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2020 PriorityMedicare Select (PPO) in Ingham, Michigan

Medicare Advantage Plan Benefit Details in Plain Text

The following Medicare Advantage plan benefits apply to the PriorityMedicare Select (PPO) (H4875 - 017) in Ingham, Michigan .

This plan is administered by . To switch to a different Medicare Advantage plan or to change your location, click here.

Click here to see the PriorityMedicare Select (PPO) health and prescription benefit details in chart format

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Plan Premium

The PriorityMedicare Select (PPO) has a monthly premium of $196.00. That is $2,352.00 for 12 months. There are a few factors that can increase or decrease this premium. If you qualify for full or partial extra help, your premium will be lower. If you have a premium penalty, your premium will be higher. Please remember that the $196.00 montly premium is in addition to your Medicare Part B premium. If you have a premium penalty, your premium will be higher. Or if you have a higher income you would be subject to the Income Related Adjustment Amount (IRMAA).

This Medicare Advantage Plan with Prescription Drug Coverage is a Local PPO plan.

Plan Membership and Plan Ratings

The PriorityMedicare Select (PPO) (H4875 - 017) currently has 4,272 members. There are 23 members enrolled in this plan in Ingham, Michigan.

The Centers for Medicare and Medicaid Services (CMS) has given this plan carrier a summary rating of 4 stars. The detail CMS plan carrier ratings are as follows:

Customer Service Rating of 3 out of 5 stars
Member Experience Rating of 3 out of 5 stars
Drug Cost Information Accuracy Rating of 4 out of 5 stars

Prescription Drug Coverage: Deductible, Cost-sharing, Formulary

This plan does NOT have a deductible for the prescription drug coverage. That means that you have first dollar coverage. Some plans have a deductible that must be paid (in full) prior to the prescription coverage assisting in your prescription costs (see cost-sharing below). The maximum deductible for 2020 is $435. This plan (PriorityMedicare Select (PPO)) has no deductible.

The following information is about the PriorityMedicare Select (PPO) formulary (or drug list). There are 3842 drugs on the PriorityMedicare Select (PPO) formulary. Click here to browse the PriorityMedicare Select (PPO) Formulary.

The Initial Coverage Phase (ICP) can be thought of as the cost-sharing phase of the plan. During this phase, you and the insurance company share your prescription costs. Since this plan has no deductible, your coverage (initial coverage phase) will start right away. All medication are divided into tiers within the plans formulary. This helps the plan to organize and manage the prescription cost-sharing. The PriorityMedicare Select (PPO)’s formulary is divided into 5 tiers. Every plan can name their tiers differently, and can place medications on any tier. The cost-sharing for this plan is divided as follows:

Tier 1 (Preferred Generic) contains 0 drugs and has a co-payment of $1.00.
Tier 2 (Generic) contains 0 drugs and has a co-payment of $7.00.
Tier 3 (Preferred Brand) contains 0 drugs and has a co-payment of $37.00.
Tier 4 (Non-Preferred Drug) contains 0 drugs and has a co-insurance of 45% of the drug cost.
Tier 5 (Specialty Tier) contains 0 drugs and has a co-insurance of 33% of the drug cost.

Click here to browse the PriorityMedicare Select (PPO) Formulary.

The Coverage Gap, which is also known as the Donut (Doughnut) Hole is the phase of your Medicare Part D plan where you are responsible for 100% of your medication costs. Healthcare Reform mandates that the insurance carrier pay 75% of your generic drug prescription costs in the donut hole on your behalf.

The brand-name drug manufacturer will pay 70% and your plan will pay an additional 5% of the cost of your brand-name drugs purchased in the Donut Hole, for a total of 75% discount. The 70% paid by the brand-name drug manufacturer is paid on your behalf and therefore counts toward your TrOOP (or True Out-of-Pocket) costs. The portion paid by your plan, does not count toward TrOOP. Some Medicare Part D plans offer coverage during the Coverage Gap that is beyond the mandated discounts. Any drug not covered by the plan’s Gap Coverage will still receive the discounts noted above -- even if the plan has "No Gap Coverage". This plan (PriorityMedicare Select (PPO)) offers No Coverage during the Coverage Gap phase.

