A non-government entity
Corewell Health
Plan ID: H4875-20-1
Plan Summary PagePriorityMedicare Edge (PPO)
2026 PriorityMedicare Edge (PPO) H4875 — 020 — 1 is a Medicare Advantage plan with drug coverage. It has received a 4-out-of-5 star rating from CMS for 2026.
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 stars for 2026
$0.00 /mo
Monthly premium
$275.00
Health deductible
$200.00
Drug deductible
$6000.00
Out-of-pocket maximum (Combined)
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Call to enroll
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Get personalized help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week!
About This Plan
The PriorityMedicare Edge (PPO) plan offers comprehensive coverage with no coinsurance for many key medical services, including inpatient hospital stays, outpatient procedures, and emergency care. Patients enjoy no copay for primary care and telehealth visits, while specialist visits, urgent care, and outpatient services require set copays. Inpatient hospital stays have a $350 daily copay for the first few days, after which there is no copay for the remainder of the stay. Preventive care, routine hearing exams, home health, and select dental services are available with no copay and no coinsurance. For specialized needs, diagnostic services and home infusions feature no copay, while durable medical equipment and dialysis require a 20% coinsurance. Vision exams, dental care, and prescription hearing aids are also covered, though they may require copays depending on the specific service.
The PriorityMedicare Edge (PPO) plan features an annual drug deductible of $200. For Tier 1 preferred generic drugs, you will pay as low as a $2 copay for a 1-month supply at preferred pharmacies and mail-order services, with no copay for a 3-month supply. Tier 2 generic drugs cost between $8 and $15 for a 1-month supply, though you can enjoy no copay for a 3-month supply when using preferred mail-order services. Higher-tier medications transition to coinsurance, with Tier 3 preferred brand drugs requiring 22% coinsurance at preferred pharmacies and 25% at standard pharmacies. Tier 4 non-preferred drugs range from 25% to 30% coinsurance depending on your pharmacy choice. Tier 5 specialty drugs require 30% coinsurance across all pharmacy and mail-order options for a 1-month supply.
Plan data sourced from the official CMS 2026 public benefit files. Reviewed by Walt Whitney. How we source and review plan information.
Plan Overview
2026 PriorityMedicare Edge (PPO) H4875 — 020 — 1 is a PPO offered in West, SW, & SE counties, lower MI by Corewell Health. It has a monthly premium of $0.00.
Premium Breakdown
Monthly plan premium
$0.00
Standard Part B premium
$202.90
Note:
The standard Medicare Part B premium for 2026 is $202.90. Your actual Part B premium may differ based on income (IRMAA), late enrollment penalties, Medicaid assistance, disability status, or other factors. Most people enrolled in Medicare Part B are required to pay this premium.
Special needs plan type
No
Out-of-pocket maximum (In-Network)
N/A
Out-of-pocket maximum (Out-of-Network)
$6000.00
Out-of-pocket maximum (Combined)
$6000.00
Plan Organization:
Corewell Health
Plan Type:
PPO
Location:
West, SW, & SE counties, lower MI
Drugs Covered:
Yes
Drug Formulary:
Pharmacies:
Doctors Link:
Deductibles
The amount you must pay each year before your plan starts to pay for covered services or drugs.
Health deductible
$275.00
Drug deductible
$200
Note:
This plan does not charge an annual deductible for all drugs. The $200.00 annual deductible only applies to drugs in certain tiers.
Sign up for PriorityMedicare Edge (PPO)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
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 Alternative
Prescription drug deductible
$200.00
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 Full |
|---|---|
$0.00 | $0.00 |
Initial Coverage Phase
After you pay your $200.00 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 $2100.00. Once you reach that amount, you will enter the next coverage phase.
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. Generic | $8.00 copay | $15.00 copay | $8.00 copay | $15.00 copay |
3. Preferred Brand | 22% coinsurance | 25% coinsurance | 22% coinsurance | 25% coinsurance |
4. Non-Preferred Drug | 25% coinsurance | 30% coinsurance | 25% coinsurance | 30% coinsurance |
5. Specialty Tier | 30% coinsurance | 30% coinsurance | 30% coinsurance | 30% coinsurance |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2100.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit.
