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PriorityMedicare Vital (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for PriorityMedicare Vital (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on PriorityMedicare Vital (PPO) in 2026, please refer to our full plan details page.
This summary reflects 2026 plan information. Where this plan continues in 2027, the full plan details page links to its 2027 benefits and costs.
PriorityMedicare Vital (PPO) is a PPO plan offered by Priority Health available for the 2026 plan year to people living in West, SW, and SE counties. This plan received an overall rating of 4 out of 5 stars in 2026.
It's important to know that PriorityMedicare Vital (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 Vital (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 Vital (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. Additionally, this plan comes with a Part B Premium reduction of $45.00. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan has a $500.00 health deductible. This means, every calendar year, you pay this amount towards covered services before your insurance coverage kicks in.
This plan has a $450.00 drug deductible that applies only to drugs in certain tiers. You pay this amount toward covered prescriptions in those tiers before the plan's cost sharing begins; drugs in the other tiers are not subject to the deductible. See the full plan details page for the tier table.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $6300.00 for in-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your out-of-pocket costs reach $6300.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
This plan has a Maximum Out-Of-Pocket cost of $6300.00 (in-network and out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your out-of-pocket costs reach $6300.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
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 Vital (PPO) plan features an annual prescription drug deductible of $450. Under this plan, Tier 1 preferred generic drugs have a low $1 copay for a 1-month supply at preferred pharmacies and no copay for a 3-month supply through preferred pharmacies or preferred mail order. Tier 2 generic drugs cost $10 for a 1-month supply at preferred pharmacies, with no copay required for a 3-month supply when using preferred mail order. For Tier 3 preferred brand drugs, copays start at $42 for a 1-month supply at preferred locations, while standard pharmacies charge up to $141 for a 3-month supply. Tier 4 non-preferred drugs require a flat 25% coinsurance across all pharmacy types and fill durations. Specialty Tier 5 medications are limited to a 1-month supply and carry a 27% coinsurance at all pharmacy and mail order options.
Additional Benefits
The PriorityMedicare Vital (PPO) plan offers robust coverage with no copay for primary care visits, preventive services, and home health care. For inpatient hospital stays, members pay a $350 daily copay for the first seven days and no copay for subsequent days, with no coinsurance. Specialist visits require a copay of up to $50, and emergency room visits have a $130 copay which is waived if admitted. This plan also includes dental, vision, and hearing benefits, featuring no copay for routine hearing exams and most preventive dental services up to a $1,500 annual limit. Prescription hearing aids require copays between $99 and $399, while routine eye exams carry a $50 copay alongside a $125 annual eyewear allowance. For durable medical equipment and dialysis services, members will pay a 20% coinsurance with no copay.
Inpatient Hospital See details
PriorityMedicare Vital (PPO) covers inpatient hospital services with no coinsurance, requiring a $350 daily copay for days 1 to 7 for acute stays and days 1 to 5 for psychiatric stays, followed by no copay for subsequent days. While unlimited additional acute days are covered at no copay, additional psychiatric days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
PriorityMedicare Vital (PPO) covers outpatient services with no coinsurance, including outpatient hospital services with a $0 to $350 copay and ambulatory surgical center services with a $50 copay. Observation services require a $130 copay per stay, outpatient substance abuse sessions have a $20 copay, and outpatient blood services are covered with no copay, no coinsurance, and no deductible.
Partial Hospitalization See details
PriorityMedicare Vital (PPO) covers partial hospitalization services with a $55 copay and no coinsurance, though prior authorization may be required.
Ambulance and Transportation Services See details
PriorityMedicare Vital (PPO) covers Medicare-covered ground and air ambulance services with a $265 copay and no coinsurance, and prior authorization is required. Transportation services to plan-approved or other health-related locations are not covered.
Emergency Services See details
Emergency services are covered by PriorityMedicare Vital (PPO) with a $130 copay and no coinsurance, with the copay waived if you are admitted to the hospital within 24 hours. Urgently needed services require a $50 copay and no coinsurance, while worldwide emergency, urgent, and transportation services are covered with copays of $130, $50, and $265, respectively, and no coinsurance.