The PriorityMedicare Select (PPO) offers many Health and Prescription Drug Coverage Benefits. The following section will describe these benefits in detail.

Base Plan
Premium
• Total monthly premium: $196.00
• Health plan premium: $147
• Drug plan premium: $49
• You must continue to pay your Part B premium.
• Part B premium reduction: No
Deductible
• Health plan deductible: $0
• Other health plan deductibles: In-network: No
• Drug plan deductible: No annual deductible
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
• $3,500 In and Out-of-network $3,500 In-network
Optional supplemental benefits
• Yes
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
• In-network: No
Doctor visits
• Primary In-network: $0-15 copay per visit
• Primary Out-of-network: 30% coinsurance per visit
• Specialist In-network: $0-40 copay per visit (authorization required)
• Specialist Out-of-network: 30% coinsurance per visit (authorization required)
Diagnostic procedures/lab services/imaging
• Diagnostic tests and procedures In-network: $20 copay (authorization required)
• Diagnostic tests and procedures Out-of-network: 30% coinsurance (authorization required)
• Lab services In-network: $20 copay (authorization required)
• Lab services Out-of-network: 30% coinsurance (authorization required)
• Diagnostic radiology services (e.g., MRI) In-network: $75 copay (authorization required)
• Diagnostic radiology services (e.g., MRI) Out-of-network: 30% coinsurance (authorization required)
• Outpatient x-rays In-network: $30 copay (authorization required)
• Outpatient x-rays Out-of-network: 30% coinsurance (authorization required)
Emergency care/Urgent care
• Emergency: $90 copay per visit (always covered)
• Urgent care: $50 copay per visit (always covered)
Inpatient hospital coverage
• In-network: $200 per day for days 1 through 6 $0 per day for days 7 through 90 (authorization required)
• Out-of-network: 30% per stay (authorization required)
Outpatient hospital coverage
• In-network: $200 copay per visit (authorization required)
• Out-of-network: 30% coinsurance per visit (authorization required)
Skilled Nursing Facility
• In-network: $0 per day for days 1 through 20 $178 per day for days 21 through 100 (authorization required)
• Out-of-network: 30% per stay (authorization required)
Preventive care
• In-network: $0 copay (referral required)
• Out-of-network: 30% coinsurance (referral required)
Ground ambulance
• In-network: $200 copay
• Out-of-network: $200 copay
Rehabilitation services
• Occupational therapy visit In-network: $30 copay
• Occupational therapy visit Out-of-network: 30% coinsurance
• Physical therapy and speech and language therapy visit In-network: $30 copay
• Physical therapy and speech and language therapy visit Out-of-network: 30% coinsurance
Mental health services
• Inpatient hospital - psychiatric In-network: $200 per day for days 1 through 6 $0 per day for days 7 through 90 (authorization required)
• Inpatient hospital - psychiatric Out-of-network: 30% per stay (authorization required)
• Outpatient group therapy visit with a psychiatrist In-network: $20 copay
• Outpatient group therapy visit with a psychiatrist Out-of-network: 30% coinsurance
• Outpatient individual therapy visit with a psychiatrist In-network: $20 copay
• Outpatient individual therapy visit with a psychiatrist Out-of-network: 30% coinsurance
• Outpatient group therapy visit In-network: $20 copay
• Outpatient group therapy visit Out-of-network: 30% coinsurance
• Outpatient individual therapy visit In-network: $20 copay
• Outpatient individual therapy visit Out-of-network: 30% coinsurance
Opioid treatment program services
• In-network: $20.00 copay
• Out-of-network: 30% coinsurance
Medical equipment/supplies
• Durable medical equipment (e.g., wheelchairs, oxygen) In-network: 20% coinsurance per item (authorization required)
• Durable medical equipment (e.g., wheelchairs, oxygen) Out-of-network: 30% coinsurance per item (authorization required)
• Prosthetics (e.g., braces, artificial limbs) In-network: 0-20% coinsurance per item (authorization required)
• Prosthetics (e.g., braces, artificial limbs) Out-of-network: 30% coinsurance per item (authorization required)
