JANUARY 1, 2023–DECEMBER 31, 2023
PriorityMedicare + Kroger
SM
(PPO)
2023
Summary
of Benefits
A plan created to prioritize you.
Inside, you’ll nd information to help
you understand what is included with
your Medicare plan.
This information is not a complete description of benets. Call 888.356.1369 (TTY 711) for more information.
This doesn’t list every service we cover or tell you if a deductible must be met before you pay the amount listed
in this document. To get a complete list of services we cover including any limitations or exclusions, review the
Evidence of Coverage document available online at prioritymedicare.com.
Contact us
Speak with Priority Health Medicare experts from 8 a.m. to 8 p.m., seven days a week
(TTY users call 711).
Already a member? Call 888.389.6648. Not a member yet? Call 888.481.2090.
Visit prioritymedicare.com to learn more about our plans and how Medicare works.
PPO stands for preferred provider organization (PPO). With this plan, we don’t require you to get a referral to
see a specialist for care. You’ll get the most value from your plan when using in-network providers, but you can
see any provider who participates with Medicare. You don’t have to choose a primary care physician (PCP),
although selecting one can help you coordinate care.
To conrm that your doctor, clinic or health center is part of the Priority Health Medicare network of providers,
go to priorityhealth.com/ndadoc.
Get a free copy of the 2023 Medicare & You handbook.
View it online at medicare.gov or get a copy by calling 800.MEDICARE (800.633.4227),
24 hours a day, seven days a week. TTY users should call 877.486.2048.
The official U.S. government
Medicare handbook
2023
PriorityMedicare + Kroger is offered
as a PPO plan.
Prescription coverage
The PriorityMedicare + Kroger plan includes prescription drug coverage. To make an informed
decision about your Medicare plan, review our provider/pharmacy directory. You generally need to
use network pharmacies to ll your prescriptions for covered Part D drugs. To save even more on
your prescription costs, use a pharmacy in our preferred pharmacy network. Make sure to review the
approved drug list to see which drugs are covered by our plans. You can nd in-network pharmacies
and approved drugs on our website at prioritymedicare.com, or call our customer service number.
Eligibility
In order to join a Priority Health Medicare plan, you need to be enrolled in Medicare Part A and
Part B and live in our service area—which includes Wayne, Oakland, Macomb, Saginaw, Genesee,
Livingston, Washtenaw or Ingham County. There are no exclusions for pre-existing conditions.
Important health insurance terms to know
To help you better understand our plans, here are some common terms you’ll come across
while researching:
Deductible: This is the amount you pay each year before the health plan starts to pay
for certain services, and you start paying a portion of the cost (copay or coinsurance).
Priority Health Medicare Advantage plans do not have an in-network medical deductible,
so you’ll start paying only your copay or coinsurance right away. Some plans, like our
PPO plans, don’t have an out-of-network medical deductible either.
Coinsurance: After you've paid your deductible, you may have a coinsurance as your
portion of the cost for medical services or prescriptions. Coinsurance is a percentage of
the cost of a medical service or prescription and is listed as a benet in your health plan.
Copay: After you’ve paid your deductible, you may have a copay as your portion of the
cost for medical services or prescriptions. This is a xed amount you pay, generally at
the time you receive a health care service or when you get a prescription lled.
Maximum out-of-pocket: This is the most you will pay for covered medical services for
the year—this means Priority Health pays 100% of the cost after you hit this amount.
Your coinsurance or copays count towards the maximum out-of-pocket; premiums and
prescription costs do not.
Coinsurance or copay
(you and insurance share costs)
Deductible
(you pay 100%)
Priority Health
(insurance pays 100%)
Deductible met
Maximum out-of-pocket met
How do health insurance costs work?
Original Medicare
Priority Health Medicare
Advantage Plans
Covers your Medicare Part A and Part B services
Coverage in addition to Medicare Part A and B
Predictable copays and limits to what you’ll pay
out of pocket for medical care
Part D prescription drug coverage
Additional dental services
Free gym membership
Routine vision, including eyewear allowance
Routine hearing, including hearing aid coverage
How does Original Medicare work with
Medicare Advantage plans?
