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PriorityMedicare Edge (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for PriorityMedicare Edge (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on PriorityMedicare Edge (PPO) in 2025, please refer to our full plan details page.
PriorityMedicare Edge (PPO) is a PPO plan offered by Corewell Health available for enrollment in 2025 to people living in West, SW, & SE counties, lower MI. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that PriorityMedicare Edge (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 Edge (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 Edge (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. 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 has a $195.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
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 $5700.00 (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 $5700.00 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 Edge (PPO) plan has a $0 deductible for prescription drugs. In the initial coverage phase, you'll pay a copay or coinsurance depending on the drug tier and the pharmacy you use. For example, preferred generic drugs have an $8 copay at preferred pharmacies and $15 at standard pharmacies. After your total drug costs reach $2,000, you enter the catastrophic coverage phase where you pay nothing for covered Part D drugs. If you qualify for the low-income subsidy, your premium may be reduced.
Additional Benefits
The PriorityMedicare Edge (PPO) plan offers a wide range of benefits with varying cost-sharing. It covers inpatient hospital stays with a copay, and outpatient services with copays ranging from $0 to $350. Emergency, primary care, and preventive services are included, often with no copay or a low copay, alongside hearing, vision, and dental benefits. The plan also provides coverage for ambulance services with a copay, home health services with no copay, and skilled nursing facility stays with a copay. Additionally, it includes services such as acupuncture and over-the-counter item coverage, with some services like cardiac rehabilitation not covered.
Inpatient Hospital See details
Inpatient Hospital benefits are covered under PriorityMedicare Edge (PPO), including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For Inpatient Hospital-Acute, there is a $350 copay for days 1-7, and no copay for days 8-90. For Inpatient Hospital Psychiatric, there is a $350 copay for days 1-5, and no copay for days 6-90. Additional Days for Inpatient Hospital-Acute is covered, and Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered. Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute are also not covered.
Outpatient Services See details
Outpatient Services are covered by the PriorityMedicare Edge (PPO) plan, including Outpatient Hospital Services with a copay between $0 and $350, Observation Services with a $120 copay, Ambulatory Surgical Center (ASC) Services with a $350 copay, and Outpatient Substance Abuse Services with a $20 copay for both individual and group sessions. The plan also covers Outpatient Blood Services.
Partial Hospitalization See details
Partial Hospitalization is covered under the PriorityMedicare Edge (PPO) plan with a $55 copay, and prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the PriorityMedicare Edge (PPO) plan. Ground and Air Ambulance Services have a $275 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 under the PriorityMedicare Edge (PPO) plan. Emergency Services and Worldwide Emergency Coverage have a $120 copay, Urgently Needed Services has a $30 copay, Worldwide Urgent Coverage has a $30 copay, and Worldwide Emergency Transportation has a $275 copay.
Primary Care See details
The PriorityMedicare Edge (PPO) plan covers primary care physician services, chiropractic services with a $20 copay, occupational therapy services with a $40 copay, physician specialist services with a $0-$35 copay, mental health specialty services with a $20 copay for individual and group sessions, physical therapy and speech-language pathology services with a $40 copay, additional telehealth benefits, and opioid treatment program services with a $20 copay. Podiatry services are not covered.
Preventive Services See details
The PriorityMedicare Edge (PPO) plan covers preventive services, including Medicare-covered services with a doctor referral, annual physical exams, health education, and nutritional/dietary benefits. This plan also covers support for caregivers, fitness benefits, enhanced disease management, telemonitoring services, home and bathroom safety devices and modifications (up to $25 per month), kidney disease education, glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs after a welcome visit.
Hearing Services See details
Hearing exams are covered with no copay, and routine hearing exams are covered once per year. Prescription hearing aids are covered, with a copay between $295 and $1495 for all types of prescription hearing aids, up to two per year. Fitting/evaluation for hearing aids is covered. However, prescription hearing aids for the inner ear, outer ear, and over the ear are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision services include routine eye exams with a $35 copay, and other eye exam services with no copay. Eyewear is covered with a combined maximum of $100 per year for both in-network and out-of-network services, while contact lenses, eyeglasses (lenses and frames), and eyeglass lenses and frames are covered with no copay. Upgrades are not covered.
Dental Services See details
Dental Services are covered, with coverage for Medicare Dental Services requiring prior authorization and costing between $0 and $350. Other dental services are covered, including oral exams with no copay and up to 2 visits per year, dental x-rays, prophylaxis (cleaning) with up to 2 visits per year, and oral and maxillofacial surgery with no copay and 1 visit per year. Fluoride treatment, restorative services, adjunctive general services, endodontics, prosthodontics, removable, implant services, and prosthodontics, fixed are optional supplemental benefits. Maxillofacial prosthetics and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, but require prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay and a coinsurance between 0% and 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the PriorityMedicare Edge (PPO) plan. You will pay 20% coinsurance.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 20% coinsurance and no copay, Prosthetics/Medical Supplies with a 20% coinsurance and no copay, and Diabetic Equipment. 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 by PriorityMedicare Edge (PPO). Diagnostic Procedures/Tests and Lab Services are not covered, while Diagnostic Radiological Services have a copay of at most $270, Therapeutic Radiological Services have a copay of at most $40, and Outpatient X-Ray Services have a $20 copay.
Home Health Services See details
Home Health Services are covered by PriorityMedicare Edge (PPO) with no copay or coinsurance, but additional hours of care and personal care services are not covered. Prior authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered under the PriorityMedicare Edge (PPO) plan. The plan does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by PriorityMedicare Edge (PPO), but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $203.
Other Services See details
The PriorityMedicare Edge (PPO) plan covers acupuncture with a $20 copay for up to 6 treatments per year. Over-the-counter items are covered up to $25 per month, and also offers nicotine replacement therapy and naloxone coverage. Other services include ambulance stabilization/non-transport with a $275 copay, and annual wellness visits. However, meal benefits, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, private duty nursing services, case management, and several other services are not covered.
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