PriorityMedicare Edge (PPO) H4875-020-3 Plan Details
PriorityMedicare Edge (PPO) H4875-020-3 Plan Details
Choosing the right Medicare Advantage plan is crucial for your healthcare needs in 2025. With PriorityMedicare Edge (PPO) as one of the options, you can compare it side-by-side with other available plans to find the best fit. Whether you prefer enrolling online or seeking advice from a licensed agent, we’ve made the process simple and straightforward.
PriorityMedicare Edge Overview
Plan ID H4875-020-3 Overview | |
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Health Plan ID: | H4875-020-3 |
Medicare Advantage Plan Type: | Local PPO |
Plan Year: | 2024 |
Monthly Premium: | $0.00 Plus your Medicare Part B premium. |
Health Plan Deductible: | $0.00 |
Annual Out-of-Pocket Maximum: | $5,300 |
Part B Give Back: | $0.00/mo |
Part D Drug Plan Benefit: | Enhanced, $0.00 deductible |
Part D Gap Coverage: | No |
Supplemental Benefits: | Vision, Hearing |
Availability: | See List |
Insured By: | Priority Health Medicare |
Why Choose PriorityMedicare Edge?
PriorityMedicare Edge is a Medicare Advantage Prescription Drug (MAPD) Preferred Provider Organization (PPO) plan offering flexibility and comprehensive healthcare coverage. With a monthly premium of $0.00, this plan provides all the benefits of Medicare Part A and Part B, along with additional services like prescription drug coverage. There is no annual deductible. Cost sharing begins with your first prescription. As a PPO plan, you have the option to see providers both in and out of the plan’s network, though using in-network providers typically results in lower costs.
One of the valuable features of PriorityMedicare Edge is its protection against high medical expenses. The annual maximum out-of-pocket (MOOP) limit is $5,300, ensuring that once you reach this amount, the plan covers 100% of your in-network healthcare costs for the rest of the year. This makes PriorityMedicare Edge a flexible and reliable choice for those seeking comprehensive coverage with the freedom to choose their healthcare providers.
We're Here to Help You Enroll |
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Out-of-Pocket Expenses
PriorityMedicare Edge has cost-sharing, meaning you'll have out-of-pocket costs when using approved healthcare services. The table below details the most common in-network out-of-pocket expenses for plan H4875-020-3.
Service | Enrollee Cost |
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Doctor's Office Visit (In-Network) | |
Primary: | $0 |
Specialist: | $45 Copay Prior Authorization Required |
Wellness & Preventive Programs: | None |
Preventive care: | $0 |
Foot Care (In-Network) | |
Foot Exams and Treatments (Medicare-covered): | $45 Copay |
Routine Foot Care: | Not Covered |
Chiropractic Treatment (In-Network) | |
Medicare-covered chiropractic: | $20 Copay |
Routine chiropractic: | Not Covered |
Emergency and Urgent Care | |
Emergency room care: | $120 Copay |
Urgent care: | $30 Copay |
Ground ambulance: | $275 Copay |
Inpatient hospital care: | $320.00 per day for days 1 through 7 $0.00 per day for days 8 and beyond |
Outpatient hospital care: | $325 Copay Prior 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: | $20 Copay |
Outpatient group therapy: | $20 Copay |
Inpatient psychiatric hospital care: | $350.00 per day for days 1 through 5 $0.00 per day for days 6 and beyond |
Outpatient group therapy: | $20 Copay |
Outpatient individual therapy: | $0 |
Rehabilitation Services (In-Network) | |
Physical therapy and speech and language therapy: | $40 Copay |
Occupational therapy: | $40 Copay |
Medical Equipment and Supplies (In-Network) | |
Diabetes supplies: | $0 |
Durable medical equipment: | 20% Coinsurance Prior Authorization Required |
Prosthetics: | 20% Coinsurance |
Diagnostics, Lab Services, and Imaging (In-Network) | |
Diagnostic radiology services: | $270 Copay Prior Authorization Required |
Lab services: | $0 Copay Prior Authorization Required |
Outpatient x-rays: | $20 Copay Prior Authorization Required |
Diagnostic tests and procedures: | $0 |
Medicare Part B Drugs (In-Network) | |
Chemotherapy: | 20% Coinsurance |
Other Part B drugs (Medicare-covered) | 20% Coinsurance |
Most preventive services are covered 100% by PriorityMedicare Edge as a Part B benefit.
