Health Care Services and Medical Supplies
PriorityMedicare D-SNP (HMO D-SNP) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).
| Coverage | Cost |
|---|---|
| Chiropractic Services | In-Network: Copayment for Medicare-covered Chiropractic Services $0.00 Copayment for Routine Care $0.00
|
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Copayment for Medicare-covered Diabetic Supplies $0.00 Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0.00 Diabetic Supplies and Services limited to those from specified manufacturers when obtained from a retail or mail order pharmacy (Please see Evidence of Coverage) Prior Authorization may be required Prior authorization required |
| Durable Medical Eqipment (DME) | In-Network: Copayment for Medicare-covered Durable Medical Equipment $0.00 Prior Authorization may be required for Durable Medical Equipment Prior authorization required |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00 Copayment for Medicare-covered Lab Services $0.00 Prior Authorization may be required for Outpatient Diag Procs/Tests/Lab Services Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $0.00 Copayment for Medicare-covered Therapeutic Radiological Services $0.00 Copayment for Medicare-covered X-Ray Services $0.00 Prior Authorization may be required for Outpatient Diag/Therapeutic Rad Services Prior authorization required |
| Home Health Care | In-Network: Copayment for Medicare-covered Home Health Services $0.00 Prior Authorization may be required for Home Health Services Prior authorization required |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: Copayment for Psychiatric Hospital Services per Stay $0.00 Prior Authorization may be required for Psychiatric Hospital Services Prior authorization required |
| Mental Health Outpatient Care | In-Network: Copayment for Medicare-covered Individual Sessions $0.00 Copayment for Medicare-covered Group Sessions $0.00 |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0.00 Outpatient Observation Services: Copayment for Medicare Covered Observation Services $0.00 Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0.00 Prior Authorization may be required for Outpatient Hospital Services and Ambulatory Surgical Center Services Prior authorization required |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $0.00 Copayment for Medicare-covered Group Sessions $0.00 |
| Over-the-counter (OTC) Items | In-Network: Over-The-Counter (OTC) Items: See "PriorityFlex" benefit below |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $0.00 Copayment for Routine Foot Care $0.00
|
| Skilled Nursing Facility Care | In-Network: Skilled Nursing Facility Services: $0.00 per day for days 1 to 20 $0.00 per day for days 21 to 100 Prior Authorization may be required for Skilled Nursing Facility Services Prior authorization required |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | In-Network: Medicare-covered Dental Services: $0 for Medicare-covered surgical procedures performed by a physician/practitioner in a provider’s office. $0 for each Medicare-covered visit with a specialist. $0 for each Medicare-covered ambulatory surgical center or outpatient hospital facility visit. Non Medicare-covered (Routine) Dental Services: $0 for two preventive exams per year.* $0 for two cleanings (regular or periodontal maintenance) per year.* $0 for two additional periodontal maintenance cleanings (four total each year).* $0 for one set (up to 4 films in a single visit) of bitewing x-rays per year.*$0 for one brush biopsy per year.* $0 for periapical x-rays (as needed), radiographs (full mouth or panoramic x-rays) once every 24 months.* $0 for one fluoride treatment per year.* $0 for non-surgical periodontal procedures (scaling and root planing) per quadrant every 24 consecutive months.* $0 for minor restorative services including fillings (once per tooth, every 24 months) and crown repair (once per tooth, every 12 months).* $0 for simple and surgical extraction of teeth (once per tooth per lifetime).* $0 for bridges and dentures (once every 5 years).* $0 for relines and repairs to bridges and dentures (once every 36 months, per appliance).* $0 for anesthesia (no limit) with qualifying dental procedures.* Maximum Plan Benefit of $2,500 annual maximum on all Covered Dental Services.* *These dental services do not apply to your deductible or out-of-pocket maximum |
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | In-Network: Medicare Covered Vision Services: Copayment for Medicare Covered Eye Exams $0.00 Copayment for Medicare Covered Eyewear $0.00 Routine (Non-Medicare) Eye Exams & Eyewear $0 copay for annual routine vision exam $0 annual retinal imaging $200 eyewear allowance to use towards lenses and frames. |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | In-Network: Medicare-covered Hearing Exams: Copayment for Medicare Covered Benefits $0.00 Routine Hearing Coverage: Copayment for Routine Hearing Exams $0.00
Hearing Aids: Copayment for TruHearing 'Advanced' Aids, one per ear, each year $0.00
|
Preventive Services and Health/Wellness Education Programs
The following services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Preventive Services and Health/Wellness Education Programs | In-Network: $0.00 copay for Medicare Covered Preventive Services: Abdominal aortic aneurysm screening Alcohol misuse screenings & counseling Bone mass measurements (bone density) Cardiovascular disease screenings Cardiovascular disease (behavioral therapy) Cervical & vaginal cancer screening Colorectal cancer screenings Depression screenings Diabetes screenings Diabetes self-management training Glaucoma tests Hepatitis B (HBV) infection screening Hepatitis C screening test HIV screening Lung cancer screening Mammograms (screening) Nutrition therapy services Obesity screenings & counseling One-time Welcome to Medicare preventive visit Prostate cancer screenings(PSA) Sexually transmitted infections screening & counseling Shots:
Yearly "Wellness" visit |
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