Original Medicare (health insurance from the federal government) may not be
enough to cover all of your health care needs in retirement. Priority Health Medicare
Advantage plans include everything that Original Medicare covers, plus extra
benets and services to help you save money and stay healthy.
PriorityMedicare + Kroger
• $0 primary care physician visits
• $0 labs
• $0 diagnostic tests and procedures
• $0 Rx deductible
• $0 virtual visits
$0 plan
An open network plan with
rich benets and affordable coverage
PriorityMedicare + Kroger fully supports
members on their health journey.
From discounts on food to comprehensive
care—our members are covered.
PREMIUMS AND BENEFITS │ PriorityMedicare + Kroger
Benefits and what you should know PriorityMedicare + Kroger (PPO)
Plan availability Genesse, Ingham, Livingston, Macomb, Oakland, Saginaw,
Washtenaw and Wayne
Monthly plan premium $0 per month. You must keep paying your Medicare Part B
premium.
Deductible
The amount you’ll pay for most covered
services before you start paying only copays
or coinsurance and Priority Health pays the
balance.
Medical services
In-network- and out-of-network (combined): $0
Prescription drugs (Part D)
$0
Maximum out-of-pocket amount
This is the most you pay for covered medical
services for the year, excluding Part D
prescription drugs.
In-network- and out-of-network services (combined): $4,900
MEDICAL BENEFITS COVERED UNDER YOUR PLAN
Benefits and what you should know PriorityMedicare + Kroger (PPO)
Inpatient hospital coverage
We cover an unlimited number of days for an
inpatient hospital stay.
Prior authorization may be required.
In- and out-of-network:
Days 1-5: $350 each day
Days 6 and beyond: $0 each day
Outpatient hospital coverage
Prior authorization may be required.
Outpatient hospital
In- and out-of-network:
$0 for each visit at a rural health clinic
$275 for each visit at all other locations
Observation
In- and out-of-network: $110 for each visit, including all
services received
Ambulatory surgical center coverage
Prior authorization may be required.
In- and out-of-network: $275 for each visit
Doctor visits
Prior authorization may be required for some
specialist visits.
Primary care physician (PCP)
In- and out-of-network:
$0 for each office visit
$0 for surgical procedures performed in a PCP’s office
Benefits and what you should know PriorityMedicare + Kroger (PPO)
Doctor visits (continued)
Specialist visit
In- and out-of-network:
$0 for palliative care physician office visit
$0 for surgical procedures performed in a specialist’s office
$40 for all other office visits
Preventive care
Services that can help with prevention and
early detection of many illnesses, disabilities
and diseases. Examples include annual
wellness visit, breast cancer screening,
diabetic screening, flu vaccine and more.
In- and out-of-network: $0 for each service
A referral from your doctor may be required for some
preventive services. Any additional preventive services
approved by Medicare during the contract year will be
covered.
Emergency care
This amount is waived if you are admitted as
inpatient to the hospital within 24 hours from
your emergency care visit.
In- and out-of-network: $110 for each visit
Urgently needed services
This amount is waived if you are admitted as
inpatient to the hospital within 24 hours from
your urgent care visit.
In- and out-of-network: $40 for each visit
Outpatient diagnostic services (labs,
radiology/imaging and X-rays)
Prior authorization may be required for some
services.
Radiology/ imaging
In- and out-of-network: $275 per day, per provider
Tests/procedures
In- and out-of-network: $0 per day, per provider
Lab services
In- and out-of-network: $0 per day, per provider
Outpatient X-rays
In- and out-of-network: $20 per day, per provider
Radiation therapy
In- and out-of-network: $40 per day, per provider
Hearing services
Medicare-covered exam performed by a
primary care physician or specialist to
diagnose and treat hearing and balance
issues.