Additional Benefits
PriorityMedicare Edge (PPO) also provides the following benefits.
Inpatient Hospital
Inpatient Hospital benefits are covered.
Inpatient Hospital-Acute
Inpatient Hospital-Acute benefits are covered – including services not usually covered by Medicare plans. Prior Authorization is required.
Cost Sharing:
| Days -: | Days -: | |
|---|---|---|
| Copayment | 350.00 | 0.00 |
| Begin Day | 1 | 8 |
| End Day | 7 | 90 |
| Copayment | 350.00 | 0.00 |
| Begin Day | 1 | 8 |
| End Day | 7 | 60 |
More Details:
Enhanced benefits
Non-Medicare-covered Stay
Do you charge the Medicare-defined cost share for tier 1?
No
Copayment for Medicare-covered stay
0.00
Periodicity
Per Admission or Per Stay
Do you charge cost sharing on the day of discharge?
No
Additional Days for Inpatient Hospital-Acute
Additional Days for Inpatient Hospital-Acute benefits are covered.
More Details:
Is this benefit unlimited?
Yes
Number of day intervals for Additional Days
Zero (No Copayment per Day)
Non-Medicare-covered Stay for Inpatient Hospital-Acute
Not covered.
Upgrades for Inpatient Hospital-Acute
Not covered.
Inpatient Hospital Psychiatric
Inpatient Hospital Psychiatric benefits are covered. Prior Authorization is required.
Cost Sharing:
| Days -: | Days -: | |
|---|---|---|
| Copayment | 350.00 | 0.00 |
| Begin Day | 1 | 6 |
| End Day | 5 | 90 |
| Copayment | 350.00 | 0.00 |
| Begin Day | 1 | 6 |
| End Day | 5 | 60 |
More Details:
Do you charge the Medicare-defined cost share for tier 1?
No
Copayment for Medicare-covered stay
0.00
Periodicity
Per Admission or Per Stay
Do you charge cost sharing on the day of discharge?
No
Additional Days for Inpatient Hospital Psychiatric
Not covered.
Non-Medicare-covered Stay for Inpatient Hospital Psychiatric
Not covered.
Outpatient Services
Outpatient Services benefits are covered.
All Outpatient Hospital Services
All Outpatient Hospital Services benefits are covered.
Cost Sharing:
More Details:
Which Services have a Copayment
Medicare-covered Outpatient Hospital Services, Medicare-covered Observation Services
Outpatient Hospital Services
Outpatient Hospital Services benefits are covered. Prior Authorization is required.
Cost Sharing:
Observation Services
Observation Services benefits are covered.
Cost Sharing:
More Details:
Periodicity
Per stay
Ambulatory Surgical Center (ASC) Services
Ambulatory Surgical Center (ASC) Services benefits are covered. Prior Authorization is required.
Cost Sharing:
Outpatient Substance Abuse Services
Outpatient Substance Abuse Services benefits are covered.
Cost Sharing:
More Details:
Which Outpatient Substance Abuse services have a Copayment
Medicare-covered Individual Sessions, Medicare-covered Group Sessions
Individual Sessions for Outpatient Substance Abuse
Individual Sessions for Outpatient Substance Abuse benefits are covered.
More Details:
Minimum copayment
20.00
Maximum copayment
20.00
Group Sessions for Outpatient Substance Abuse
Group Sessions for Outpatient Substance Abuse benefits are covered.
More Details:
Minimum copayment
20.00
Maximum copayment
20.00
Outpatient Blood Services
Outpatient Blood Services benefits are covered.
More Details:
Is there a deductible?
No
Do you waive the deductible for the first three pints of blood?
Yes
Partial Hospitalization
Partial Hospitalization benefits are covered.
Partial Hospitalization
Partial Hospitalization benefits are covered. Prior Authorization is required.
Cost Sharing:
Partial Hospitalization
Partial Hospitalization benefits are covered.
Cost Sharing:
Ambulance and Transportation Services
Ambulance and Transportation Services benefits are covered.
All Ambulance Services
All Ambulance Services benefits are covered. Prior Authorization is required.
More Details:
Is there a coinsurance?
