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Priority Health Medicare

Plan ID: H4875-20-1

PriorityMedicare Edge (PPO)

2024 PriorityMedicare Edge (PPO) H4875 — 020— 1 is a Medicare Advantage plan with drug coverage. It has received a 4.5-out-of-5 star rating from CMS for 2024.

Learn more about PriorityMedicare Edge (PPO) H4875 - 020 - 1, including the health and drug services it covers, by reading our easy-to-use guide. Or contact a licensed insurance agent for help now.

4.5 / 5 stars for 2024

$0 /mo

Monthly premium

Health deductible

Drug deductible

$5300.00

Out-of-pocket maximum

Enroll online

Call to enroll

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1-877-649-2073 TTY 711. 8am-11pm EST. 7 days a week!

Overview Benefits & Costs Drug Coverage Additional Benefits

Plan Overview

2024 PriorityMedicare Edge (PPO) H4875 — 020— 1 is a Local PPO offered in Region 1 by Priority Health Medicare. It has a monthly premium of $0.00.

Premium Breakdown

Standard Part B Premium

$174.80

Part B premium reduction

Part C Premium

Part D Basic Premium

Part D Supplemental Premium

Part D Total

$0.00

Monthly Premium (Parts C & D)

$0.00

Total Premium (Parts B, C, & D)

$164.90

Special needs plan type

Out-of-pocket maximum

$5300.00

Plan Organization:

Priority Health Medicare

Plan Type:

Local PPO

Location:

Region 1

Drugs Covered:

Yes

Drug Formulary:

Formulary Link

Pharmacies:

Pharmacies Link

Doctor Choice:

Any Doctor

Doctors Link:

Doctors Link

Deductibles

The amount you must pay each year before your plan starts to pay for covered services or drugs.

Health deductible

Drug deductible

Sign up for PriorityMedicare Edge (PPO)

Enroll online

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Drug Coverage

PriorityMedicare Edge (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Benefit Type

Enhanced

Prescription drug deductible

Increased initial coverage limit

Additional gap coverage

Part D Premium Reduction

This plan's premium may be reduced for you if you qualify for the low-income subsidy (also known as LIS or "Extra help"). The following is what you'll pay for with LIS.

Part D	LIS 25%	LIS 50%	LIS 75%	LIS Full
$0.00	$0.00	$0.00	$0.00	$0.00

Initial Coverage Phase

After you pay your $0.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $4,660.00. Once you reach that amount, you will enter the next coverage phase.

30 Days

60 Days

90 Days

Tier	Preferred Pharmacy	Standard Pharmacy	Preferred Mail	Standard Mail
1. Preferred Generic	$2.00 copay	$7.00 copay	$2.00 copay	$7.00 copay
2. Standard Generic	$8.00 copay	$15.00 copay	$8.00 copay	$15.00 copay
3. Preferred Brand	$38.00 copay	$47.00 copay	$38.00 copay	$47.00 copay
4. Non-Preferred Drug	40%	45%	40%	45%
5. Specialty Tier	33%	33%	33%	33%

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,400.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.

Generic Drugs

$4.15 copay or 5% (whichever costs more)

Brand-name

$10.35 copay or 5% (whichever costs more)

Additional Benefits

PriorityMedicare Edge (PPO) also provides the following benefits.

Comprehensive dental

Non-routine services

Not covered

Diagnostic services

Not covered

Restorative services

Not covered

Endodontics

Not covered

Periodontics

In-Network: $0 copay

Out-Of-Network: $0 copay

Extractions

Not covered

Prosthodontics, other oral/maxillofacial surgery, other services

In-Network: $0 copay

Out-Of-Network: $0 copay

Preventive dental

Oral exam

In-Network: $0 copay

Out-Of-Network: $0 copay

Cleaning

In-Network: $0 copay

Out-Of-Network: $0 copay

Fluoride treatment

Not covered

Dental x-ray(s)

In-Network: $0 copay

Out-Of-Network: $0 copay

Diagnostic procedures/lab services/imaging

Diagnostic tests and procedures

In-Network: $0 copay

Out-Of-Network: 40% coinsurance

Lab services

In-Network: $0 copay

Out-Of-Network: 0-40% coinsurance

Diagnostic radiology services (eg, MRI)

