2022 PriorityMedicare Edge (PPO)

PriorityMedicare Edge (PPO) H4875-020 is a 2022 Medicare Advantage Plan or Part-C by Priority Health Medicare available to residents in Michigan. This plan includes additional prescription drug (Part-D) coverage. The PriorityMedicare Edge (PPO) has a monthly premium of $0 and has an in-network maximum out-of-pocket limit of $5,300 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $5,300 out-of-pocket. This can be a extremely nice safety net.

PriorityMedicare Edge (PPO) is a Local PPO. A preferred provider organization (PPO) is a Medicare plan that has created contracts with a network of "preferred" providers for you to choose from at reduced rates. You do not need to select a primary care physician and you do not need referrals to see other providers in the network. Offering you a little more flexibility overall. You can get medical attention from a provider outside of the network but you will have to pay the difference between the out-of-network bill and the PPOs discounted rate.

Priority Health Medicare works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for PriorityMedicare Edge (PPO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Priority Health Medicare and not Original Medicare. With Medicare Advantage you are always covered for urgently needed and emergency care. Plus you receive all the benefits of Original Medicare from Priority Health Medicare except hospice care. Original Medicare still provides you with hospice care even if you sign up for Medicare Advantage.

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2022 Priority Health Medicare Medicare Advantage Plan Costs

PriorityMedicare Edge (PPO) Part-C Premium

Priority Health Medicare charges a $0.00 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.

H4875-020 Part-D Deductible and Premium

PriorityMedicare Edge (PPO) has a monthly drug premium of $0.00 and a $0.00 drug deductible. This Priority Health Medicare plan offers a $0.00 Part-D Basic Premium that is not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0.00 this Premium covers any enhanced plan benefits offered by Priority Health Medicare above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments and coverage of non-Part D drugs. The Part D Total Premium is $0.00 . The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.

Priority Health Medicare Gap Coverage

In 2022 once you and your plan provider have spent $4430 on covered drugs. (combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 25% for prescription drugs unless your plan offers additional coverage. This Priority Health Medicare plan does not offer additional coverage through the gap.

H4875-020 Formulary or Drug Coverage

PriorityMedicare Edge (PPO) formulary is divided into Tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers. By reviewing different Medicare Drug formularies, you can pick a Medicare Advantage plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price. You can see complete 2022 PriorityMedicare Edge (PPO) H4875-020 Formulary here.

Drug Tier	Copay Preferred Pharmacy	Copay Nonpreferred Pharmacy
Tier 1	$2	$7
Tier 2	$8	$13
Tier 3	$38	$43
Tier 4	40%	45%
Tier 5	33%	33%

*Initial Coverage Phase and 30 day supply

2021 PriorityMedicare Edge (PPO) Summary of Benefits

*This will be updated with 2022 data when available.

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Additional Benefits

No

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Comprehensive Dental

Diagnostic services	Not covered
Endodontics	Not covered
Extractions	Not covered
Non-routine services	Not covered
Periodontics	0% coinsurance
Periodontics	$0 copay (Out-of-Network)
Prosthodontics, other oral/maxillofacial surgery, other services	Not covered
Restorative services	Not covered

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Deductible

$0

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Diagnostic Tests and Procedures

Diagnostic radiology services (e.g., MRI)	40% coinsurance (Out-of-Network)
Diagnostic radiology services (e.g., MRI)	$275 copay
Diagnostic tests and procedures	$0 copay
Diagnostic tests and procedures	40% coinsurance (Out-of-Network)
Lab services	40% coinsurance (Out-of-Network)
Lab services	$0 copay
Outpatient x-rays	$20 copay
Outpatient x-rays	40% coinsurance (Out-of-Network)

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Doctor Visits

Primary	40% coinsurance per visit (Out-of-Network)
Primary	$0 copay
Specialist	$0-40 copay per visit
Specialist	40% coinsurance per visit (Out-of-Network)

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Emergency care/Urgent Care

Emergency	$90 copay per visit (always covered)
Urgent care	$30 copay per visit (always covered)

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Foot Care (podiatry services)

Foot exams and treatment	$0-40 copay
Foot exams and treatment	40% coinsurance (Out-of-Network)
Routine foot care	Not covered

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Ground Ambulance

$275 copay
$275 copay (Out-of-Network)

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Hearing

Fitting/evaluation	$0 copay (Out-of-Network)
Fitting/evaluation	$0 copay
Hearing aids	$295-1,495 copay
Hearing aids	$295-1,495 copay (Out-of-Network)
Hearing exam	$0-40 copay
Hearing exam	40% coinsurance (Out-of-Network)