No
Is there a copayment ?
Yes
Which Services have a Copayment
Medicare-covered Ground Ambulance Services, Medicare-covered Air Ambulance Services
Is this Copayment waived if admitted to hospital?
No
Ground Ambulance Services
Ground Ambulance Services benefits are covered.
Cost Sharing:
Air Ambulance Services
Air Ambulance Services benefits are covered.
Cost Sharing:
Transportation Services
Transportation Services benefits are covered.
Transportation Services - Plan Approved Health-related Location
Not covered.
Transportation Services - Any Health-related Location
Not covered.
Emergency Services
Emergency Services benefits are covered.
Emergency Services
Emergency Services benefits are covered.
Cost Sharing:
More Details:
Is there a coinsurance?
No
Is there a copayment?
Yes
Is the copayment for Medicare-covered benefits waived if admitted to hospital?
Yes
Select either days or hours within which admission must occur for waiver
Hours
Enter number of days or hours
24
Does the cost sharing count towards any plan-level deductible?
No
Urgently Needed Services
Urgently Needed Services benefits are covered.
Cost Sharing:
More Details:
Is there a coinsurance?
No
Is there a copayment?
Yes
Is the copayment for Medicare-covered benefits waived if admitted to hospital?
Yes
Select either days or hours within which admission must occur for waiver
Hours
Enter number of days or hours
24
Does the cost sharing count towards any plan-level deductible?
No
Worldwide Emergency Services
Worldwide Emergency Services benefits are covered – including services not usually covered by Medicare plans.
Cost Sharing:
More Details:
Which Worldwide Services have a Copayment
Worldwide Emergency Coverage, Worldwide Urgent Coverage, Worldwide Emergency Transportation
Is there a maximum plan benefit coverage?
No
Worldwide Emergency Coverage
Worldwide Emergency Coverage benefits are covered.
Cost Sharing:
Worldwide Urgent Coverage
Worldwide Urgent Coverage benefits are covered.
Cost Sharing:
Worldwide Emergency Transportation
Worldwide Emergency Transportation benefits are covered.
Cost Sharing:
Primary Care
Primary Care benefits are covered.
Primary Care Physician Services
Primary Care Physician Services benefits are covered.
Chiropractic Services
Chiropractic Services benefits are covered – including services not usually covered by Medicare plans.
Cost Sharing:
More Details:
Which Chiropractic Services have a Copayment
Medicare-covered Chiropractic Services, Routine Care, Other
Is there a maximum plan benefit coverage amount?
No
Routine Chiropractic Care
Routine Chiropractic Care benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
No, indicate number
Visits
12
Periodicity
Every year
Other Chiropractic Services
Other Chiropractic Services benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
No, indicate number
Visits
1
Periodicity
Every year
Service Name
X-rays
Occupational Therapy Services
Occupational Therapy Services benefits are covered.
Cost Sharing:
Physician Specialist Services
Physician Specialist Services benefits are covered. Prior Authorization is required.
Cost Sharing:
Mental Health Specialty Services
Mental Health Specialty Services benefits are covered.
Cost Sharing:
More Details:
Which Mental Health Specialty Services have a Copayment
Medicare-covered Individual Sessions, Medicare-covered Group Sessions
Individual Sessions for Mental Health Specialty Services
Individual Sessions for Mental Health Specialty Services benefits are covered.
More Details:
Minimum copayment
20.00
Maximum copayment
20.00
Group Sessions for Mental Health Specialty Services
Group Sessions for Mental Health Specialty Services benefits are covered.
More Details:
Minimum copayment
20.00
Maximum copayment
20.00
Podiatry Services
Not covered.
Other Health Care Professional
Other Health Care Professional benefits are covered.
Cost Sharing:
More Details:
Minimum copayment
0.00
Maximum copayment
35.00
Psychiatric Services
Psychiatric Services benefits are covered.
Cost Sharing:
More Details:
Which Psychiatric Services have a Copayment
Medicare-covered Individual Sessions, Medicare-covered Group Sessions
Individual Sessions for Psychiatric Services
Individual Sessions for Psychiatric Services benefits are covered.
