- Priority Health Medicare Advantage is based in Michigan and offers plans to state residents.
- You can choose from several plan options, including HMO-POS, HMO D-SNP, and PPO plans with prescription drug coverage.
- Priority Health plans offer add-on vision, dental, hearing, and other benefits.
- These plans also offer several no-cost preventive health benefits, such as screenings, vaccines, and other wellness programs.
Priority Health offers Medicare Advantage (Part C) plans with prescription drug options. You can choose from several plans as long as you’re eligible for Medicare in the state of Michigan.
The three main types of plans offered are:
- Health Maintenance Organization Point-of-Service (HMO-POS) plans
- HMO Dual Eligible Special Needs Plans (D-SNPs)
- Preferred Provider Organization (PPO) plans
This article reviews information about the different Priority Health plans, costs, and coverage options available in Michigan.
Priority Health offers Medicare Advantage HMO-POS and PPO plans. Here’s an overview of each type.
Priority Health Medicare Advantage HMO-POS plans
Priority Health Medicare Advantage HMO plans have agreements with doctors, hospitals, pharmacies, and other healthcare providers to offer health and medical services to people with Medicare. These agreements qualify their services as in-network benefits.
HMO plans require you to choose a primary care physician (PCP). These physicians serve as your main point of contact for any services you may need. They can also provide referrals for specialists, when necessary.
Priority Health offers a specific type of HMO plan called an HMO-POS. These plans are a blend of an HMO and a PPO.
You’re still required to choose a PCP, but you may go to an out-of-network provider without a referral. If you do this, though, the cost of these visits may be higher.
Priority Health Medicare Advantage HMO D-SNPs
Priority Health offers Medicare Advantage HMO D-SNPs to people who are eligible for both Medicare and Medicaid in Michigan. This type of plan has a $0 premium and no doctor visit copays. Some of the other benefits include:
- dental, vision, and hearing coverage
- $145 quarterly allowance for over-the-counter drugs and health products
- care management services to help manage chronic conditions
- acupuncture and chiropractic care
- SilverSneakers membership
Priority Health Medicare Advantage PPO plans
Priority Health PPO plans also have agreements with doctors and other providers for healthcare services. However, PPO plans don’t require you to get a referral to see a specialist or to get other services.
You can visit any provider you’d like. But if you visit an out-of-network provider, you may have to pay a higher copay or coinsurance.
Here are some important things to know about coverage under a Priority Health Medicare Advantage plan:
- Inpatient hospital stays are covered with separate rates for days 1 through 6. There are no limits to the number of days covered for each hospital stay.
- Plan-approved PCPs are covered with set copays and specialists are covered based on HMO or PPO plan rules.
- Emergency room and urgent care visits are covered with set copays. These can be located anywhere in the nation or around the world. Costs may be higher for out-of-network providers based on plan rules.
Priority Health plans offer several preventive and wellness benefits at no cost. For diagnostic tests, though, you may have to pay a copay or coinsurance.
Some of the covered preventive care services include:
- annual wellness checkup
- one time Welcome to Medicare wellness visit and diabetes prevention counseling
- bone density screening for those at risk of osteoporosis once every 24 months
- breast cancer screening once every 24 months
- depression screening annually
- heart disease risk screening every 5 years
- cervical (pap smear) and vaginal (pelvic) cancer screening every 24 months
- colon cancer screening
- prostate cancer screening annually
- vaccines such as influenza (flu) shots, hepatitis B vaccine, and pneumococcal (pneumonia) shots (one or two based on risk)
Depending on the plan you choose, additional coverage benefits may include:
- Priority Health allows you to visit any Medicare-participating provider outside of Michigan when you’re traveling out of state. This includes international travel with in-network rates.
- Routine hearing exams are covered and discounts on hearing aids are offered through TruHearing.
- Routine eye exams are covered by EyeMed and discounts toward eyewear.
- Telehealth or virtual doctor visit coverage with $0 copays.
- Priority Health plans offer optional dental coverage through Delta Dental for annual exams and cleanings.
- You can also buy extra dental and vision coverage for a higher monthly premium.
All Priority Health Medicare Advantage plans come with prescription drug coverage. These are known as Medicare Advantage Prescription Drug (MAPD) plans. Priority Health does not have standalone Medicare Part D plans.
