PriorityMedicare Vital (PPO)
PriorityMedicare Vital (PPO) H4875-022 Plan Details
PriorityMedicare Vital (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Priority Health
Plan ID: H4875-022
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$0.00
Monthly Premium
PriorityMedicare Vital (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Priority Health
Plan ID: H4875-022
Have Medicare questions?
Talk to a licensed agent today to find a plan that fits your needs.
Michigan Counties Served
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $350 |
| Out of Pocket Max |
In-Network: $5100 Out-of-Network: N/A |
| Initial Coverage Limit | $5030 |
| Catastrophic Coverage Limit | $8,000 |
| Primary Care Doctor Visit | In-Network & Out-of-Network: Doctor Office Visit: Copayment for Medicare Covered Primary Care Office Visit $0.00 |
| Specialty Doctor Visit | In-Network & Out-of-Network: Doctor Specialty Visit: Copayment for Medicare Covered Physician Specialist Office Visit $0.00 to $50.00 Prior Authorization may be required for Doctor Specialty Visit Prior authorization required |
| Inpatient Hospital Care | In-Network & Out-of-Network: Acute Hospital Services: $350.00 per day for days 1 to 5 $0.00 per day for days 6 to 90 Prior Authorization may be required for Acute Hospital Services Prior authorization required |
| Urgent Care | Copayment for Urgent Care $60.00 Copayment for Medicare Covered Urgent Care waived if you are admitted to hospital within 24 hours Worldwide Coverage: Copayment for Worldwide Urgent Coverage $60.00 |
| Emergency Room Visit | Copayment for Emergency Care $120.00 Worldwide Coverage: Copayment for Worldwide Emergency Coverage $120.00 Copayment for Worldwide Emergency Transportation $265.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours |
| Ambulance Transportation | In-Network & Out-of-Network: Ground Ambulance: Copayment for Ground Ambulance Services $265.00 Air Ambulance: Copayment for Air Ambulance Services $265.00 Please see Evidence of Coverage for Prior Authorization rules Prior authorization required |
Health Care Services and Medical Supplies
PriorityMedicare Vital (PPO) 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 & Out-of-Network: Copayment for Medicare-covered Chiropractic Services $20.00 Copayment for Routine Care $20.00
|
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network & Out-of-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) |
| Durable Medical Eqipment (DME) | In-Network & Out-of-Network: Coinsurance for Medicare-covered Durable Medical Equipment 20% Prior Authorization may be required for Durable Medical Equipment Prior authorization required |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network & Out-of-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: Coinsurance for Medicare-covered Diagnostic Radiological Services 20% Copayment for Medicare-covered Therapeutic Radiological Services $40.00 Copayment for Medicare-covered X-Ray Services $40.00 Prior Authorization may be required for Outpatient Diag/Therapeutic Rad Services Prior authorization required |
| Home Health Care | In-Network & Out-of-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 & Out-of-Network: Psychiatric Hospital Services: $350.00 per day for days 1 to 5 $0.00 per day for days 6 to 90 Prior Authorization may be required for Psychiatric Hospital Services Prior authorization required |
| Mental Health Outpatient Care | In-Network & Out-of-Network: Copayment for Medicare-covered Individual Sessions $20.00 Copayment for Medicare-covered Group Sessions $20.00 |
| Outpatient Services / Surgery | In-Network & Out-of-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $300.00 Prior Authorization may be required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $120.00 Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $300.00 Prior Authorization may be required for Ambulatory Surgical Center Services Prior authorization required |
| Outpatient Substance Abuse Care | In-Network & Out-of-Network: Copayment for Medicare-covered Individual Sessions $20.00 Copayment for Medicare-covered Group Sessions $20.00 |
| Over-the-counter (OTC) Items | Over-The-Counter (OTC) PLUS Items: Copayment for Over-The-Counter (OTC) PLUS Items $0.00 You have a $30 allowance per month to use on OTC items. If eligible, this allowance can be used on healthy food and produce. Maximum Plan Benefit of $30.00 every month. |
| Podiatry Services | In-Network & Out-of-Network: Copayment for Medicare-Covered Podiatry Services $0.00 to $50.00 |
| Skilled Nursing Facility Care | In-Network & Out-of-Network: Skilled Nursing Facility Services: $0.00 per day for days 1 to 20 $203.00 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 | Routine (Non Medicare-covered) Dental: $0 copay for two exams, two cleanings (regular or periodontal), one set of bitewing x-rays, one brush biopsy per year. A $2,500 allowance to use towards simple (non-surgical extractions), fillings, crown repairs, and anesthesia when used in conjunction with the other services (see EOC for more details). Maximum Plan Benefit of $2500.00 every year for Non Medicare-covered comprehensive. In-Network & Out-of-Network: Medicare Covered Dental Services: Copayment for Medicare-covered Benefits $0.00 to $300.00 Prior Authorization may be required for Medicare-covered Dental. Prior authorization required |
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | In-Network & Out-of-Network: Medicare Covered Vision Services: Copayment for Medicare Covered Eye Exams $0.00 to $50.00 Copayment for Medicare Covered Eyewear $0.00 In-Network: Routine (Non-Medicare) Eye Exams & Eyewear $0 copay for annual routine vision exam $0 annual retinal imaging $125 eyewear allowance to use towards lenses and frames. Out-of-Network: Routine (Non-Medicare) Eye Exams & Eyewear Up to $50 reimbursement for routine eye exam Up to $20 reimbursement for routine retinal imaging Up to $125 reimbursement towards eyeglasses (lenses and frames). |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | Routine Hearing Coverage: Copayment for Routine Hearing Exams $0.00
Hearing Aids: Copayment for TruHearing 'Advanced' Aids, one per ear, each year $0.00
In-Network & Out-of-Network: Medicare-covered Hearing Exams: Copayment for Medicare Covered Benefits $0.00 to $50.00 |
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 & Out-of-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 |
Prescription Drug Costs and Coverage
The PriorityMedicare Vital (PPO) plan offers the following prescription drug coverage, with an annual drug deductible of $350 (excludes Tiers 1 and 2) per year.
| Coverage |
Cost
|
|---|---|
|
Coverage & Cost
|
|
| Annual Drug Deductible | $350 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
| Annual Drug Deductible | $350 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
| Annual Drug Deductible | $350 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
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