More Details:
Minimum copayment
20.00
Maximum copayment
20.00
Group Sessions for Psychiatric Services
Group Sessions for Psychiatric Services benefits are covered.
More Details:
Minimum copayment
20.00
Maximum copayment
20.00
Physical Therapy and Speech-Language Pathology Services
Physical Therapy and Speech-Language Pathology Services benefits are covered.
Cost Sharing:
Additional Telehealth Benefits
Additional Telehealth Benefits benefits are covered – including services not usually covered by Medicare plans.
More Details:
Medicare-covered benefits that may have Additional Telehealth Benefits available
7a: Primary Care Physician Services, 7d: Physician Specialist Services, 7e1: Individual Sessions for Mental Health Specialty Services, 7e2: Group Sessions for Mental Health Specialty Services, 7h1: Individual Sessions for Psychiatric Services, 7h2: Group Sessions for Psychiatric Services, 7k: Opioid Treatment Program Services
Opioid Treatment Program Services
Opioid Treatment Program Services benefits are covered.
Cost Sharing:
More Details:
Minimum copayment
20.00
Maximum copayment
20.00
Preventive Services
Preventive Services benefits are covered.
Medicare-covered Zero Dollar Preventive Services
Medicare-covered Zero Dollar Preventive Services benefits are covered. A doctor referral is required.
Annual Physical Exam
Annual Physical Exam benefits are covered – including services not usually covered by Medicare plans.
More Details:
Is there a maximum plan benefit coverage amount?
No
Additional Preventive Services
Additional Preventive Services benefits are covered – including services not usually covered by Medicare plans.
More Details:
Is there a service-specific Maximum Plan Benefit Coverage amount for Other Defined Supplemental Benefits?
No
Health Education
Health Education benefits are covered.
In-Home Safety Assessment
In-Home Safety Assessment benefits are covered.
Personal Emergency Response System (PERS)
Not covered.
Medical Nutrition Therapy (MNT)
Not covered.
Post discharge In-Home Medication Reconciliation
Post discharge In-Home Medication Reconciliation benefits are covered.
Re-admission Prevention
Not covered.
Wigs for Hair Loss Related to Chemotherapy
Not covered.
Weight Management Programs
Not covered.
Alternative Therapies
Not covered.
Therapeutic Massage
Not covered.
Adult Day Health Services
Not covered.
Nutritional/Dietary Benefit
Nutritional/Dietary Benefit benefits are covered.
More Details:
Is this benefit unlimited?
Yes
Setting for Nutritional/Dietary Benefit
Both Sessions (Individual and Group)
Home-Based Palliative Care
Not covered.
In-Home Support Services
Not covered.
Support for Caregivers of Enrollees
Support for Caregivers of Enrollees benefits are covered.
More Details:
Type of benefit for Support for Caregivers of Enrollees
Mandatory
Type of benefit offered for Support for Caregivers of Enrollees
Respite Care, Other
Description
Support for caregivers: support services (counseling, navigation and support), digital coaching, and education for enrollees and their caregivers.
Additional Sessions of Smoking and Tobacco Cessation Counseling
Not covered.
Fitness Benefit
Fitness Benefit benefits are covered.
More Details:
Type of Fitness Benefit offered
Memory Fitness, Activity Tracker
Enhanced Disease Management
Enhanced Disease Management benefits are covered.
Telemonitoring Services
Telemonitoring Services benefits are covered.
Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline)
Not covered.
Home and Bathroom Safety Devices and Modifications
Home and Bathroom Safety Devices and Modifications benefits are covered.
Counseling Services
Not covered.
Kidney Disease Education Services
Kidney Disease Education Services benefits are covered.
Other Preventive Services
Other Preventive Services benefits are covered.
More Details:
Is a referral required for any Services?
No
Glaucoma Screening
Glaucoma Screening benefits are covered.
Diabetes Self-Management Training
Diabetes Self-Management Training benefits are covered.
Digital Rectal Exams
Digital Rectal Exams benefits are covered.
EKG following Welcome Visit
EKG following Welcome Visit benefits are covered.
Hearing Services
Hearing Services benefits are covered.
Hearing Exams
Hearing Exams benefits are covered – including services not usually covered by Medicare plans.