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Inpatient Hospital Coverage

$350 per day for days 1 through 5 $0 per day for days 6 through 90
40% per stay (Out-of-Network)

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Medical Equipment/Supplies

Diabetes supplies	40% coinsurance per item (Out-of-Network)
Diabetes supplies	$0 copay
Durable medical equipment (e.g., wheelchairs, oxygen)	30% coinsurance per item (Out-of-Network)
Durable medical equipment (e.g., wheelchairs, oxygen)	20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs)	30% coinsurance per item (Out-of-Network)
Prosthetics (e.g., braces, artificial limbs)	0-20% coinsurance per item

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Medicare Part B Drugs

Chemotherapy	20% coinsurance
Chemotherapy	20% coinsurance (Out-of-Network)
Other Part B drugs	20% coinsurance (Out-of-Network)
Other Part B drugs	20% coinsurance

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Mental Health Services

Inpatient hospital - psychiatric	$350 per day for days 1 through 5 $0 per day for days 6 through 90
Inpatient hospital - psychiatric	40% per stay (Out-of-Network)
Outpatient group therapy visit	40% coinsurance (Out-of-Network)
Outpatient group therapy visit	$20 copay
Outpatient group therapy visit with a psychiatrist	$20 copay
Outpatient group therapy visit with a psychiatrist	40% coinsurance (Out-of-Network)
Outpatient individual therapy visit	$20 copay
Outpatient individual therapy visit	40% coinsurance (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist	40% coinsurance (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist	$20 copay

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MOOP

$5,300 In and Out-of-network $5,300 In-network

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Option

No

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Optional supplemental benefits

Yes

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Outpatient Hospital Coverage

$325 copay per visit
40% coinsurance per visit (Out-of-Network)

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Package #1

Deductible
Monthly Premium	$37.00

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Preventive Care

40% coinsurance (Out-of-Network)
$0 copay

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Preventive Dental

Cleaning	$0 copay (Out-of-Network)
Cleaning	$0 copay
Dental x-ray(s)	$0 copay
Dental x-ray(s)	$0 copay (Out-of-Network)
Fluoride treatment	Not covered
Oral exam	$0 copay
Oral exam	$0 copay (Out-of-Network)

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Rehabilitation Services

Occupational therapy visit	40% coinsurance (Out-of-Network)
Occupational therapy visit	$40 copay
Physical therapy and speech and language therapy visit	$40 copay
Physical therapy and speech and language therapy visit	40% coinsurance (Out-of-Network)

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Skilled Nursing Facility

$0 per day for days 1 through 20 $178 per day for days 21 through 100
40% per stay (Out-of-Network)

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Transportation

Not covered

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Vision

Contact lenses	$0 copay (Out-of-Network)
Contact lenses	$0 copay
Eyeglass frames	$0 copay (Out-of-Network)
Eyeglass frames	$0 copay
Eyeglass lenses	$0 copay
Eyeglass lenses	$0 copay (Out-of-Network)
Eyeglasses (frames and lenses)	$0 copay
Eyeglasses (frames and lenses)	$0 copay (Out-of-Network)
Other	$0 copay
Other	$0 copay (Out-of-Network)
Routine eye exam	$0 copay (Out-of-Network)
Routine eye exam	$0 copay
Upgrades	Not covered

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Wellness Programs (e.g. fitness nursing hotline)

Covered

CMS Star Ratings for PriorityMedicare Edge (PPO) H4875

Staying Healthy, Screening, Testing, & Vaccines

Managing Chronic And Long Term Care for Older Adults

Member Experience with Health Plan

Member Complaints and Changes in PriorityMedicare Edge (PPO) Plans Performance

Health Plan Customer Service Rating for PriorityMedicare Edge (PPO)

PriorityMedicare Edge (PPO) Drug Plan Customer Service Ratings

Ratings For Member Complaints and Changes in the Drug Plans Performance

Member Experience with the Drug Plan

Drug Safety and Accuracy of Drug Pricing

Ready to Enroll?

Click Here

Or Call
1-855-778-4180
Mon-Fri 8am-8pm EST
Sat 8am-8pm EST

Coverage Area for PriorityMedicare Edge (PPO)

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Source: CMS.
Data as of September 1, 2021.
Notes: Data are subject to change as contracts are finalized. For 2022, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part-D benefit. Includes 2022 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.