PriorityMedicare Select (PPO)
PriorityMedicare Select (PPO) H4875-017 Plan Details
PriorityMedicare Select (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Priority Health
Plan ID: H4875-017
HelpAdvisor Editorial Team analysis of data from the 2024 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
$157.00
Monthly Premium
PriorityMedicare Select (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Priority Health
Plan ID: H4875-017
HelpAdvisor Editorial Team analysis of data from the 2024 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
Michigan Counties Served
Allegan
Barry
Ottawa
Kent
Lenawee
Lapeer
Monroe
Alcona
Antrim
Mecosta
Clare
Hillsdale
Grand Traverse
Crawford
Benzie
Leelanau
Charlevoix
Manistee
Lake
Kalamazoo
Midland
Montcalm
Calhoun
Isabella
Newaygo
Van Buren
Mason
Missaukee
Osceola
Wexford
Cass
Muskegon
Berrien
Ionia
Saint Clair
Otsego
Oceana
Gladwin
Gratiot
Oscoda
Cheboygan
Montmorency
Kalkaska
Presque Isle
Iosco
Saint Joseph
Alpena
Sanilac
Roscommon
Shiawassee
Eaton
Emmet
Jackson
Wayne
Ingham
Clinton
Oakland
Branch
Macomb
Tuscola
Arenac
Bay
Washtenaw
Genesee
Saginaw
Ogemaw
Huron
Livingston
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
Hearing Aids: Copayment for Hearing Aids $295.00 to $1495.00
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:
Yearly "Wellness" visit Out-of-Network: Medicare-covered Zero Dollar Preventive Services: Coinsurance for Medicare Covered Medicare-covered Preventive Services 30% |
