PriorityMedicare Select (PPO)

PriorityMedicare Select (PPO) H4875-017 Plan Details
4.5 out of 5 stars

PriorityMedicare Select (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Priority Health
Plan ID: H4875-017

Have Medicare questions?

Talk to a licensed agent today to find a plan that fits your needs.

$157.00
Monthly Premium

PriorityMedicare Select (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Priority Health
Plan ID: H4875-017

Have Medicare questions?

Talk to a licensed agent today to find a plan that fits your needs.

PriorityMedicare Select (PPO) H4875-017 Plan Details
4.5 out of 5 stars

PriorityMedicare Select (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Priority Health
Plan ID: H4875-017

Have Medicare questions?

Talk to a licensed agent today to find a plan that fits your needs.

$157.00
Monthly Premium

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $0
Out of Pocket Max In-Network: $3500
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 to $15.00

Out-of-Network:

Doctor Office Visit:
Coinsurance for Medicare Covered Primary Care Office Visit 30%
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $0.00 to $40.00

Out-of-Network:

Doctor Specialty Visit:
Coinsurance for Medicare Covered Physician Specialist Office Visit 30%

Prior Authorization may be required for Doctor Specialty Visit
Prior authorization required
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$200.00 per day for days 1 to 6
$0.00 per day for days 7 to 90

Out-of-Network:
Coinsurance for Acute Hospital Services per Stay 30%

Prior Authorization may be required for Acute Hospital Services
Prior authorization required
Urgent Care
Copayment for Urgent Care $50.00

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $50.00

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 Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours

Copayment for Worldwide Emergency Transportation $215.00
Ambulance Transportation
In-Network:

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $215.00
Copayment for Medicare Covered Ambulance Services - Air $215.00

Out-of-Network:

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $215.00
Copayment for Medicare Covered Ambulance Services - Air $215.00

Please see Evidence of Coverage for Prior Authorization rules
Prior authorization required

Health Care Services and Medical Supplies

PriorityMedicare Select (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:
Copayment for Medicare-covered Chiropractic Services $20.00

Out-of-Network:
Coinsurance for Medicare Covered Chiropractic Services 30%
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)

Out-of-Network:
Coinsurance for Medicare Covered Diabetic Supplies and Services 30%

Prior Authorization may be required.
Prior authorization required
Durable Medical Eqipment (DME)
In-Network:
Coinsurance for Medicare-covered Durable Medical Equipment 20%

Out-of-Network:
Coinsurance for Medicare Covered Durable Medical Equipment 30%

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 $20.00
Copayment for Medicare-covered Lab Services $0.00 to $20.00

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $75.00
Copayment for Medicare-covered Therapeutic Radiological Services $25.00
Copayment for Medicare-covered X-Ray Services $30.00

Out-of-Network:

Outpatient Diag Procs/Tests/Lab Services:
Coinsurance for Medicare Covered Diagnostic Procedures/Tests 30%
Coinsurance for Medicare Covered Lab Services 0% to 30%
Coinsurance for Medicare Covered Diagnostic Radiological Services 30%
Coinsurance for Medicare Covered Therapeutic Radiological Services 30%
Coinsurance for Medicare Covered Outpatient X-Ray Services 30%

Prior Authorization may be required for Outpatient Diag Procs/Tests/Lab Services /Outpatient Diag/Therapeutic Rad Services
Prior authorization required
Home Health Care
In-Network:
Copayment for Medicare-covered Home Health Services $0.00

Out-of-Network:
Copayment for Medicare Covered Home Health $0.00

Prior Authorization may be required for Home Health Services
Prior authorization required
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
$200.00 per day for days 1 to 6
$0.00 per day for days 7 to 90

Out-of-Network:
Coinsurance for Psychiatric Hospital Services per Stay 30%

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

Out-of-Network:
Coinsurance for Medicare Covered Individual Sessions 30%
Coinsurance for Medicare Covered Group Sessions 30%
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $15.00 to $200.00

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $120.00

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $200.00

Out-of-Network:

Outpatient Hospital and ASC Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 30%
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 30%

Prior Authorization may be required for Outpatient Hospital and Ambulatory Surgical Center Services
Prior authorization required
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $20.00
Copayment for Medicare-covered Group Sessions $20.00

Out-of-Network:
Coinsurance for Medicare Covered Individual or Group Sessions 30%
Over-the-counter (OTC) Items
In-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0.00
You have a $25 allowance per quarter to use on OTC items.
Maximum Plan Benefit of $25.00 every three months
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $0.00 to $40.00

Out-of-Network:
Coinsurance for Medicare Covered Podiatry Services 30%
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

Out-of-Network:
Coinsurance for Skilled Nursing Facility Services per Stay 30%

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 $15.00 to $200.00

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.

Out-of-Network:

Medicare Covered Dental Services:
Coinsurance for Medicare Covered Comprehensive Dental 30%

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.
$40 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
$100 eyewear allowance to use towards eyeglasses (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 $100 reimbursement towards eyeglasses (lenses and frames).

Medicare Covered Vision Care
30% Coinsurance for Medicare Covered vision care.

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 $15.00 to $40.00
Copayment for Routine Hearing Exams $0.00
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0.00

Hearing Aids:
Copayment for Hearing Aids $295.00 to $1495.00
  • Maximum 2 Hearing Aids every year

Out-of-Network:

Medicare Covered Hearing Services:
Coinsurance for Medicare Covered Hearing Exams 30%

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:
  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
Tobacco use cessation
Yearly "Wellness" visit


Out-of-Network:

Medicare-covered Zero Dollar Preventive Services:
Coinsurance for Medicare Covered Medicare-covered Preventive Services 30%