Routine hearing services must be received
from a TruHearing
®
provider.
Medicare-covered diagnostic hearing exam
In- and out-of-network: $0-$40 for each office visit
Routine hearing coverage (TruHearing
®
provider)
$0 for one routine hearing exam, per year
$295, $695, $1,095 or $1,495 copay, per ear per year, for
hearing aids from top manufacturers depending on level
selected
Hearing aid cost includes a 60-day trial period, one year of post-
purchase follow-up visits, 80 batteries per non-rechargeable
hearing aid and a full 3-year manufacturer warranty
Benefits and what you should know PriorityMedicare + Kroger (PPO)
Dental services
Prior authorization may be required for
Medicare-covered dental services.
Delta Dental
®
is the preferred provider for
additional dental services.
Medicare-covered dental services
In- and out-of-network: $0-$275 for each visit, depending on
the service performed
Additional dental services
$0 for two cleanings (regular or periodontal maintenance) per
year
$0 for two exams per year
$0 for one set of bitewing X-rays per year
$0 for one brush biopsy per year
$0 for other X-rays (i.e. panoramic) once every two years
$1,500 annual maximum that applies to the following
services:
$0 for fillings (includes composite resin and amalgam), once
per tooth, every 24 months
$0 for simple extractions, once 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
Vision services
Medicare-covered exam performed by a
specialist to diagnose and treat diseases and
conditions of the eye and additional
Medicare-covered services.
In-network routine vision services must be
provided by an EyeMed
®
“Select” provider. If
received by a non-EyeMed “Select” provider
(out-of-network), you must seek
reimbursement. In-network and out-of-
network benefit cannot be combined.
Medicare-covered services
In- and out-of-network:
$40 for each visit
$0 for eyeglasses or contact lenses after cataract surgery
$0 for a yearly glaucoma screening
Routine vision services
In-network:
$0 for one routine exam each year (includes dilation and
refraction)
$0 for one retinal imaging per year
$200 eyewear allowance per year
Out-of-network:
Up to $200 reimbursement for eyewear
Up to $50 reimbursement for one routine exam
Up to $20 reimbursement for retinal imaging
Benefits and what you should know
PriorityMedicare + Kroger (PPO)
Mental health care
We cover up to 190 days in a lifetime for
inpatient mental health care in a psychiatric
hospital.
Prior authorization may be required.
Inpatient visit
In- and out-of-network:
Days 1-5: $350 each day
Days 6 and beyond: $0 each day
Outpatient therapy (individual or group)
In- and out-of-network: $20 for each visit
Skilled Nursing Facility (SNF)
Our plan covers up to 100 days each benefit
period. A benefit period starts the day you go
into a SNF and ends when you go for 60 days
in a row without SNF care.
Prior authorization may be required.
In- and out-of-network:
Days 1-20: $0 each day
Days 21-100:
$196 each day
Physical therapy
In- and out-of-network: $40 for each service
Ambulance
Prior authorization may be required.
In- and out-of-network:
$290 each way
Transportation
Not covered
PRESCRIPTION DRUG BENEFITS
Prescription drug benefits
PriorityMedicare + Kroger (PPO)
Medicare Part B drugs
Prior authorization or step therapy may be
required.
Chemotherapy drugs
In- and out-of-network: Up to 20% for each drug
Other Part B drugs
In- and out-of-network: Up to 20% for each drug
Select home infusion drugs:
In- and out-of-network: $0 for each drug
Effective 7/1/23 all Part B insulin administered through an
item of durable medical equipment (such as insulin pumps
or continuous glucose monitors (CGM)) will be capped at
$35. You will pay 20% up to $35 and will never pay more
than $35 for a one-month supply.
PART D OUTPATIENT PRESCRIPTION DRUGS
Prescription drug benefits PriorityMedicare + Kroger (PPO)
Deductible stage
You’ll pay this amount before you begin
paying copays or coinsurance only.
