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PriorityMedicare Merit (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for PriorityMedicare Merit (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on PriorityMedicare Merit (PPO) in 2026, please refer to our full plan details page.
PriorityMedicare Merit (PPO) is a PPO plan offered by Corewell Health available for enrollment in 2025 to people living in 68 lower peninsula Michigan counties. This plan received an overall rating of 4 out of 5 stars in 2026.
It's important to know that PriorityMedicare Merit (PPO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about PriorityMedicare Merit (PPO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For PriorityMedicare Merit (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $115.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $4200.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $4200.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The PriorityMedicare Merit (PPO) plan features a $0 drug deductible, meaning your prescription coverage begins immediately. For Tier 1 preferred generics, you will pay a low $2 copay for a 1-month supply at preferred pharmacies and preferred mail order, or no copay for a 3-month supply. Tier 2 generics cost a $10 copay for a 1-month supply at preferred pharmacies, with no copay required for a 3-month supply filled through preferred mail order. Brand-name and specialty drugs transition to coinsurance, with Tier 3 preferred brands requiring 25% coinsurance across all pharmacy options. Tier 4 non-preferred drugs carry a 32% coinsurance at preferred pharmacies and 37% coinsurance at standard pharmacies. Specialty drugs in Tier 5 are covered with a 33% coinsurance for a 1-month supply at both preferred and standard pharmacies.
Additional Benefits
The PriorityMedicare Merit (PPO) plan offers robust coverage for essential medical services, often featuring no coinsurance and predictable copays. You will pay no copay and no coinsurance for primary care visits, routine preventive services, and home health care. For inpatient hospital stays, there is no coinsurance and a $275 daily copay for the first six days, while emergency room visits require a $130 copay that is waived if you are admitted. Specialty care under this plan includes dental cleanings and exams with no copay, alongside routine hearing exams and fitting evaluations that also feature no copay. Prescription hearing aids require a copay ranging from $295 to $1,495, and eyewear is covered with no copay up to a $100 annual limit. For durable medical equipment and dialysis services, you can expect no copay and a standard 20% coinsurance.
Inpatient Hospital See details
PriorityMedicare Merit (PPO) inpatient hospital benefits are partially covered, as upgrades and non-Medicare-covered stays are excluded. Acute hospital stays require no coinsurance and a $275 daily copay for days 1 to 6 with no copay thereafter, while psychiatric stays require no coinsurance and a $350 daily copay for days 1 to 5 with no copay for days 6 to 90.
Outpatient Services See details
PriorityMedicare Merit (PPO) covers outpatient hospital services with no coinsurance and a copay ranging from no copay to $225, along with a $130 copay per stay for observation services. Ambulatory surgical center services require a $45 copay with no coinsurance, outpatient substance abuse sessions have a $20 copay with no coinsurance, and outpatient blood services are covered with no copay and no coinsurance.
Partial Hospitalization See details
Partial hospitalization services are covered by PriorityMedicare Merit (PPO) with a $55 copay and no coinsurance. Prior authorization is required for some of these covered services.
Ambulance and Transportation Services See details
PriorityMedicare Merit (PPO) covers ground and air ambulance services with a $270 copay and no coinsurance, though prior authorization is required. While some transportation services are covered, transportation to plan-approved or any health-related locations is not covered.
Emergency Services See details
PriorityMedicare Merit (PPO) covers emergency services with a $130 copay and urgently needed services with a $55 copay, both with no coinsurance and copays waived if admitted to the hospital within 24 hours. Worldwide emergency, urgent, and transportation services are also covered with no coinsurance, requiring copays of $130, $55, and $270 respectively.
Primary Care See details
PriorityMedicare Merit (PPO) offers primary care and telehealth services with no copay and no coinsurance, while specialist visits have a $0 to $45 copay and therapy services have a $35 copay, both with no coinsurance. Mental health, psychiatric, and opioid services require a $20 copay with no coinsurance, but podiatry is not covered and chiropractic care is only partially covered with a $15 copay and no coinsurance, excluding routine and other chiropractic services.
Preventive Services See details
Preventive services under the PriorityMedicare Merit (PPO) plan are covered with no copay and no coinsurance, including annual physical exams, kidney disease education, and diabetes self-management. Additional preventive services are partially covered with no copay and no coinsurance, but exclude personal emergency response systems, medical nutrition therapy, re-admission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, home-based palliative care, in-home support, caregiver support, remote access technologies, home safety devices, and counseling.
Hearing Services See details
Hearing services are partially covered by PriorityMedicare Merit (PPO), offering routine hearing exams (one per year) and fitting evaluations with no copay and no coinsurance. Up to two prescription hearing aids are covered per year with no coinsurance and a copay ranging from $295.00 to $1,495.00, though OTC hearing aids and inner ear, outer ear, and over-the-ear prescription hearing aids are not covered.
Vision Services See details
PriorityMedicare Merit (PPO) covers routine eye exams and retinal imaging with a $45 copay, no coinsurance, and no deductible. Eyewear, including contacts and eyeglasses, is covered with no copay and no coinsurance up to a combined maximum of $100 annually.
Dental Services See details
PriorityMedicare Merit (PPO) partially covers dental services, offering no copay and no coinsurance for key benefits like cleanings, exams, X-rays, periodontics, and oral surgery, while Medicare-covered dental services have a copay of $0 to $225 and no coinsurance. Orthodontics, maxillofacial prosthetics, other diagnostic dental services, and other preventive dental services are not covered under this plan.
Home Infusion bundled Services See details
PriorityMedicare Merit (PPO) covers home infusion bundled services with no copay, though prior authorization is required. Under this benefit, Medicare Part B chemotherapy, radiation, and other Part B drugs have no copay and no coinsurance to 20% coinsurance, while Part B insulin drugs require a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered under PriorityMedicare Merit (PPO) with no copay and a 20% coinsurance.
Medical Equipment See details
PriorityMedicare Merit (PPO) covers durable medical equipment and medical supplies with no copay and 20% coinsurance, and prosthetic devices with no copay and 0% to 20% coinsurance. Diabetic equipment is partially covered with no copay and no coinsurance, but diabetic supplies and therapeutic shoes or inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by PriorityMedicare Merit (PPO) with no coinsurance, though prior authorization is required. There is no copay for lab services, a $20 copay for diagnostic tests, a $35 copay for outpatient X-rays, and minimum copays ranging from $30 for therapeutic radiological services to $125 for diagnostic radiological services.
Home Health Services See details
Home Health Services are covered by PriorityMedicare Merit (PPO) with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac rehabilitation services are covered under PriorityMedicare Merit (PPO) with no coinsurance, but only some services are covered as standard cardiac, intensive cardiac, pulmonary, and SET for PAD services are not covered in practice and require a $10 copay.
Skilled Nursing Facility (SNF) See details
PriorityMedicare Merit (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, offering no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, a prior three-day inpatient hospital stay is not required for admission, and additional days beyond the standard Medicare limit are not covered.
Other Services See details
PriorityMedicare Merit (PPO) offers partial coverage for other services, featuring annual wellness visits with no copay and no coinsurance, acupuncture limited to six treatments yearly with a $20 copay and no coinsurance, and ambulance stabilization with a $270 copay and no coinsurance. Over-the-counter items, meal benefits, and dual-eligible SNP services are not covered.
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