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PriorityMedicare Select (PPO) - H4875-017-002
$147.00
Monthly Premium
PriorityMedicare Select (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Priority Health
Plan ID: H4875-017-002
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$147.00
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.
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 | $147.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $0.00 |
| Out-of-pocket maximum | $3,500.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $8,000.00 |
| 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 |
| 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 |
| Urgent care | 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 | Emergency Care: 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 |
Health Care Services and Medical Supplies
PriorityMedicare Select (PPO) covers a range of additional benefits. Learn more about PriorityMedicare Select (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| Chiropractic services | In-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $20.00 Out-of-Network: Chiropractic Services: Coinsurance for Medicare Covered Chiropractic Services 30% |
| Diabetes supplies, training, nutrition therapy and monitoring | In-Network: Diabetic Supplies and Services: 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: Diabetic Supplies and Services: Coinsurance for Medicare Covered Diabetic Supplies and Services 30% Prior Authorization may be required. |
| Durable medical equipment (DME) | In-Network: Durable Medical Equipment: Coinsurance for Medicare-covered Durable Medical Equipment 20% Out-of-Network: Durable Medical Equipment: Coinsurance for Medicare Covered Durable Medical Equipment 30% Prior Authorization may be required for Durable Medical Equipment |
| 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 |
| Home health care | In-Network: Home Health Services: Copayment for Medicare-covered Home Health Services $0.00 Out-of-Network: Home Health Services: Copayment for Medicare Covered Home Health $0.00 Prior Authorization may be required for Home Health Services |
| 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 |
| Mental health outpatient care | In-Network: Outpatient Mental Health Services: Copayment for Medicare-covered Individual Sessions $20.00 Copayment for Medicare-covered Group Sessions $20.00 Out-of-Network: Outpatient Mental Health Services: 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 |
| Outpatient substance abuse care | In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $20.00 Copayment for Medicare-covered Group Sessions $20.00 Out-of-Network: Outpatient Substance Abuse Services: Coinsurance for Medicare-covered Individual Sessions 30% Coinsurance for Medicare-covered Group Sessions 30% |
| Over-the-counter 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: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $0.00 to $40.00 Out-of-Network: Podiatry Services: Coinsurance for Medicare Covered Podiatry Services 30% |
| Skilled Nursing Facility (SNF) 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 |
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 | 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 |
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: 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, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Hearing care | 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, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| 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% |
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
We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.