MAPD plans may have a $0 deductible and low copayments, as long as you visit Priority Health preferred pharmacies and use medications on the approved drugs list or formulary. You can find a list of Priority Health’s covered medications here.
Every plan has five tiers or groups for medication coverage. Copays and coinsurance costs vary based on the tier your medication falls under. Many plans have $0 or low-cost copayments for tier 1 and 2 drugs. You pay coinsurance and copayments on medications until your costs total $4,130 in 2021.
The table below provides an example of the Priority Health’s HMO-POS prescription drug benefits.
|Tier||Preferred pharmacy (30-day supply)||Nonpreferred, standard retail pharmacy (30-day supply)||Mail order (90-day supply)|
|1 (preferred generic)||$2 copay||$6 copay||$0 copay|
|2 (generic)||$8 copay||$13 copay||$0 copay|
|3 (preferred brand)||$38 copay||$43 copay||$95 copay|
|4 (nonpreferred drugs)||40% coinsurance||45% coinsurance||40% coinsurance|
|5 (specialty drugs)||33% coinsurance||33% coinsurance||33% coinsurance|
After you reach $4,130 in costs, you enter the coverage gap for that part of the plan. You then pay 25 percent for generic and brand-name medications, plus a dispensing fee (if applicable), until you reach $6,550.
After this, you enter catastrophic coverage and will pay 5 percent of the cost of a medication or copays of $3.70 for generic drugs and $9.20 for all other drugs.
Prescription drug copay, deductible, and coinsurance costs vary with different plans. You can compare plans and costs based on your ZIP code, as well as costs for Medigap plans offered by Priority Health here.
You can choose from several different types of plans with various levels of coverage and rates, depending on where you live in Michigan.
You must also pay the Part B premium in addition to your Medicare Advantage plan costs.
All plans also cover medications with different copays and coinsurance.
Here are a few examples of the costs you may see with Priority Health Medicare Advantage plans in 2021 throughout different locations in Michigan.
|City/plan||Monthly premium||Health deductible, drug deductible||PCP copay, specialist copay||Out-of-pocket maximum||Estimated total yearly costs for care|
|Detroit, MI: PriorityMedicare (HMO-POS)||$120||$500 (out of network), $0||$0–$10, $0–$40||$4,500 (in network)||$4,579|
|Kalamazoo, MI: PriorityMedicare Value (HMO-POS)||$32||$1,00 (out of network), $75||$0–$5, $0–$45||$4,900 (in network)||$3,655|
|Ann Arbor, MI: PriorityMedicare D-SNP (HMO D-SNP)||$0||$0, $445||$0, $0||$7,550 (in network)||—|
|East Lansing, MI: PriorityMedicare Select (PPO)||$206||$0, $0||$0–$15, $0–$40||$3,500 (in and out of network), $3,500 (in network)||$5,467|
|Saginaw, MI: PriorityMedicare Edge (PPO)||$0||$0, $0||$0, $0–$40||$5,300 (in and out of network), $5,300 (in network)||$3,307|
Annual costs will vary based on how often you visit your PCP, diagnostic tests needed, how many medications you take, and any additional medical services you use each year, up to your plan’s out-of-pocket max.
Here are some things to consider when selecting a Priority Health Medicare Advantage plan:
- Review the health services and medications you need.
- Assess your budget and each plan’s costs (premiums, deductibles, coinsurance, copays).
- Decide whether an HMO-POS, HMO D-SNP, or PPO plan fits your needs based on costs and if flexibility with providers and network is important.
- Consider any extra benefits that you might need, like certain specialists or services.
You can use Medicare’s plan finder tool to compare rates and costs of the different plans, including those from Priority Health, available in your area.
Medicare Advantage (Part C) plans are private insurance plans that provide the same coverage as original Medicare (Part A and Part B). Part C plans may also offer extra coverage for prescription medications, vision, dental, wellness, and other benefits.
You’re eligible for Part C as soon as you’re eligible for enrollment in original Medicare.
Medicare Advantage plan options and costs vary by state. Before signing up with a plan, check which services are available in your area and compare costs.
If you have questions about Priority Health plans, coverage, and costs, you can call the company directly at 888-389-6648 or contact them through their website.
As a plan member, you can also access your prescription and claim history online.
If you have questions about all the different Medicare Advantage plan options, you can visit Medicare.gov or call 800-MEDICARE for more information on plans and costs.
This article was updated on November 13, 2020, to reflect 2021 Medicare information.
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