PriorityMedicare Edge (PPO) 2024 Benefit Details for Plan H4875-020-2 in Isabella County, MI
PriorityMedicare Edge is a 2024 Medicare Advantage PPO plan, {with_without_pdp} prescription drug coverage.
Delivery of healthcare services and costs are different than in Original Medicare, but this plan option, by Priority Health Medicare, may offer extra benefits.
See more 2024 Medicare Advantage Plans available in Isabella County, Michigan.
This plan is rated 4.5 (Good+) stars by CMS making it a top-rated plan.
Plan Basics | |
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Plan ID: | H4875 020 2 |
Plan Type: | Local PPO |
Plan Year: | 2024 |
Premium: | $0.00/mo Plus your Medicare Part B premium. |
Health Plan Deductible: | $0.00 |
Out-of-Pocket Maximum: | $5,300/yr |
Part B Reduction: | $0.00/mo |
Drug Plan Benefit: | Enhanced, $0.00 deductible |
Rx Gap Coverage: | No |
Supplemental Benefits: | Vision, Hearing |
Availability: | Isabella County, MI |
Insured By: | Priority Health Medicare |
Summary of Benefits |
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Health Plan Cost Sharing
This Priority Health Medicare Medicare Advantage plan has cost-sharing. These are costs you must pay out-of-pocket when you use approved health services.
NOTE: Most preventive services are covered 100% by the plan as a Part B benefit.
The following table summarizes the most common out-of-pocket costs you will incur if you join this plan unless you go out-of-network:
Healthcare Service | Member Cost |
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Doctor Visits (In-Network) | |
Primary: | $0 |
Specialist: | $45 Copay Authorization Required |
Wellness programs (e.g., fitness, nursing hotline): | None |
Preventive care: | $0 |
Foot Care (In-Network) | |
Foot exams and treatment (Medicare-covered): | $45 Copay |
Routine foot care: | Not Covered |
Chiropractic Care (In-Network) | |
Medicare-covered chiropractic care: | $20 Copay |
Routine chiropractic care: | Not Covered |
Emergency Care / Urgent Care | |
Emergency room care: | $120 Copay |
Urgent care: | $30 Copay |
Ground ambulance: | $275 Copay |
Inpatient hospital coverage: | $320.00 per day for days 1 through 7 $0.00 per day for days 8 and beyond |
Outpatient hospital coverage: | $325 Copay Authorization Required |
Skilled Nursing Facility: | $0.00 per day for days 1 through 20 $203.00 per day for days 21 and beyond |
Optional supplemental benefits: | |
Mental Health Services (In-Network) | |
Outpatient individual therapy visit with a psychiatrist: | $20 Copay |
Outpatient group therapy visit with a psychiatrist: | $20 Copay |
Inpatient hospital - psychiatric: | $350.00 per day for days 1 through 5 $0.00 per day for days 6 and beyond |
Outpatient group therapy visit: | $20 Copay |
Outpatient individual therapy visit: | $0 |
Rehabilitation Services (In-Network) | |
Physical therapy and speech and language therapy visit: | $40 Copay |
Occupational therapy visit: | $40 Copay |
Medical Equipment / Supplies (In-Network) | |
Diabetes supplies: | $0 |
Durable medical equipment (e.g., wheelchairs, oxygen): | 20% Coinsurance Authorization Required |
Prosthetics (e.g., braces, artificial limbs): | 20% Coinsurance |
Diagnostic Procedures / Lab Services / Imaging (In-Network) | |
Diagnostic radiology services (e.g., MRI): | $270 Copay Authorization Required |
Lab services: | $0 Copay Authorization Required |
Outpatient x-rays: | $20 Copay Authorization Required |
Diagnostic tests and procedures: | $0 |
Medicare Part B Drugs (In-Network) | |
Chemotherapy: | 20% Coinsurance |
Other Part B drugs (Medicare-covered) | 20% Coinsurance |
Feel free to download our PriorityMedicare Edge Summary of Benefits information.
Supplemental Benefits
The following is a summary of the supplemental benefits Priority Health Medicare includes with this plan:
Supplemental Healthcare Service | Member Cost |
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Preventive Dental | |
Oral exam (In-Network) | Not Covered |
Fluoride treatment (In-Network) | Not Covered |
Dental x-ray(s) (In-Network) | Not Covered |
Cleaning (In-Network) | Not Covered |
Comprehensive Dental | |
Periodontics (In-Network) | Not Covered |
Non-routine services (In-Network) | Not Covered |
Diagnostic services (In-Network) | Not Covered |
Extractions (In-Network) | Not Covered |
Endodontics (In-Network) | Not Covered |
Restorative services (In-Network) | Not Covered |
Prosthodontics, other oral/maxillofacial surgery, other services (In-Network) | Not Covered |
Hearing Aids | |
Fitting/evaluation (In-Network) | Covered Limits may apply |
Hearing aids (In-Network) | Covered Limits may apply |
Hearing exam (In-Network) | Covered Limits may apply |
Vision | Maximum vision benefit: | $100.00 Every year |
Eyeglasses (frames and lenses) (In-Network) | Covered Limits may apply |
Routine eye exam (In-Network) | Covered Limits may apply |
Contact lenses (In-Network) | Covered Limits may apply |
Additional Benefits
None specified.