Primary Care See details
PriorityMedicare Vital (PPO) offers partially covered primary care services, providing no copay and no coinsurance for primary care physician visits, telehealth, and opioid treatment, while podiatry services are not covered. Other covered benefits feature no coinsurance and varying copays, including $15 to $40 for chiropractic care, $20 for mental health and psychiatric sessions, $30 for physical, occupational, and speech therapies, and up to $50 for specialist visits.
Preventive Services See details
PriorityMedicare Vital (PPO) covers preventive services 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 or coinsurance, offering benefits like fitness and nutritional therapy while excluding services such as medical nutrition therapy and personal emergency response systems.
Hearing Services See details
PriorityMedicare Vital (PPO) covers hearing exams with no copay and no coinsurance, which includes one routine exam yearly and unlimited fitting evaluations. Prescription hearing aids are partially covered with no coinsurance and copays ranging from $99.00 to $399.00 for up to two devices every two years, though OTC hearing aids and inner ear, outer ear, and over the ear prescription hearing aids are not covered.
Vision Services See details
Vision services covered by PriorityMedicare Vital (PPO) include annual routine eye exams for a $50 copay and no coinsurance. Eyewear is covered with no copay and no coinsurance up to a combined maximum of $125 per year for contacts, frames, and lenses.
Dental Services See details
Dental Services are partially covered by PriorityMedicare Vital (PPO), featuring no copay and no coinsurance for most preventive and comprehensive care, while Medicare-covered dental services require a $0 to $350 copay and no coinsurance. A $1,500 annual maximum benefit applies to both in-network and out-of-network services, but other diagnostic services, other preventive services, maxillofacial prosthetics, and orthodontics are not covered.
Home Infusion bundled Services See details
PriorityMedicare Vital (PPO) covers home infusion bundled services with no copay, though prior authorization and step therapy are required. Associated Medicare Part B drugs, including chemotherapy and other covered drugs, require a coinsurance of 0% to 20% with no copay, while Part B insulin has a $35 copay and 0% to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered under the PriorityMedicare Vital (PPO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
PriorityMedicare Vital (PPO) partially covers medical equipment with no copays, requiring a 20% coinsurance for durable medical equipment and medical supplies, and 0% to 20% coinsurance for prosthetics. Diabetic equipment is covered with no copay or coinsurance, but diabetic supplies and therapeutic shoes or inserts are not covered.
Diagnostic and Radiological Services See details
PriorityMedicare Vital (PPO) covers radiological services with prior authorization, while diagnostic procedures, tests, and lab services are not covered. Outpatient X-rays require a $40 copay and no coinsurance, diagnostic radiological services carry a 20% coinsurance and a copay, and therapeutic radiological services require a $40 copay and coinsurance.
Home Health Services See details
Home health services are covered under the PriorityMedicare Vital (PPO) plan with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
PriorityMedicare Vital (PPO) covers some cardiac rehabilitation services with no coinsurance, but several specific services are not covered in practice. Specifically, cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) are not covered, each requiring a $10 copay.
Skilled Nursing Facility (SNF) See details
PriorityMedicare Vital (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but allowing admission without a prior three-day hospital stay. There is no copay for days 1 through 20 and a $218 copayment for days 21 through 100, though additional days beyond the standard Medicare-covered period are not covered.
Other Services See details
PriorityMedicare Vital (PPO) provides partially covered other services, which exclude meal benefits but include acupuncture for a $20 copay and no coinsurance for up to six treatments per year. Over-the-counter items and annual wellness visits are covered with no copay and no coinsurance, while ambulance stabilization services require a $265 copay and no coinsurance.
Plan Providers
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross and Blue Shield, Aspire Health Plan, Dean Health Plan, Devoted Health, Florida Blue Medicare, Freedom Health, Health Care Service Corporation, HealthSpringSM, HealthSun, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Medica Central Health Plan, Optimum HealthCare, Premera Blue Cross, SCAN Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.
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1-877-649-2073 / TTY 711. Call-center hours (ET): Mon-Fri 8am-10pm; Sat 9am-8pm; Sun closed.
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