In-Network: $270 copay

Out-Of-Network: 40% coinsurance

Outpatient x-rays

In-Network: $20 copay

Out-Of-Network: 40% coinsurance

Doctor visits

Primary

In-Network: $0 copay

Out-Of-Network: 40% coinsurance per visit

Specialist

In-Network: $0-45 copay per visit

Out-Of-Network: 40% coinsurance per visit

Emergency care/Urgent care

Emergency

$120 copay per visit (always covered)

Urgent care

$30 copay per visit (always covered)

Foot care (podiatry services)

Foot exams and treatment

In-Network: $0-45 copay

Out-Of-Network: 40% coinsurance

Routine foot care

Not covered

Ground ambulance

Service

In-Network: $275 copay

Out-Of-Network: $275 copay

Hearing

Hearing exam

In-Network: $0-45 copay

Out-Of-Network: 40% coinsurance

Fitting/evaluation

In-Network: $0 copay

Out-Of-Network: $0 copay

Hearing aids

In-Network: $295-1,495 copay

Out-Of-Network: $295-1,495 copay

Inpatient hospital coverage

Service

In-Network: $320 per day for days 1 through 7 $0 per day for days 8 through 90

Out-Of-Network: 40% per stay

Outpatient hospital coverage

Service

In-Network: $0-325 copay per visit

Out-Of-Network: 40% coinsurance per visit

Outpatient prescription drugs

PriorityMedicare Edge (PPO) does not provide this type of benefit.

Optional benefits

PriorityMedicare Edge (PPO) does not provide this type of benefit.

Medical equipment/supplies

Durable medical equipment (eg, wheelchairs, oxygen)

In-Network: 20% coinsurance per item

Out-Of-Network: 30% coinsurance per item

Prosthetics (eg, braces, artificial limbs)

In-Network: 0-20% coinsurance per item

Out-Of-Network: 30% coinsurance per item

Diabetes supplies

In-Network: $0 copay

Out-Of-Network: 40% coinsurance per item

Medicare Part B drugs

Chemotherapy

In-Network: 0-20% coinsurance

Out-Of-Network: 0-20% coinsurance

Other Part B drugs

In-Network: 0-20% coinsurance

Out-Of-Network: 0-20% coinsurance

Part B Insulin drugs

In-Network: 0-20% coinsurance (up to $35)

Out-Of-Network: 0-20% coinsurance

Mental health services

Inpatient hospital - psychiatric

In-Network: $350 per day for days 1 through 5 $0 per day for days 6 through 90

Out-Of-Network: 40% per stay

Outpatient group therapy visit with a psychiatrist

In-Network: $20 copay

Out-Of-Network: 40% coinsurance

Outpatient individual therapy visit with a psychiatrist

In-Network: $20 copay

Out-Of-Network: 40% coinsurance

Outpatient group therapy visit

In-Network: $20 copay

Out-Of-Network: 40% coinsurance

Outpatient individual therapy visit

In-Network: $20 copay

Out-Of-Network: 40% coinsurance

Preventive care

Service

In-Network: $0 copay

Out-Of-Network: 40% coinsurance

Rehabilitation services

Occupational therapy visit

In-Network: $40 copay

Out-Of-Network: 40% coinsurance

Physical therapy and speech and language therapy visit

In-Network: $40 copay

Out-Of-Network: 40% coinsurance

Skilled Nursing Facility

Service

In-Network: $0 per day for days 1 through 20 $203 per day for days 21 through 100

Out-Of-Network: 40% per stay

Transportation

Service

Not covered

Vision

Routine eye exam

In-Network: $0 copay

Out-Of-Network: $0 copay

Other

In-Network: $0 copay

Out-Of-Network: $0 copay

Contact lenses

In-Network: $0 copay

Out-Of-Network: $0 copay

Eyeglasses (frames and lenses)

In-Network: $0 copay

Out-Of-Network: $0 copay

Eyeglass frames

In-Network: $0 copay

Out-Of-Network: $0 copay

Eyeglass lenses

In-Network: $0 copay

Out-Of-Network: $0 copay

Upgrades

Not covered

Wellness programs (eg, fitness, nursing hotline)

Service

Covered

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1-877-649-2073 TTY 711. 8am-11pm EST. 7 days a week

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