Prescription Drug Plan Costs & Benefits
PriorityMedicare Edge includes an enhanced benefit Medicare Part D plan (PDP). Enhanced plans have a higher actuarial value than basic plans. Actuarial value simply refers to the percentage of cost that's covered by the plan.
Prescription Drug Plan Premium
Although the prescription drug plan (Part D) premium is bundled with the total plan cost, some plans have supplemental costs and/or offer low-income subsidy (LIS) assistance. LIS, also known as Extra Help, is a Social Security program that helps people with limited income and resources lower or cut Part D costs.
The following table outlines the prescription drug plan premium details of this plan.
Basic Part D Premium: | $0.00 |
Supplemental Part D Premium: | $0.00 |
Total Part D Premium: | $0.00 |
Part D Premium with Full LIS Assistance: | $0.00 |
If you would like more information about the Extra Help program, you can refer to the Social Security Extra Help page.
Prescription Drug Plan Deductible
The Medicare Part D annual deductible with this plan is $0.00. This is the amount you must pay at the pharmacy before Priority Health Medicare begins paying its share.
Prescription Drug Plan Out-of-Pocket Costs
In addition to the plan's monthly premium and deductible, PriorityMedicare Edge has out-of-pocket costs that you must pay when you pick up your prescriptions.
Drug Tier | Preferred | Standard |
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1 (Preferred Generic) | $2.00 copay | $7.00 copay |
2 (Generic) | $8.00 copay | $15.00 copay |
3 (Preferred Brand) | $38.00 copay | $47.00 copay |
4 (Non-Preferred Drug) | 40% | 45% |
5 (Specialty Tier) | 33% | 33% |
CMS Rating Marks for 2024
Each year Medicare rates health plans (Part C) and drug plans (Part D) in several major categories based on a 5-star rating system. These ratings are designed to help you understand the quality of care and service you can expect if you join this Priority Health Medicare plan.
CMS Measure | Star Rating |
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2024 Overall Rating | |
Staying Healthy: Screenings, Tests, Vaccines | |
Managing Chronic (Long Term) Conditions | |
Member Experience with Health Plan | |
Complaints and Changes in Plans Performance | |
Health Plan Customer Service | |
Drug Plan Customer Service | |
Complaints and Changes in the Drug Plan | |
Member Experience with the Drug Plan | |
Drug Safety and Accuracy of Drug Pricing |
Additional Medicare Advantage Plan Options
The Medicare Advantage program offers a myriad of options, including these plans:
- PriorityMedicare Vital
- PriorityMedicare Thrive
- PriorityMedicare Ideal
- PriorityMedicare Vital
- PriorityMedicare Ideal
Contact Priority Health Medicare
Plan Website: | http://www.prioritymedicare.com |
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Formulary Information: | http://www.prioritymedicare.com |
Pharmacy Information: | Priority Health Medicare Pharmacy Page |
Prospective Members: | (888)384-1695 |
TTY Users: | 711 |
If you qualify for Medicare benefits but have not yet enrolled or verified your enrollment status, you can do so on the Social Security Administration website. You can learn more about the Medicare Advantage program on www.medicare.gov.
Plans Offered
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Aspire Health Plan, Dean Health Plan, Devoted Health, GlobalHealth, Health Care Service Corporation, Cigna Healthcare, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Scott and White Health Plan now part of Baylor Scott & White Health, UnitedHealthcare(R), and Wellcare.
Citations & References
- Priority Health Medicare, http://www.prioritymedicare.com, Last Accessed February 20, 2024
- Medicare.gov, "Understanding Medicare Advantage Plans", Last Accessed January 21, 2024
- Medicare.gov, "Your Medicare coverage choices", Last Accessed February 19, 2024
- Medicare.gov, "Medicare & You in Different Formats", Last Accessed February 19, 2024
- Medicare.gov, "Your Medicare Coverage", Last Accessed April 11, 2023
- CMS.gov, Landscape Source Files, Last Accessed February 21, 2024
- CMS.gov, Medicare Part C & D Performance, Last Accessed February 21, 2024
- CMS.gov, Plan Benefits Package, Last Accessed February 21, 2024
About This H4875-020-2 Plan Detail Page
The data on this PriorityMedicare Edge plan detail page is derived from the 2024 Landscape Source Files, Plan Benefit Package, and Medicare Part C and Part D Performance Data published by CMS.
The author interprets these files, and their associated data dictionary, with great care, making every attempt to communicate the data submitted by Priority Health Medicare to CMS as clearly and accurately as possible. Given the complexity of the data, the author recommends that all potential enrollees request an official Summary of Benefits from Priority Health Medicare, at (888)384-1695, prior to enrollment.