Cost Sharing:
More Details:
Which Hearing Exam Benefits have a Copayment
Routine Hearing Exams
Is there a deductible?
No
Is there a deductible?
No
Is there a maximum plan benefit coverage?
No
Routine Hearing Exams
Routine Hearing Exams benefits are covered.
More Details:
Is this benefit unlimited?
No, indicate number
Number of visits
1
Periodicity
Every year
Fitting/Evaluation for Hearing Aid
Fitting/Evaluation for Hearing Aid benefits are covered.
More Details:
Is this benefit unlimited?
Yes
Prescription Hearing Aids
Prescription Hearing Aids benefits are covered – including services not usually covered by Medicare plans.
Cost Sharing:
More Details:
Service maximum plan benefit coverage
No
Prescription Hearing Aids (all types)
Prescription Hearing Aids (all types) benefits are covered.
More Details:
Is this benefit unlimited?
No, indicate number
Number of visits
2
Periodicity
Every year
Minimum copayment
295.00
Maximum copayment
1495.00
Prescription Hearing Aids - Inner Ear
Not covered.
Prescription Hearing Aids - Outer Ear
Not covered.
Prescription Hearing Aids - Over the Ear
Not covered.
OTC Hearing Aids
Not covered.
Vision Services
Vision Services benefits are covered.
Eye Exams
Eye Exams benefits are covered – including services not usually covered by Medicare plans.
Cost Sharing:
More Details:
Which Eye Exams have a Copayment
Routine Eye Exams
Is there a deductible?
No
Is there a deductible?
No
Is there a maximum plan benefit coverage?
No
Routine Eye Exams
Routine Eye Exams benefits are covered.
More Details:
Is this benefit unlimited?
No, indicate number
Number of visits
1
Periodicity
Every year
Other Eye Exam Services
Other Eye Exam Services benefits are covered.
More Details:
Is this benefit unlimited?
No, indicate number
Number of visits
1
Periodicity
Every year
Service Name
Retinal Imaging - Eye Exam Services
Eyewear
Eyewear benefits are covered – including services not usually covered by Medicare plans.
More Details:
Is there a deductible?
No
Is there a deductible?
No
Is there a maximum plan benefit coverage?
Yes
Does the Maximum Plan Benefit Coverage amount apply to In-network services only OR does it apply to both In-network and Out-of-network services?
Both In-network and Out-of-network services
Maximum plan benefit coverage type
Plan-specified amount per period
Do you offer a Combined Max Plan Benefit Coverage Amount for all Eyewear?
Yes
Combined maximum amount
100.00
Periodicity
Every year
Contact Lenses
Contact Lenses benefits are covered.
More Details:
Is this benefit unlimited?
Yes
Eyeglasses (lenses and frames)
Eyeglasses (lenses and frames) benefits are covered.
More Details:
Is this benefit unlimited?
Yes
Eyeglass lenses
Eyeglass lenses benefits are covered.
More Details:
Is this benefit unlimited?
Yes
Eyeglass frames
Eyeglass frames benefits are covered.
More Details:
Is this benefit unlimited?
Yes
Upgrades
Upgrades benefits are covered.
Dental Services
Dental Services benefits are covered.
Medicare Dental Services
Medicare Dental Services benefits are covered. Prior Authorization is required.
Cost Sharing:
Other Dental Services
Other Dental Services benefits are covered.
More Details:
Is there a maximum plan benefit coverage?
No
Oral Exams
Oral Exams benefits are covered.
More Details:
Is this benefit unlimited?
No
Number of visits
2
Periodicity
Every year
Dental X-Rays
Dental X-Rays benefits are covered.
More Details:
Is this benefit unlimited?
No
Number of X-Rays
1
Periodicity
Other, Describe
Description
Bitewing X-rays are covered once per calendar year. Full mouth (includes bitewing X-rays) or panoramic X-rays are payable once in any 2 year period.
Prophylaxis (Cleaning)
Prophylaxis (Cleaning) benefits are covered.
More Details:
Is this benefit unlimited?
No
Number of visits
2
Periodicity
Every year
Fluoride Treatment
Fluoride Treatment benefits are covered.
