Your 2018 PriorityMedicare Merit plan information

Find out what our 2018 PriorityMedicare℠ Merit (PPO) plan offers you. Review your benefits in the chart below or by downloading any of your coverage documents.

Your 2018 plan documents

Your coverage documents provide detailed explanations about how your plan works.

2018 PriorityMedicare Merit coverage summary

This chart shows what our 2018 PriorityMedicare Merit plan offers plan members.

Deductible

$65

The amount you pay for combined in- and out-of-network covered health care services before Priority Health begins to pay.

In-network benefits

Out-of-pocket maximum

$3,750

This is the most you pay during a policy period (usually a year) before Priority Health begins to pay 100% of the allowed amount. This includes your copayments, deductibles and coinsurance payments. This limit does not include your monthly premium, Part D drug costs or services from out-of-network providers.

Inpatient hospital care

$220 copay per day
Days 1-7
$0 copay per day
Days 8 and beyond

$0 copay for additional non-Medicare covered hospital days.

No limit to the number of days covered by the plan each hospital stay.

Doctor office visits

$20 copay
Each primary care doctor visit
$45 copay
Each specialist visit
Authorization rules may apply.

Emergency  & urgent care

$80 copay
Each emergency room visit
$55 copay
Each urgent care visit

Get emergency or urgent care services wherever you are in the United States or all over the world.

Deductible does not apply.

Lab services

$35 copay
Medicare-covered lab services

If you receive additional services, cost-sharing for those services may apply.

Authorization rules may apply.

Diagnostic tests and procedures

$35 copay
Medicare-covered diagnostic procedures and tests

If you receive additional services, cost-sharing for those services may apply.

Authorization rules may apply.

Outpatient X-rays

$35 copay
Medicare-covered outpatient X-rays

If you receive additional services, cost-sharing for those services may apply.

Authorization rules may apply.

Diagnostic radiology services

$150 copay
Medicare-covered diagnostic radiology services

Diagnostic radiology services include services such as MRIs and CT scans.

If you receive additional services, cost-sharing for those services may apply.

Authorization rules may apply.

Radiation therapy

$30 copay
Medicare-covered radiation therapy services, such as cancer treatment

If you receive additional services, cost-sharing for these services may apply.

Authorization rules may apply.

Preventive care

$0 copay
Annual physical exam and preventive services covered under Original Medicare

See a list of preventive services covered at $0 copay. Any additional preventive services approved by Medicare during the contract year will be covered. 

Services may require a referral from your doctor.

Part D prescription drugs, deductible

$0
tier 1 and 2 drugs
$75
tier 3-5 drugs

This deductible applies to the cost of all drugs on the plan's list of approved drugs, or "formulary." Download the formulary to see approved drugs or view the Approved Drug List on this website.

Tier 1 (preferred generic drugs)

$2 copay
Preferred retail (30-day)
$7 copay
Standard retail (30-day)
$0 copay
90-day mail order

You pay copays for drugs on this plan's formulary until your total yearly drug costs reach $3,750.

Have questions on drug tiers? Learn more.

You have lower copays when you use a preferred pharmacy. See if your pharmacy is on the "preferred" list.

Tier 2 (generic drugs)

$10 copay
Preferred retail (30-day)
$15 copay
Standard retail (30-day)
$0 copay
90-day mail order

You pay copays for drugs on this plan's formulary until your total yearly drug costs reach $3,750.

Have questions on drug tiers? Learn more.

You have lower copays when you use a preferred pharmacy. See if your pharmacy is on the "preferred" list.

Tier 3 (preferred brand drugs)

$42 copay
Preferred retail (30-day)
$47 copay
Standard retail (30-day)
$105 copay
90-day mail order

You pay copays for drugs on this plan's formulary until your total yearly drug costs reach $3,750.

Have questions on drug tiers? Learn more.

You have lower copays when you use a preferred pharmacy. See if your pharmacy is on the "preferred" list.

Tier 4 (non-preferred drugs)

45% coinsurance
Preferred retail (30-day)
50% coinsurance
Standard retail (30-day)
45% coinsurance
90-day mail order

You pay coinsurance for drugs on this plan's formulary until your total yearly drug costs reach $3,750.

Have questions on drug tiers? Learn more.

You have lower copays when you use a preferred pharmacy. See if your pharmacy is on the "preferred" list.

Tier 5 (specialty drugs)

31% coinsurance

You pay coinsurance for drugs on this plan's formulary until your total yearly drug costs reach $3,750.

Have questions on drug tiers? Learn more.

You have lower copays when you use a preferred pharmacy. See if your pharmacy is on the "preferred" list.

Part D prescription drugs, while in the coverage gap

44% coinsurance
Covered generic drugs
35% coinsurance
Covered brand drugs

When you reach your total yearly drug cost (includes what our plan has paid and what you've paid) of $3,750, you'll enter what is called a coverage gap. At this time, you'll pay 44% of the plan's cost for covered generic drugs and 35% of the plan's cost for covered brand drugs, plus dispensing fee, until your total costs reach $5,000.

Most Medicare plans have this coverage gap (also called the "donut hole"), but not everyone will enter the coverage gap.

Part D prescription drugs, catastrophic coverage

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $5,000, you pay the greater of either: 5% of the cost OR a copay of $3.35 for generic and $8.35 for all other drugs.

Dental services

$0 copay
1 oral exam and 1 cleaning per year
50% of costs
1 set of bitewing X-rays per year

If you receive additional services, cost-sharing for those services may apply.

Enhanced vision, dental & hearing coverage

Optional benefit available to add vision, dental and hearing coverage to your MAPD plan for an extra $20.50 monthly premium.

Get details and learn how to add this coverage to your plan.

Virtual care

$20 copay
Per visit

Also referred to as "remote access technologies," which is visiting with a health care professional over the phone or using online video.

Wellness (fitness) programs

Included with this plan through Silver&Fit®:

$0 copay for a fitness membership at a participating Silver&Fit facility or up to 2 home fitness kits.