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PriorityMedicare Vital (PPO) - H4875-022-002
$0.00
Monthly Premium
PriorityMedicare Vital (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Priority Health
Plan ID: H4875-022-002
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$0.00
Monthly Premium
Michigan Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.
Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.
Learn more about Michigan Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price. Speak with a licensed insurance agent to review plans available to you at 1-800-557-6059 (TTY 711,24/7).
Enrollment may be limited to certain times of the year. See why you may be able to enroll.
Basic Costs and Coverage
| Coverage | Details |
|---|---|
| Monthly plan premium | $0.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $350.00 |
| Out-of-pocket maximum | $5,600.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,000.00 |
| Primary care doctor visit | In-Network & Out-of-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0 Deductible may apply. |
| Specialty doctor visit | In-Network & Out-of-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $0 to $50
Prior Authorization may be required for Doctor Specialty Visit |
| Inpatient hospital care | In-Network & Out-of-Network: Acute Hospital Services: $350 per day for days 1 to 5 $0 per day for days 6 to 90 Deductible applies. Prior Authorization may be required for Acute Hospital Services. |
| Urgent care | In-Network & Out-of-Network: Urgent Care: Copayment for Urgent Care $55
Worldwide Coverage: Copayment for Worldwide Urgent Care $55
Deductible does not apply. |
| Emergency room visit | In-Network & Out-of-Network: Emergency Care: Copayment for Emergency Care $120
Worldwide Coverage: Copayment for Worldwide Emergency Coverage $120
Copayment for Worldwide Emergency Transportation $265 Deductible does not apply. |
| Ambulance transportation | In-Network & Out-of-Network: Ground Ambulance: Copayment for Ground Ambulance Services $265 Air Ambulance: Copayment for Air Ambulance Services $265 Deductible does not apply. Prior authorization may apply for Ambulance Services |
Health Care Services and Medical Supplies
PriorityMedicare Vital (PPO) covers a range of additional benefits. Learn more about PriorityMedicare Vital (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| Chiropractic services | In-Network & Out-of-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $20 Copayment for Routine Care $20
|
| Diabetes supplies, training, nutrition therapy and monitoring | In-Network & Out-of-Network: Diabetic Supplies and Services: Copayment for Medicare-covered Diabetic Supplies $0 Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0 Deductible may apply. |
| Durable medical equipment (DME) | In-Network & Out-of-Network: Durable Medical Equipment: Coinsurance for Medicare-covered Durable Medical Equipment 20% Deductible may apply. Prior Authorization may be required for Durable Medical Equipment. |
| 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 Copayment for Medicare-covered Lab Services $0 Deductible may apply Outpatient Diag/Therapeutic Rad Services: |
| Home health care | In-Network & Out-of-Network: Home Health Services: Copayment for Medicare-covered Home Health Services $0 Decutible applies. Prior Authorization may be required for Home Health Services |
| Mental health inpatient care | In-Network & Out-of-Network: Psychiatric Hospital Services: $350 per day for days 1 to 5 $0 per day for days 6 to 90 Deductible applies. Prior Authorization may be required for Psychiatric Hospital Services |
| Mental health outpatient care | In-Network & Out-of-Network: Outpatient Mental Health Services: Copayment for Medicare-covered Individual Sessions $20 Copayment for Medicare-covered Group Sessions $20 Deductible may apply. |
| Outpatient services/surgery | In-Network & Out-of-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0 to $350 $0 for each rural health clinic visit. $350 for each Medicare-covered outpatient hospital facility visit. Deductible may apply Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $120
Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $350 Deductible may apply. Prior Authorization may be required for Outpatient Hospical Services and Ambulatory Surgical Center Services. |
| Outpatient substance abuse care | In-Network & Out-of-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $20 Copayment for Medicare-covered Group Sessions $20 Deductible may apply. |
| Over-the-counter items | Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0
|
| Podiatry services | In-Network & Out-of-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $0 to $50
|
| Skilled Nursing Facility (SNF) care | In-Network & Out-of-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $203 per day for days 21 to 100 Deductible applies. Prior Authorization may be required for Skilled Nursing Facility Services |
Dental Benefits
The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| 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 $1,500 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).
In-Network & Out-of-Network: Medicare Covered Dental Services: Copayment for Medicare-covered Benefits $0 to $350 Prior Authorization may be required for Medicare-covered Dental. |
Vision Benefits
The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage
| Coverage | Details |
|---|---|
| Vision care | In-Network & Out-of-Network: Medicare Covered Vision Services: Copayment for Medicare Covered Eye Exams $0 to $50 Copayment for Medicare Covered Eyewear $0 Deductible may apply. 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 eyeglasses (lenses and frames). Deductible does not apply. 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). Deductible does not apply. |
Hearing Benefits
The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Hearing care | Routine Hearing Coverage: Copayment for Routine Hearing Exams $0
Deductible does not apply. Hearing Aids: Copayment for TruHearing 'Advanced' Aids, one per ear, each year $0
In-Network & Out-of-Network: Medicare-covered Hearing Exams: Copayment for Medicare Covered Benefits $0 to $50 Deductible may apply. |
Preventive Services and Health/Wellness Education Programs
The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| 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 Deductible may apply. |
Prescription Drug Costs and Coverage
The PriorityMedicare Vital (PPO) offers prescription drug coverage, with an annual drug deductible of $350.00 (excludes Tiers 1 and 2)
Coverage & Cost | |
|---|---|
| Coverage | Cost |
| Annual drug deductible | $350.00 (excludes Tiers 1 and 2) |
| Tier 1 |
|
| Tier 2 |
|
| Annual drug deductible | $350.00 (excludes Tiers 1 and 2) |
| Tier 1 |
|
| Tier 2 |
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| Annual drug deductible | $350.00 (excludes Tiers 1 and 2) |
| Tier 1 |
|
| Tier 2 |
|
When reviewing Michigan Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.
You may be able to find plans in your part of Michigan that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.
Plan Documents
| Links to plan documents |
Michigan Counties Served
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