Your PriorityMedicare ONESM plan information
Find out what our PriorityMedicare ONESM (HMO-POS) plan offers you. Review your benefits in the chart below or by downloading any of your coverage documents.
Your coverage documents provide detailed explanations about how your plan works.
- 2024 Annual Notice of Changes
- 2024 Evidence of Coverage
The Evidence of Coverage is the legal, detailed description of your benefits and costs. It also explains your rights and rules you need to follow when using your coverage for medical care and prescription drugs. - 2024 Priority Health Medicare Advantage Formulary
Important Message About What You Pay for Vaccines - Our plan covers most Part D vaccines at no cost to you, even if you haven’t paid your deductible (if your plan has a deductible). Call Customer Service for more information.
Important Message About What You Pay for Insulin - You won’t pay more than $35 for a one-month supply of each insulin product covered by our plan, no matter what cost-sharing tier it’s on, even if you haven’t paid your deductible (if your plan has a deductible).
2024 PriorityMedicare ONE coverage summary
This chart shows what our PriorityMedicare ONE plan offers members.
Deductible
The amount you'll pay for most covered in-network medical services before you start paying only copayments or coinsurance and Priority Health pays the balance.
Out-of-pocket maximum
This is the most you pay during a calendar year for in-network and out-of-network services before Priority Health begins to pay 100% of the allowed amount. This limit includes copayments and coinsurance payments. It does not include your monthly premium or Part D drug costs.
Inpatient hospital care
Days 1-7
Days 8 and beyond
There is no limit to the number of days covered by the plan each hospital stay.
Authorization rules may apply.
Doctor office visits
Each primary care visit
Each specialist visit
Each palliative care physician visit
Authorization rules may apply.
Emergency & urgent care
Each emergency room visit
Each urgent care visit
Get emergency or urgent care services wherever you are in the United States or all over the world.
Lab services
Medicare-covered lab services
Diagnostic tests and procedures
Outpatient X-rays
Medicare-covered outpatient X-rays
Diagnostic radiology services
Medicare-covered diagnostic radiology services
Diagnostic radiology includes services such as MRIs and CT scans.
Authorization rules may apply.
Radiation therapy
Medicare-covered radiation therapy services, such as cancer treatment
Preventive care
Annual physical exam and preventive services covered under Original Medicare
See a list of preventive services covered at $0 copay. Any additional preventive services approved by Medicare during the contract year will be covered.
Routine vision (by EyeMed®)
One routine exam (including refraction with dilation as necessary) & one retinal imaging per year
Each year
Preventive dental services (by Delta Dental®)
Two oral exams and two cleanings per year (regular or periodontal maintenance)
One brush biopsy, one fluoride treatment and one set of bitewing x-rays each year
Periapical radiographs as needed and all other radiographs (full-mouth series or panoramic x-rays) every 24 months
Routine hearing (by TruHearing™)
Routine exam
Per year, per ear for hearing aids from top manufacturers
Hearing aid cost includes three fitting and follow-up evaluations within the first year and 48 batteries per hearing aid.
Chiropractic services
Routine visit, up to 12 visits per year
Chiropractic X-ray services, performed once per year
Medicare-covered visit
Acupuncture services
Medicare-covered visit
Routine visit, up to six visits per year for other conditions
Priority Health Travel Pass
Priority Health Travel Pass has you covered for out-of-area care at in-network prices, access to MultiPlan® Medicare Advantage providers, unlimited worldwide emergency and urgent care and Assist America® for global travel assistance. Learn more.
You may stay enrolled in the plan when outside of the service area for up to 12 months, as long as your residency remains in the service area.
OTC Plus allowance
(no rollover) monthly
For use on drugs and health related products that do not need a prescription, such as allergy medication and eye drops. Eligible members can also use their monthly allowance towards healthy food and produce. Learn more.
Virtual care
Each primary care, specialist or behavioral health provider virtual visit
Also referred to as "evisits" or "telehealth," virtual care is a cost-effective and convenient way to visit with a health care professional via phone or video for non-emergencies.
PriorityCare
Per year of companion care with Papa plus unlimited Social Care Navigation.
Transportation
For 30 one-way trips each year (40 miles each way).
SilverSneakers health and fitness program
For membership at participating SilverSneakers® fitness centers, plus access to online educational programs and SilverSneakers On-Demand™ workout videos. Learn more.
BrainHQ
A personal gym for the brain. You can access online exercises that improve memory, attention, brain speed and more. Learn more.
Prescription drug benefits
Have questions on drug tiers? Learn more.
You have lower copays when you use a preferred pharmacy. See if your pharmacy is on the "preferred" list.
Plan D prescription drugs, deductible
This deductible applies to the cost of all drugs on the plan's list of approved drugs, or "formulary." Download the formulary to see approved drugs or view the Approved Drug List on this website.
Tier 1 (preferred generic drugs)
Preferred retail (30-day)
Standard retail (30-day)
Mail order (90-day)
You pay copays or coinsurance for drugs on this plan's formulary until your total yearly drug costs reach $5,030.
Tier 2 (generic drugs)
Preferred retail (30-day)
Standard retail (30-day)
Mail order (90-day)
You pay copays for drugs on this plan's formulary until your total yearly drug costs reach $5,030.
Tier 3 (preferred brand drugs)
Preferred retail (30-day)
Standard retail (30-day)
Preferred mail order through Express Scripts (90-day)
You pay copays or coinsurance for drugs on this plan's formulary until your total yearly drug costs reach $5,030.
Tier 4 (non-preferred drugs)
Preferred retail (30-day)
Standard retail (30-day)
Mail order (90-day)
You pay copays or coinsurance for drugs on this plan's formulary until your total yearly drug costs reach $5,030.
Tier 5 (specialty drugs)
(30-day supplies only)
You pay copays or coinsurance for drugs on this plan's formulary until your total yearly drug costs reach $5,030.
Part D prescription drugs, while in the coverage gap
Covered generic drugs
Covered brand drugs
When you reach your total yearly drug cost (includes what our plan has paid and what you've paid) of $5,030, you'll enter what is called a coverage gap. At this time, you'll pay 25% of the plan's cost for covered generic drugs and 25% of the plan's cost for covered brand drugs, plus dispensing fee, until your total costs reach $8,000.
Most Medicare plans have this coverage gap (also called the "donut hole"), but not everyone will enter the coverage gap.
Part D prescription drugs, catastrophic coverage
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $8,000 you pay $0 and the plan pays 100% of your drug costs.
Optional benefits
Enhanced Dental and Vision package
Optional benefit: Add additional dental and vision coverage to your plan for an extra $42 monthly premium, including additional dental coverage for things like crowns, root canals, extractions, fillings, implants, dentures and more with $2,500 to spend each calendar year and another $150 per year toward your eyewear allowance.
Get details and learn how to add this coverage to your plan.
*The ONE plan is available in Kent, Ottawa, Wayne, Oakland and Macomb counties.