PriorityMedicare ONE (HMO-POS)
PriorityMedicare ONE (HMO-POS) H2320-030 Plan Details
PriorityMedicare ONE (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Priority Health
Plan ID: H2320-030
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$0.00
Monthly Premium
PriorityMedicare ONE (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Priority Health
Plan ID: H2320-030
Have Medicare questions?
Talk to a licensed agent today to find a plan that fits your needs.
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $4300 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 POS (Out-of-Network): Doctor Office Visit: Coinsurance for Medicare Covered Primary Care Office Visit 50% Deductible may apply |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $0.00 to $35.00 POS (Out-of-Network): Doctor Specialty Visit: Coinsurance for Medicare Covered Physician Specialist Office Visit 50% Deductible may apply Prior Authorization may be required for Doctor Specialty Visit Prior authorization required |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: $285.00 per day for days 1 to 7 $0.00 per day for days 8 to 90 Out-of-Network: Coinsurance for Acute Hospital Services per Stay 50% Prior Authorization may be required for Acute Hospital Services Prior authorization required |
| Urgent Care | Copayment for Urgent Care $35.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $35.00 Copayment for Medicare Covered Urgent Care waived if you are admitted to hospital within 24 hours |
| Emergency Room Visit | Copayment for Emergency Care $120.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $120.00 Copayment for Worldwide Emergency Care waived if you are admitted to the hospital within 24 hours. Copayment for Worldwide Emergency Transportation $285.00 |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $265.00 Air Ambulance: Copayment for Air Ambulance Services $265.00 POS (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 ONE (HMO-POS) 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 $20.00 Copayment for Routine Care $20.00
POS (Out-of-Network): Coinsurance for Medicare Covered Chiropractic Services 50% Deductible does apply |
| 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) POS (Out-of-Network): Coinsurance for Medicare Covered Diabetic Supplies and Services 50% Deductible does apply Prior Authorization may be required Prior authorization required |
| Durable Medical Eqipment (DME) | In-Network: Coinsurance for Medicare-covered Durable Medical Equipment 20% POS (Out-of-Network): Durable Medical Equipment: Coinsurance for Medicare Covered Durable Medical Equipment 30% Deductible does apply 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 Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $175.00 Copayment for Medicare-covered Therapeutic Radiological Services $35.00 Copayment for Medicare-covered X-Ray Services $20.00 POS (Out-of-Network) 50% per day, per provider, for Outpatient Diag Procs/Tests/Lab Services. 50% per day, per provider for Outpatient Diag/Therapeutic Rad Services. Deductible does apply Prior Authorization may be required for Outpatient Diag/Therapeutic Rad Services/Diag Procs/Tests/Lab Services Prior authorization required |
| Home Health Care | In-Network: Copayment for Medicare-covered Home Health Services $0.00 POS (Out-of-Network:) Home Health Services: Copayment for Medicare-covered Home Health Services $0.00. Deductible does apply Prior Authorization may be required for Home Health Services. Prior authorization required |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $285.00 per day for days 1 to 7 $0.00 per day for days 8 to 90 Out-of-Network: Coinsurance for Psychiatric Hospital Services per Stay 50% Prior Authorization may be required for Psychiatric Hospital Services Prior authorization required |
| Mental Health Outpatient Care | In-Network: Copayment for Medicare-covered Individual Sessions $20.00 Copayment for Medicare-covered Group Sessions $20.00 POS (Out-of-Network): Coinsurance for Medicare Covered Individual Sessions 50% Coinsurance for Medicare Covered Group Sessions 50% Deductible does apply |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $285.00 Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $120.00 Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $285.00 POS (Out-of-Network): Outpatient Hospital and ASC Services: Coinsurance for Medicare Covered Ambulatory Surgical Center Services 50% Coinsurance for Medicare Covered Outpatient Hospital Services 50% Deductible does apply Prior Authorization may be required for Outpatient Hospital Services and Ambulatory Surgical Center Services |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $20.00 Copayment for Medicare-covered Group Sessions $20.00 POS (Out-of-Network): Coinsurance for Medicare-covered Individual Sessions 50% Coinsurance for Medicare-covered Group Sessions 50% Deductible does apply |
| Over-the-counter (OTC) Items | In-Network: Over-The-Counter (OTC) PLUS: Copayment for Over-The-Counter (OTC) PLUS Items $0.00 $26 allowance per month to use on OTC items. If eligible, this allowance can be used on healthy food and produce. Maximum Plan Benefit of $26.00 every month Deductible does not apply |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $0.00 to $35.00 Copayment for Routine Foot Care $0.00 to $35.00
POS (Out-of-Network): Coinsurance for Medicare Covered Podiatry Services 50% Deductible does apply |
| Skilled Nursing Facility Care | In-Network: Skilled Nursing Facility Services: $0.00 per day for days 1 to 20 $203.00 per day for days 21 to 100 (POS) Out-of-Network: Coinsurance for Skilled Nursing Facility Services per stay 50% Deductible does apply 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: Copayment for Medicare-covered Benefits $0.00 to $285.00 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. POS (Out-of-Network): Medicare Covered Dental Services: Coinsurance for Medicare Covered Comprehensive Dental 50% Deductible does apply 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: Medicare Covered Vision Services: $0 for annual glaucoma screenings. $0 for Medicare-covered eyewear after cataract surgery. $35 for each Medicare-covered exam to diagnose and treat diseases or conditions of the eye. $0 for annual diabetic retinopathy screening. Routine (Non-Medicare) Eye Exams & Eyewear $0 copay for annual routine vision exam $0 annual retinal imaging $175 eyewear allowance to use towards eyeglasses (lenses and frames). POS (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 $175 reimbursement towards eyeglasses (lenses and frames). Deductible does not apply. Medicare Covered Vision Care 50% Coinsurance for Medicare Covered vision care. Deductible does apply. |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $0.00 to $35.00 Copayment for Routine Hearing Exams $0.00
Hearing Aids: Copayment for Hearing Aids $295.00 to $1495.00
POS (Out-of-Network): Medicare Covered Hearing Services: Coinsurance for Medicare Covered Hearing Exams 50% |
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 POS (Out-of-Network): Medicare-covered Zero Dollar Preventive Services: Coinsurance for Medicare Covered Medicare-covered Preventive Services 50% Deductible does apply |
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