PriorityMedicare Vital (PPO)

PriorityMedicare Vital (PPO) H4875-022 Plan Details
3.5 out of 5 stars

PriorityMedicare Vital (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Priority Health.
Plan ID: H4875-022.

$0.00
Monthly Premium

PriorityMedicare Vital (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Priority Health.
Plan ID: H4875-022.

PriorityMedicare Vital (PPO) H4875-022 Plan Details
3.5 out of 5 stars

PriorityMedicare Vital (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Priority Health.
Plan ID: H4875-022.

$0.00
Monthly Premium

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $350
Out of Pocket Max In-Network: $4700
Out-of-Network: 4700
Initial Coverage Limit $4430
Catastrophic Coverage Limit $7,050
Primary Care Doctor Visit
In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0.00

Out-of-Network:

Doctor Office Visit:
Copayment for Medicare Covered Primary Care Office Visit $0.00
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Coinsurance for Physician Specialist Office Visit 0% to 20%
Prior Authorization may be required for Doctor Specialty Visit

Out-of-Network:

Doctor Specialty Visit:
Coinsurance for Medicare Covered Physician Specialist Office Visit 0% to 20%
Prior authorization required
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$435.00 per day for days 1 to 4
$0.00 per day for days 5 to 90
Prior Authorization may be required for Acute Hospital Services
Prior authorization required
Out-of-Network:
$435.00 per day for days 1 to 4
$0.00 per day for days 5 to 90
Urgent Care
Coinsurance for Urgent Care 20% up to $65.00
Coinsurance for Medicare Covered Urgent Care waived if you are admitted to hospital within 24 hours

Worldwide Coverage:
Coinsurance for Worldwide Urgent Coverage 20% up to $65.00
Emergency Room Visit
Coinsurance for Emergency Care 20% up to $90.00
Coinsurance for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours

Worldwide Coverage:
Coinsurance for Worldwide Emergency Coverage 20% up to $90.00
Ambulance Transportation
In-Network:

Ground Ambulance:
Coinsurance for Ground Ambulance Services 20%

Air Ambulance:
Coinsurance for Air Ambulance Services 20%
Out-of-Network:

Ambulance Services:
Coinsurance for Medicare Covered Ambulance Services - Ground 20%
Coinsurance for Medicare Covered Ambulance Services - Air 20%

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:
Coinsurance for Medicare-covered Chiropractic Services 20%
Coinsurance for Routine Care 20%
  • Maximum 12 Routine Care every year
Coinsurance for X-rays 20%
  • Maximum 1 Set every year
Out-of-Network:
Coinsurance for Medicare Covered Chiropractic Services 20% Coinsurance for Non-Medicare Covered Chiropractic Services 20%
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(Please see Evidence of Coverage)
Out-of-Network:
Copayment for Medicare Covered Diabetic Supplies and Services $0.00
Durable Medical Eqipment (DME)
In-Network:
Coinsurance for Medicare-covered Durable Medical Equipment 20%
Prior Authorization may be required for Durable Medical Equipment
Prior authorization required
Out-of-Network:
Coinsurance for Medicare Covered Durable Medical Equipment 20%
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Coinsurance for Medicare-covered Diagnostic Procedures/Tests 20%
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%
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Coinsurance for Medicare-covered X-Ray Services 20%
Prior Authorization may be required for Outpatient Diag/Therapeutic Rad Services

Out-of-Network:

Outpatient Diag Procs/Tests/Lab Services:
Coinsurance for Medicare Covered Diagnostic Procedures/Tests
20%
Copayment for Medicare Covered Lab Services
$0.00
Coinsurance for Medicare Covered Diagnostic Radiological Services 20%
Coinsurance for Medicare Covered Therapeutic Radiological Services 20%
Coinsurance for Medicare Covered Outpatient X-Ray Services 20%
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
Out-of-Network:
Copayment for Medicare Covered Home Health $0.00
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
$435.00 per day for days 1 to 4
$0.00 per day for days 5 to 90
Prior Authorization may be required for Psychiatric Hospital Services
Prior authorization required
Out-of-Network:
$435.00 per day for days 1 to 4
$0.00 per day for days 5 to 90
Mental Health Outpatient Care
In-Network:
Coinsurance for Medicare-covered Individual Sessions 20%
Coinsurance for Medicare-covered Group Sessions 20%
Out-of-Network:
Coinsurance for Medicare Covered Individual Sessions 20%
Coinsurance for Medicare Covered Group Sessions 20%
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 0% to 20%
Prior Authorization may be required for Outpatient Hospital Services

Outpatient Observation Services:
Coinsurance for Medicare Covered Observation Services 20%

Ambulatory Surgical Center Services:
Coinsurance for Ambulatory Surgical Center Services 20%
Prior Authorization may be required for Ambulatory Surgical Center Services

Out-of-Network:

Outpatient Hospital and ASC Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 0% to 20%
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 20%
Prior authorization required
Outpatient Substance Abuse Care
In-Network:
Coinsurance for Medicare-covered Individual Sessions 20%
Coinsurance for Medicare-covered Group Sessions 20%

Out-of-Network:
Coinsurance for Medicare-covered Individual Sessions 20%
Coinsurance for Medicare Covered Individual or Group Sessions 20%
Over-the-counter (OTC) Items
In-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $40.00 every three months
Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit
Podiatry Services
In-Network:
Coinsurance for Medicare-Covered Podiatry Services 20%
Out-of-Network:
Coinsurance for Medicare Covered Podiatry Services 20%
Skilled Nursing Facility Care
In-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$188.00 per day for days 21 to 100
Prior Authorization may be required for Skilled Nursing Facility Services
Prior authorization required
Out-of-Network:
$0.00 per day for days 1 to 20
$188.00 per day for days 21 to 100

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care
In-Network:

Preventive Dental:
Copayment for Oral Exams $0.00
  • Maximum 2 visits every year
Copayment for Prophylaxis (Cleaning) $0.00
  • Maximum 2 visits every year
Copayment for Dental X-Rays $0.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)

Comprehensive Dental:
Coinsurance for Medicare-covered Benefits 0% to 20%
Copayment for Periodontics $0.00
  • Maximum 2 visits every year
Prior Authorization may be required for Comprehensive Dental

Out-of-Network:

Medicare Covered Dental Services:
Coinsurance for Medicare Covered Comprehensive Dental 20%
Prior authorization required

Vision Benefits

The following vision services are covered from in-network providers.

Coverage Cost
Vision Benefits
In-Network:

Eye Exams:
Coinsurance for Medicare Covered Benefits 20%
Copayment for Routine Eye Exams $0.00
  • Maximum 1 Routine Eye Exam every year
Copayment for Retinal imaging $0.00
  • Maximum 1 Retinal imaging every year

Eyewear:
Copayment for Medicare-Covered Benefits $0.00
Maximum Plan Allowance of $100.00 every year for all Non-Medicare covered eyewear

Out-of-Network:

Medicare Covered Vision Services:
Coinsurance for Medicare Covered Eye Exams 20%
Coinsurance for Medicare Covered Eyewear 20%

Non Medicare Covered Vision Services:
Routine Vision Services
Up to $50.00 reimbursement for one routine exam
Up to $20.00 reimbursement for retinal imaging
Up to $100.00 reimbursement for eyewear

Hearing Benefits

The following hearing services are covered from in-network providers.

Coverage Cost
Hearing Benefits
In-Network:

Hearing Exams:
Coinsurance for Medicare Covered Benefits 0% to 20%
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 $0.00
  • Maximum 2 Hearing Aids
Up to two TruHearing-branded hearing aids every year (one per ear per year). Benefit is limited to TruHearings Advanced hearing aids, which come in various styles and colors. You must see a TruHearing provider to use this benefit.

Hearing aid purchases include:
"First year of follow-up provider visits
" 3-year warranty for loss and damage
" 60-day risk-free trial
" 80 batteries per aid
" Rechargeable battery option is available on Advanced Aids and Premium Aids

Benefit does not include or cover any of the following:

" Hearing aid accessories
" Additional provider visits
" Additional batteries
" Hearing aids that are not TruHearing-branded hearing aids
" Costs associated with loss & damage warranty claims
Costs associated with excluded items are the responsibility of the member and not covered by the plan.
Routine hearing exam and hearing aid copayments are not subject to the maximum out-of-pocket.



Out-of-Network:

Medicare Covered Hearing Services:
Coinsurance for Medicare Covered Hearing Exams 0% to 20%

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:
    Copayment for Medicare Covered Medicare-covered Preventive Services $0.00

    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
    • Preferred retail $1.00
    • Standard retail $6.00
    • Preferred mail order $1.00
    • Standard mail order $6.00
    Generic
    • Preferred retail $10.00
    • Standard retail $15.00
    • Preferred mail order $10.00
    • Standard mail order $15.00
    Annual Drug Deductible $350 (excludes Tiers 1 and 2)
    Preferred Generic
    • Preferred retail $2.00
    • Standard retail $12.00
    • Preferred mail order $2.00
    • Standard mail order $12.00
    Generic
    • Preferred retail $20.00
    • Standard retail $30.00
    • Preferred mail order $20.00
    • Standard mail order $30.00
    Annual Drug Deductible $350 (excludes Tiers 1 and 2)
    Preferred Generic
    • Preferred retail $3.00
    • Standard retail $18.00
    • Preferred mail order $0.00
    • Standard mail order $18.00
    Generic
    • Preferred retail $30.00
    • Standard retail $45.00
    • Preferred mail order $0.00
    • Standard mail order $45.00