Note:
This benefit is offered as an optional, supplemental benefit. That means that you may have to pay more for access to this benefit. Contact the plan for details.
Orthodontic Services
Orthodontic Services benefits are covered.
More Details:
Is there a maximum plan benefit coverage?
No
Restorative Services
Restorative Services benefits are covered.
Note:
This benefit is offered as an optional, supplemental benefit. That means that you may have to pay more for access to this benefit. Contact the plan for details.
Adjunctive General Services
Adjunctive General Services benefits are covered.
Note:
This benefit is offered as an optional, supplemental benefit. That means that you may have to pay more for access to this benefit. Contact the plan for details.
Endodontics
Endodontics benefits are covered.
Note:
This benefit is offered as an optional, supplemental benefit. That means that you may have to pay more for access to this benefit. Contact the plan for details.
Periodontics
Periodontics benefits are covered.
More Details:
Is this benefit unlimited?
No
Number of visits
2
Periodicity
Every year
Prosthodontics, removable
Prosthodontics, removable benefits are covered.
Note:
This benefit is offered as an optional, supplemental benefit. That means that you may have to pay more for access to this benefit. Contact the plan for details.
Maxillofacial Prosthetics
Not covered.
Implant Services
Implant Services benefits are covered.
Note:
This benefit is offered as an optional, supplemental benefit. That means that you may have to pay more for access to this benefit. Contact the plan for details.
Prosthodontics, fixed
Prosthodontics, fixed benefits are covered.
Note:
This benefit is offered as an optional, supplemental benefit. That means that you may have to pay more for access to this benefit. Contact the plan for details.
Oral and Maxillofacial Surgery
Oral and Maxillofacial Surgery benefits are covered.
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Every year
Orthodontics
Not covered.
Home Infusion bundled Services
Home Infusion bundled Services benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Which Medicare Part B Rx Drugs have a Coinsurance
Medicare Part B Chemotherapy/Radiation Drugs, Other Medicare Part B Drugs
Does this plan have a service specific maximum enrollee out-of-pocket cost (MOOP)?
No
Does the plan offer step therapy?
Yes
Does the benefit step from?
Part B to Part B, Part B to Part D, Part D to Part B
Does the plan provide Part D home infusion drugs as part of a bundled service as a mandatory supplemental benefit?
Yes
Insulin
Insulin benefits are covered.
Medicare Part B Insulin Drugs
Medicare Part B Insulin Drugs benefits are covered.
Cost Sharing:
More Details:
Minimum coinsurance
0
Maximum coinsurance
20
Does the Part B drugs - Insulin cost sharing count towards any plan-level deductible?
No
Medicare Part B Chemotherapy/Radiation Drugs
Medicare Part B Chemotherapy/Radiation Drugs benefits are covered.
More Details:
Minimum coinsurance
0
Maximum coinsurance
20
Other Medicare Part B Drugs
Other Medicare Part B Drugs benefits are covered.
More Details:
Minimum coinsurance
0
Maximum coinsurance
20
Dialysis Services
Dialysis Services benefits are covered.
Cost Sharing:
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Medical Equipment
Medical Equipment benefits are covered.
Durable Medical Equipment (DME)
Durable Medical Equipment (DME) benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Are there preferred vendors/manufacturers for Durable Medical Equipment (DME)?
No
Prosthetics/Medical Supplies - Non-Medicare benefit
Prosthetics/Medical Supplies - Non-Medicare benefit benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Which Prosthetics/Medical Supplies have a Coinsurance
Medicare-covered Prosthetic Devices, Medicare-covered Medical Supplies
Prosthetic Devices
Prosthetic Devices benefits are covered.
More Details:
Minimum coinsurance
0
Maximum coinsurance
20
Medical Supplies
Medical Supplies benefits are covered.
Cost Sharing:
Diabetic Equipment
Diabetic Equipment benefits are covered.
More Details:
Do you limit Diabetic supplies and services to those from specified manufacturers
Yes
Diabetic Supplies
Not covered.
Diabetic Therapeutic Shoes/Inserts
Not covered.
Diagnostic and Radiological Services
Diagnostic and Radiological Services benefits are covered.
