Your 2025 plan documents
Find out what our PriorityMedicare VitalSM (PPO) 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.
- 2025 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. - 2025 Annual Notice of Change
For existing members who have a 2023 Priority Health Medicare Advantage plan, the Annual Notice of Change outlines the year-over-year changes to the plan, including basic benefits and embedded extras. - 2025 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).
2025 PriorityMedicareVital coverage summary
This chart shows what our PriorityMedicare Vital plan offers members.
Deductible | |
|---|---|
The amount you'll pay for most covered medical services, in-network and out-of-network combined, before you start paying only copayments or coinsurance and Priority Health pays the balance. | $375 |
Part B premium credit | |
|---|---|
Per month | $45 |
You must keep paying your Medicare Part B premium, but will receive a $540 Part B premium credit each year ($45 per month) if you enroll in this plan.
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 monthly premiums, Part D drug costs or services from out-of-network providers. | $5,600 |
Inpatient hospital care | |
|---|---|
Days 1-5 | $350 copay per day |
Days 6 and beyond | $0 copay per day |
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 | $0 copay |
Each specialist visit | $50 copay |
Each palliative care physician visit | $0 copay |
Authorization rules may apply.
Emergency and urgent care | |
|---|---|
Each emergency room visit | $120 copay |
Each urgent care visit | $55 copay |
Get emergency or urgent care services wherever you are in the United States or all over the world.
Deductible does not apply.
Lab services | |
|---|---|
Medicare-covered lab services | $0 copay |
Diagnostic tests and procedures | |
|---|---|
Medicare-covered diagnostic procedures and tests | $0 copay |
Authorization rules may apply.
Outpatient X-rays | |
|---|---|
Medicare-covered outpatient X-rays | $40 copay |
Diagnostic radiology services | |
|---|---|
Medicare-covered diagnostic radiology services | 20% coinsurance |
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 | $40 copay |
Preventive care | |
|---|---|
Annual physical exam and preventive services covered under Original Medicare | $0 copay |
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 | $0 copay |
Each year | $125 eyewear allowance |
Preventive dental services (by Delta Dental®) | |
|---|---|
Two exams, two cleanings, one set of bitewing X-rays & one brush biopsy each year | $0 copay |
All other X-rays, including panoramic, once every two years | $0 copay |
$1,500 annual maximum that applies to the following services: $0 for fillings (includes composite resin and amalgam once per tooth per lifetime, $0 for simple extractions one per tooth per lifetime, $0 for crown repairs once per tooth every 12 months, $0 for anesthesia, no limit when used during any of the services above.
Routine hearing (by TruHearingTM) | |
|---|---|
Routine exam | $0 copay |
Up to two TruHearing-branded "Advanced" hearing aids | $0 copay |
Hearing aid cost includes three fitting and follow-up evaluations within the first year. 48 batteries per hearing aid.
Chiropractic services | |
|---|---|
Routine visit, up to 12 visits per year | $20 copay |
Chiropractic X-ray services, performed once per year | $40 copay |
Medicare-covered visit | $20 copay |
Acupuncture services | |
|---|---|
Medicare-covered visit | $20 copay |
Routine visit, up to six visits per year for other conditions | $20 copay |
Over-the-counter (OTC) items | |
|---|---|
Per month (no rollover) | $25 |
For use on drugs and health related products that do not need a prescription, such as allergy medication and eye drops. Learn more.
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.
Virtual care | |
|---|---|
Each primary care, specialist or behavioral health provider virtual visit | $0 copay |
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.
One Pass® | |
|---|---|
Access to the largest nationwide network of gyms and fitness locations, live digital fitness classes, on-demand workouts, and home fitness kits. Learn more. | $0 copay |
CogniFit® | |
|---|---|
Get online brain training mode just for you to help improve your memory and focus all through your One Pass user account. Learn more. | $0 copay |
Prescription drug benefits
Have questions on drug tiers and costs? Learn more.
You have lower copays when you use a preferred pharmacy. See if your pharmacy is on the "preferred" list.
Part D prescription drug, deductible | |
|---|---|
Tiers 1 and 2 | $0 |
Tiers 3-5 | $350 |
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 Drugs List on this website.
Tier 1 (preferred generic drugs) | |
|---|---|
Preferred retail (30-day) | $1 copay |
Standard retail (30-day) | $6 copay |
Mail order (90-day) | $0 copay |
You pay copays/coinsurance for drugs on this plan's formulary until your total yearly drug costs reach $2,000.
Tier 2 (generic drugs) | |
|---|---|
Preferred retail (30-day) | $10 copay |
Standard retail (30-day) | $15 copay |
Mail order (90-day) | $0 copay |
You pay copays/coinsurance for drugs on this plan's formulary until your total yearly drug costs reach $2,000.
Tier 3 (preferred brand drugs) | |
|---|---|
Preferred retail (30-day) | $42 copay |
Standard retail (30-day) | $47 copay |
Mail order (90-day) | $105 copay |
You pay copays/coinsurance for drugs on this plan's formulary until your total yearly drug costs reach $2,000.
Tier 4 (non-preferred drugs) | |
|---|---|
Preferred retail (30-day) | 45% coinsurance |
Standard retail (30-day) | 50% coinsurance |
Mail order (90-day) | 45% coinsurance |
You pay copays/coinsurance for drugs on this plan's formulary until your total yearly drug costs reach $2,000.
Tier 5 (specialty drugs) | |
|---|---|
(30-day supplies only) | 28% coinsurance |
You pay copays/coinsurance for drugs on this plan's formulary until your total yearly drug costs reach $2,000.
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 $2,000 you pay $0 for the remainder of the plan year.
Optional benefits
Enhanced Dental and Vision package
Optional benefit: Add additional dental and vision coverage to your plan for an extra $39 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.