• Diabetes supplies In-network: $0 copay (authorization required)
• Diabetes supplies Out-of-network: 30% coinsurance per item (authorization required)
Dialysis
• 20% coinsurance (authorization required)
Hearing
• Hearing exam In-network: $15-40 copay
• Hearing exam Out-of-network: 30% coinsurance
• Fitting/evaluation: Not covered
• Hearing aids In-network: $295-1,495 copay (limits apply)
• Hearing aids Out-of-network: $295-1,495 copay (limits apply)
Preventive dental
• Oral exam In-network: $0 copay (limits apply)
• Oral exam Out-of-network: $0 copay (limits apply)
• Cleaning In-network: $0 copay (limits apply)
• Cleaning Out-of-network: $0 copay (limits apply)
• Fluoride treatment: Not covered
• Dental x-ray(s) In-network: $0 copay (limits apply)
• Dental x-ray(s) Out-of-network: $0 copay (limits apply)
Comprehensive dental
• Non-routine services: Not covered
• Diagnostic services In-network: 0% coinsurance (limits apply, authorization required)
• Diagnostic services Out-of-network: $0 copay (limits apply, authorization required)
• Restorative services: Not covered
• Endodontics: Not covered
• Periodontics In-network: 0% coinsurance (limits apply, authorization required)
• Periodontics Out-of-network: $0 copay (limits apply, authorization required)
• Extractions: Not covered
• Prosthodontics, other oral/maxillofacial surgery, other services: Not covered
Vision
• Routine eye exam In-network: $0 copay (limits apply)
• Routine eye exam Out-of-network: $0 copay (limits apply)
• Other In-network: $0 copay (limits apply)
• Other Out-of-network: $0 copay (limits apply)
• Contact lenses In-network: $0 copay (limits apply)
• Contact lenses Out-of-network: $0 copay (limits apply)
• Eyeglasses (frames and lenses) In-network: $0 copay (limits apply)
• Eyeglasses (frames and lenses) Out-of-network: $0 copay (limits apply)
• Eyeglass frames In-network: $0 copay (limits apply)
• Eyeglass frames Out-of-network: $0 copay (limits apply)
• Eyeglass lenses In-network: $0 copay (limits apply)
• Eyeglass lenses Out-of-network: $0 copay (limits apply)
• Upgrades: Not covered
Wellness programs (e.g., fitness, nursing hotline)
• Covered
Transportation
• Not covered
Foot care (podiatry services)
• Foot exams and treatment In-network: $0-40 copay
• Foot exams and treatment Out-of-network: 30% coinsurance
• Routine foot care: Not covered
Medicare Part B drugs
• Chemotherapy In-network: 20% coinsurance (authorization required)
• Chemotherapy Out-of-network: 20% coinsurance (authorization required)
• Other Part B drugs In-network: 20% coinsurance (authorization required)
• Other Part B drugs Out-of-network: 20% coinsurance (authorization required)
Package #1
• Monthly Premium: $29.00
• Deductible:
Medically-approved non-opioid pain management services
• Chiropractic services: Not covered
• Acupuncture: Not covered
• Therapeutic Massage: Not covered
• Alternative Therapies: Not covered
More benefits
• Over-the-counter drug benefits: Not covered
• Meals for short duration: Not covered
• Annual physical exams: Some coverage
• Telehealth: Some coverage
• WorldWide emergency transportation: Some coverage
• WorldWide emergency coverage: Some coverage
• WorldWide emergency urgent care: Some coverage
• Fitness Benefit: Some coverage
• In-Home Support Services: Not covered
• Bathroom Safety Devices: Not covered
• Health Education: Some coverage
• In-Home Safety Assessment: Some coverage
• Personal Emergency Response System (PERS): Not covered
• Medical Nutrition Therapy (MNT): Not covered
• Post discharge In-Home Medication Reconciliation: Some coverage
• Re-admission Prevention: Not covered
• Wigs for Hair Loss Related to Chemotherapy: Not covered
• Weight Management Programs: Not covered
• Adult Day Health Services: Not covered
• Nutritional/Dietary Benefit: Some coverage
• Home-Based Palliative Care: Not covered
• Support for Caregivers of Enrollees: Not covered
• Additional Sessions of Smoking and Tobacco Cessation Counseling: Not covered
• Enhanced Disease Management: Some coverage
• Telemonitoring Services: Some coverage
• Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline): Not covered
• Counseling Services: Not covered

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