All Diagnostic services
All Diagnostic services benefits are covered. Prior Authorization is required.
More Details:
Is there a copayment?
No
Diagnostic Procedures/Tests
Not covered.
Lab Services
Not covered.
All Radiological Services
All Radiological Services benefits are covered. Prior Authorization is required.
More Details:
Is there a copayment?
Yes
Which Outpatient Diagnostic/Therapeutic Radiological Services have a Copayment
Medicare-covered Diagnostic Radiological Services, Medicare-covered Therapeutic Radiological Services, Medicare-covered X-Ray Services
If a member receives multiple services at the same location on the same day, does only the maximum copay apply?
No
Diagnostic Radiological Services
Diagnostic Radiological Services benefits are covered.
Cost Sharing:
More Details:
Minimum copayment
270.00
Therapeutic Radiological Services
Therapeutic Radiological Services benefits are covered.
Cost Sharing:
More Details:
Minimum copayment
40.00
Outpatient X-Ray Services
Outpatient X-Ray Services benefits are covered.
Cost Sharing:
Home Health Services
Home Health Services benefits are covered. Prior Authorization is required.
Cardiac Rehabilitation Services
Cardiac Rehabilitation Services benefits are covered.
Cost Sharing:
More Details:
Which Cardiac and Pulmonary Rehabilitation Services have a Copayment
Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, Additional Cardiac Rehabilitation Services
Cardiac Rehabilitation Services
Not covered.
Intensive Cardiac Rehabilitation Services
Not covered.
Pulmonary Rehabilitation Services
Not covered.
SET for PAD Services
Not covered.
Skilled Nursing Facility (SNF)
Skilled Nursing Facility (SNF) benefits are covered. Prior Authorization is required.
Cost Sharing:
| Days 1-20: | Days 21-100: | |
|---|---|---|
| Copayment | 0.00 | 218.00 |
More Details:
Does the plan provide Skilled Nursing Facility Services as a supplemental benefit under Part C?
Yes
Do you allow less than 3 day inpatient hospital stay prior to SNF admission?
Yes
Days
Zero
Do you charge the Medicare-defined cost share for tier 1?
No
Periodicity
Original Medicare
Additional Days beyond Medicare-covered for Skilled Nursing Facility (SNF)
Not covered.
Other Services
Other Services benefits are covered.
Acupuncture
Acupuncture benefits are covered – including services not usually covered by Medicare plans.
Cost Sharing:
More Details:
Is this benefit unlimited for Number of Treatments?
No
Limit for Number of Treatments
6
Periodicity
Every year
Is there a maximum plan benefit coverage amount?
No
Over-the-Counter (OTC) Items
Over-the-Counter (OTC) Items benefits are covered.
More Details:
Does the plan provide Over-The-Counter (OTC) Items as a supplemental benefit under Part C?
Yes
Is there a maximum plan benefit coverage amount?
No
Plan offers Nicotine Replacement Therapy (NRT) as a Part C OTC benefit?
Yes
The Nicotine Replacement Therapy (NRT) being offered does not duplicate any Part D OTC or formulary drugs.
The Nicotine Replacement Therapy (NRT) being offered does not duplicate any Part D OTC or formulary drugs.
Plan offers Naloxone coverage as a Part C OTC benefit?
Yes
Does this cover all of the drugs on the CMS OTC list which may be found in Chapter 4 of the Medicare Managed Care Manual
Yes
Indicate mode of delivery for the OTC Items
Claims Processing, Reimbursement, Other
Meal Benefit
Not covered.
Other 1
Other 1 benefits are covered.
Cost Sharing:
More Details:
Service Name
Ambulance Stabilization/Non-transport
Is there a maximum plan benefit coverage?
No
Other 2
Other 2 benefits are covered.
More Details:
Service Name
Annual Wellness Visits
Is there a maximum plan benefit coverage amount?
No
Dual Eligible SNPs with Highly Integrated Services
Not covered.
Plan Providers
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Anthem Blue Cross, Aspire Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, GlobalHealth, Health Care Service Corporation, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Baylor Scott & White Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
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Every year, Medicare evaluates plans based on a 5-star rating system.
Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
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