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2020 PriorityMedicare Merit (PPO) in Leelanau, Michigan

Medicare Advantage Plan Benefit Details in Plain Text
The following Medicare Advantage plan benefits apply to the PriorityMedicare Merit (PPO) (H4875 - 016) in Leelanau, 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 Merit (PPO) health and prescription benefit details in chart format or email and view benefits chart

Plan Premium
The PriorityMedicare Merit (PPO) has a monthly premium of $97.00. That is $1,164.00 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 $97.00 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 Merit (PPO) (H4875 - 016) currently has 19,163 members. There are 237 members enrolled in this plan in Leelanau, 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:
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 Merit (PPO)) has no deductible.

The following information is about the PriorityMedicare Merit (PPO) formulary (or drug list). There are 3842 drugs on the PriorityMedicare Merit (PPO) formulary. Click here to browse the PriorityMedicare Merit (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 Merit (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 $2.00.
  • Tier 2 (Generic) contains 0 drugs and has a co-payment of $10.00.
  • Tier 3 (Preferred Brand) contains 0 drugs and has a co-payment of $42.00.
  • Tier 4 (Non-Preferred Drug) contains 0 drugs and has a co-insurance of 50% of the drug cost.
  • Tier 5 (Specialty Tier) contains 0 drugs and has a co-insurance of 33% of the drug cost.
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Click here to browse the PriorityMedicare Merit (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 Merit (PPO)) offers No Coverage during the Coverage Gap phase.

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

** Base Plan **
Premium Total monthly premium: $97.00
  Health plan premium: $59.70
  Drug plan premium: $37.30
  Standard Part B premium: $135.50
  Part B premium reduction: No
Deductible Health plan deductible: $0
  Drug plan deductible: $0.00
Estimated yearly costs Estimated total yearly costs for care: $4,842.00
Out-of-pocket max Out-of-pocket max: $4,100 In and Out-of-network $4,100 In-network
Doctor services Primary doctor visit: In-network: $0-20 per visit Out-of-network: 30% per visit
  Specialist visit: In-network: $0-45 per visit Out-of-network: 30% per visit
Tests, labs, & imaging Diagnostic tests & procedures: In-network: $20 Out-of-network: 30%
  Lab services: In-network: $20 Out-of-network: 30%
  Diagnostic radiology services (like MRI): In-network: $125 Out-of-network: 30%
  Outpatient x-rays: In-network: $35 Out-of-network: 30%
  Emergency care: $90 per visit (always covered)
  Urgent care: $55 per visit (always covered)
Hospital services Inpatient hospital coverage: In-network: $375 per day for days 1 through 5 $0 per day for days 6 through 90 Out-of-network: 30% per stay
  Outpatient hospital coverage: In-network: $225 per visit Out-of-network: 30% per visit
Skilled nursing facility Skilled nursing facility: In-network: $0 per day for days 1 through 20 $178 per day for days 21 through 100 Out-of-network: 30% per stay
Preventive services Preventive services: In-network: $0 copay Out-of-network: 30%
Ambulance Ground ambulance: In-network: $250 Out-of-network: $250
Therapy services Occupational therapy visit: In-network: $35 Out-of-network: 30%
  Physical therapy & speech & language therapy visit: In-network: $35 Out-of-network: 30%
Mental health services Outpatient group therapy with a psychiatrist: In-network: $20 Out-of-network: 30%
  Outpatient individual therapy with a psychiatrist: In-network: $20 Out-of-network: 30%
  Outpatient group therapy visit: In-network: $20 Out-of-network: 30%
  Outpatient individual therapy visit: In-network: $20 Out-of-network: 30%
Opioid treatment services Opioid treatment services: Covered
Other services Durable medical equipment (like wheelchairs & oxygen): In-network: 20% per item Out-of-network: 30% per item
  Prosthetics (like braces, artificial limbs): In-network: 0-20% per item Out-of-network: 30% per item
  Diabetes supplies: In-network: $0 copay Out-of-network: 30% per item
Hearing Hearing exam: In-network: $20-45 Out-of-network: 30%
  Fitting/evaluation: Not covered
  Hearing aids - All types: In-network: $295-1,495 Out-of-network: $295-1,495
Preventive dental Oral exam: In-network: $0 copay Out-of-network: $0 copay
  Cleaning: In-network: $0 copay Out-of-network: $0 copay
  Fluoride treatment: Not covered
  Dental x-rays: In-network: $0 copay Out-of-network: $0 copay
Comprehensive dental Non-routine services: Not covered
  Diagnostic services: In-network: 0% Out-of-network: $0 copay
  Restorative services: Not covered
  Endodontics: Not covered
  Periodontics: In-network: 0% Out-of-network: $0 copay
  Extractions: Not covered
  Prosthodontics, other oral/maxillofacial surgery, other services: Not covered
Vision Routine eye exam: In-network: $0 copay Out-of-network: $0 copay
  Contact lenses: In-network: $0 copay Out-of-network: $0 copay
  Eyeglasses (frames & lenses): In-network: $0 copay Out-of-network: $0 copay
  Eyeglass frames (only): In-network: $0 copay Out-of-network: $0 copay
  Eyeglass lenses (only): In-network: $0 copay Out-of-network: $0 copay
  Upgrades: Not covered
More benefits Fitness benefit: Limited coverage
  Over the counter drug benefits: Not covered
  In-home support services: Not covered
  Home and bathroom safety devices: Not covered
  Meals for short duration: Not covered
  Annual physical exams: Limited coverage
  Telehealth: Limited coverage
Part B drugs Chemotherapy drugs: In-network: 20% Out-of-network: 20%
  Other Part B drugs: In-network: 20% Out-of-network: 20%
Optional Packages Package #1 Includes comprehensive dental services, and eyewear: Monthly premium: $29.00, Deductible: N/A




Tips & Disclaimers
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.