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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 2025, 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 4.5 out of 5 stars in 2025.
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 $95.00. 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 $4100.00 (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 $4100.00 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 has an enhanced alternative drug benefit. The plan has a $0 deductible for prescription drugs. During the initial coverage phase, you will pay a copay or coinsurance depending on the drug tier and pharmacy used. For example, preferred generic drugs have a $10 copay at a preferred pharmacy, while preferred brand drugs have 50% coinsurance. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase where you pay nothing for covered drugs.
Additional Benefits
The PriorityMedicare Merit (PPO) plan offers a range of benefits, including inpatient hospital stays with copays ranging from $0 to $350, and outpatient services with copays from $0 to $225. Primary care visits have a $20 copay, and specialist visits range from $0 to $45. The plan also covers preventive, hearing, vision, and dental services, with varying copays and coverage limits. Additional benefits include ambulance services with a $270 copay, and emergency services with copays of $55 to $120. Home health services have no copay, and skilled nursing facilities have a $0 copay for the first 20 days, and a $203 copay for days 21-100. This plan also covers home infusion services, dialysis, and medical equipment with coinsurance, as well as diagnostic and radiological services and acupuncture.
Inpatient Hospital See details
Inpatient Hospital coverage includes acute and psychiatric services. For Inpatient Hospital-Acute, you will pay a $275 copay for days 1-6, and no copay for days 7-90, while Inpatient Hospital Psychiatric has a $350 copay for days 1-5, and no copay for days 6-90. Additional days for Inpatient Hospital-Acute are covered with no copay, but Non-Medicare-covered stay and upgrades are not covered, and Additional days and Non-Medicare-covered stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services, including outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services, are covered under the PriorityMedicare Merit (PPO) plan. Outpatient hospital services have a copay between $0 and $225, observation services have a $120 copay, ambulatory surgical center services have a $225 copay, and individual and group sessions for outpatient substance abuse have a copay of $20.
Partial Hospitalization See details
Partial Hospitalization is covered by the PriorityMedicare Merit (PPO) plan, but requires prior authorization. The copay for this benefit is $55.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the PriorityMedicare Merit (PPO) plan. Ground and Air Ambulance Services require a $270 copay, with no coinsurance. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the PriorityMedicare Merit (PPO) plan. Emergency Services have a $120 copay, and Urgently Needed Services have a $55 copay, while Worldwide Emergency Coverage has a $120 copay, Worldwide Urgent Coverage has a $55 copay, and Worldwide Emergency Transportation has a $270 copay.
Primary Care See details
The PriorityMedicare Merit (PPO) plan covers primary care physician services, chiropractic services with a $20 copay, and occupational therapy with a $35 copay. Physician specialist services have a copay between $0 and $45, while mental health and psychiatric individual and group sessions have a $20 copay. Physical therapy and speech-language pathology services have a $35 copay, and opioid treatment program services have a $20 copay. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
Preventive Services are covered, including Annual Physical Exams and Kidney Disease Education Services. Health Education, In-Home Safety Assessment, Post discharge In-Home Medication Reconciliation, Fitness Benefit, Enhanced Disease Management, Telemonitoring Services, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit are also covered. However, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), Re-admission Prevention, Wigs for Hair Loss Related to Chemotherapy, Weight Management Programs, Alternative Therapies, Therapeutic Massage, Adult Day Health Services, Home-Based Palliative Care, In-Home Support Services, Support for Caregivers of Enrollees, Additional Sessions of Smoking and Tobacco Cessation Counseling, Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline), Home and Bathroom Safety Devices and Modifications, and Counseling Services are not covered.
Hearing Services See details
Hearing Services includes routine hearing exams with no copay, and fitting/evaluation for hearing aids. Prescription hearing aids (all types) are covered with a copay between $295 and $1495, but prescription hearing aids for the inner, outer, and over the ear are not covered, and OTC hearing aids are not covered.
Vision Services See details
The PriorityMedicare Merit (PPO) plan covers vision services, including routine eye exams with a $45 copay. Eyewear is covered with a combined maximum of $100 every year, and contact lenses, eyeglasses (lenses and frames), and eyeglass lenses and frames are covered.
Dental Services See details
Dental Services are covered, with Medicare Dental Services requiring prior authorization and costing between $0 and $225 per visit. Other dental services include oral exams (2 visits per year), dental x-rays (limited to 1 bitewing x-ray per year or 1 full mouth/panoramic x-ray every 2 years), prophylaxis (cleaning) with 2 visits per year, and oral and maxillofacial surgery (1 visit per year). Fluoride treatment, restorative services, adjunctive general services, endodontics, prosthodontics (removable and fixed), implant services, and orthodontics are offered as optional, supplemental benefits. Maxillofacial prosthetics and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay and 0-20% coinsurance, as well as Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with 0-20% coinsurance. Prior authorization is required for these services.
Dialysis Services See details
Dialysis Services are covered under the PriorityMedicare Merit (PPO) plan. You will pay a 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment is covered, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has a 20% coinsurance, and Prosthetic Devices have a 0-20% coinsurance, while Medical Supplies have a 20% coinsurance; however, Durable Medical Equipment for use outside the home, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including diagnostic procedures/tests with a $20 copay, lab services with no copay, diagnostic radiological services with a $125 copay, therapeutic radiological services with a $30 copay, and outpatient X-ray services with a $35 copay. All services require prior authorization.
Home Health Services See details
Home Health Services are covered by the PriorityMedicare Merit (PPO) plan, with no copay or coinsurance, but authorization is required. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the PriorityMedicare Merit (PPO) plan. The plan does not cover Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, or Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the PriorityMedicare Merit (PPO) plan, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $203. Additional days beyond Medicare-covered for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
The PriorityMedicare Merit (PPO) plan covers acupuncture with a $20 copay, limited to 6 treatments per year. Other services like over-the-counter items, meal benefits, and several additional services are not covered.
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