Supplemental Benefits
Here’s an overview of the additional benefits that Priority Health Medicare offers 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.
Part D Prescription Drug Costs & Benefits
PriorityMedicare Edge includes an enhanced benefit Medicare Part D plan (PDP), which offers greater coverage than basic plans. An enhanced benefit plan has a higher actuarial value, meaning it covers a larger percentage of your healthcare costs.
Part D Plan Premium
While the prescription drug plan (Part D) premium is included in the overall plan cost, some plans may have additional costs or provide assistance through the Low-Income Subsidy (LIS) program. Also known as Extra Help, LIS is a Social Security program that assists individuals with limited income and resources in reducing or eliminating Part D expenses.
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. You must pay this amount 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% |
Understanding CMS Star Ratings
Each year, the Centers for Medicare & Medicaid Services (CMS) assesses health plans (Part C) and drug plans (Part D) based on a 5-star rating system. These ratings provide an overview of the plan’s performance in areas such as preventive care, managing chronic conditions, and member experience.
Considering a plan’s star rating can be an important part of your decision-making process, as higher ratings often reflect stronger performance in key areas of healthcare and customer service.
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 |
Plan Availability
PriorityMedicare Edge (H4875-020-3) is available in the following locations (click to open):
Eligibility Requirements for PriorityMedicare Edge
To qualify for enrollment in PriorityMedicare Edge, you must:
- Be entitled to Medicare Part A and enrolled in Medicare Part B.
- Live within the plan’s designated service area.
- Not have End-Stage Renal Disease (ESRD), except under certain conditions.
If you fulfill these criteria, you can enroll in PriorityMedicare Edge and enjoy the extensive healthcare benefits it offers.
When Can I Enroll in PriorityMedicare Edge?
Knowing when you can enroll in PriorityMedicare Edge is essential. Here are the main enrollment periods:
- Initial Enrollment Period (IEP): Your IEP starts three months before your 65th birthday and ends three months after, giving you a seven-month window to enroll in Medicare.
- Annual Enrollment Period (AEP): The AEP, from October 15 to December 7, allows you to make changes to your Medicare Advantage plan.
- Medicare Advantage Open Enrollment Period (MA OEP): Running from January 1 to March 31, the MA OEP lets you switch plans or return to Original Medicare.
- Special Enrollment Periods (SEPs): Life events such as moving or losing coverage may qualify you for a SEP, enabling you to enroll or make changes outside the usual periods.
If you're uncertain about the right time to enroll, Call HealthCompare (our trusted enrollment partner) at 1-877-388-0596 (TTY 711) for expert guidance from a licensed insurance agent.
Steps to Enroll in PriorityMedicare Edge
Enrolling in PriorityMedicare Edge is easy. Choose the option that works best for you:
- Online through MedicareEnrollment.com: Visit the enrollment page and complete your enrollment through their Secure Online Enrollment Form.
- By Phone: Call HealthCompare (our trusted enrollment partner) at 1-877-388-0596 (TTY 711). A licensed insurance agent can assist you with the enrollment process and provide answers to any questions.
- Through Medicare.gov: Go to Medicare.gov, log in or create an account, and follow the instructions to join PriorityMedicare Edge through the official Medicare website.
- Directly with PriorityMedicare Edge: You can also enroll directly with the plan. The necessary contact details are provided below in the "Contact" section.
Remember to enroll during the correct enrollment period to ensure your coverage starts on time.
Contact Priority Health Medicare
Website: | http://www.prioritymedicare.com |
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Formulary: | http://www.prioritymedicare.com |
Pharmacy: | Priority Health Medicare Pharmacy Page |
New Members: | (888)384-1695 |
TTY Users: | 711 |
If you're eligible for Medicare but haven't enrolled or need to verify your enrollment status, you can do so on the Social Security Administration website. For more information about the Medicare Part C program, visit the official Medicare website or call 1-800-MEDICARE.
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.
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