$0
Initial coverage stage
You are in this stage until your drug total
reaches $4,660, which includes what you pay
out-of-pocket and what we pay for your
covered drugs.
You pay what is listed in the chart below.
PREFERRED RETAIL PHARMACY
Prescription drug benefits PriorityMedicare + Kroger (PPO)
Initial coverage stage 30-day supply 60-day supply 90-day supply
Tier 1 (Preferred generic) $3 $6 $0
Tier 2 (Generic) $10 $20 $30
Tier 3 (Preferred brand) $42 $84 $126
Tier 4 (Non-preferred drug) 45% 45% 45%
Tier 5 (Specialty) 33% N/A N/A
Covered Insulin (defined by Medicare) Up to $35 Up to $70 Up to $105
Vaccines (defined by Medicare) $0 for certain vaccines regardless of the drug tier the
vaccine is in.
Your costs will be less for your covered drugs when you use a pharmacy in our preferred network (includes
Meijer, Walgreens, Walmart, Rite Aid, Kroger, Family Fare Supermarkets, Costco, Dollar General and Dollar
Tree). Go to prioritymedicare.com to view the list in the provider/pharmacy directory.
STANDARD RETAIL PHARMACY
Prescription drug benefits PriorityMedicare + Kroger (PPO)
Initial coverage stage 30-day supply 60-day supply 90-day supply
Tier 1 (Preferred generic) $11 $22 $33
Tier 2 (Generic) $18 $36 $54
Tier 3 (Preferred brand) $47 $94 $141
Tier 4 (Non-preferred drug) 50% 50% 50%
Tier 5 (Specialty) 33% N/A N/A
Covered Insulin (defined by Medicare) Up to $35 Up to $70 Up to $105
Vaccines (defined by Medicare) $0 for certain vaccines regardless of the drug tier the
vaccine is in.
MAIL ORDER THROUGH EXPRESS SCRIPTS (ESI)
Prescription drug benefits PriorityMedicare + Kroger (PPO)
Initial coverage stage 30-day supply 60-day supply 90-day supply
Tier 1 (Preferred generic) $3 $6 $0
Tier 2 (Generic) $10 $20 $0
Tier 3 (Preferred brand) $42 $84 $105
Tier 4 (Non-preferred drug) 45% 45% 45%
Tier 5 (Specialty) 33% N/A N/A
Covered Insulin (defined by Medicare) Up to $35 Up to $70 Up to $105
Vaccines (defined by Medicare) $0 for certain vaccines regardless of the drug tier the
vaccine is in.
Prescription drug benefits PriorityMedicare + Kroger (PPO)
Coverage gap stage
(also known as the “donut hole”)
Once the total yearly drug costs (what you’ve paid plus what
we’ve paid) reach $4,660 you enter the coverage gap and then
you pay a percentage of the cost we have negotiated for the
drug:
• 25% of what we would pay for the covered brand name
drug
• 25% of what we would pay for the covered generic drug
During the Coverage Gap stage, your out-of-pocket cost for
covered insulins (defined by Medicare) will be the same as
what you pay in the initial coverage stage whether you fill your
prescription at a preferred or standard pharmacy.
When your out-of-pocket drug costs reach $7,400, this is the
end of the coverage gap stage.
Catastrophic coverage stage
Once your out-of-pocket drug costs reach $7,400 you will pay
the larger amount, which is either:
• 5% of the drug, or
• $4.15 for generics and
• $10.35 for all other drugs
Long-term care (LTC)
If you are a resident of a long-term care (LTC) facility, you may
get your prescription drugs through the facility’s pharmacy as
long as it is part of our network.
OPTIONAL ENHANCED DENTAL AND VISION PACKAGE
Benefits and what you should know PriorityMedicare + Kroger (PPO)
Benefits Additional dental coverage, including coverage for dental
services and an additional vision allowance for use on
eyeglasses or contacts
Premium $29.00 per month. You must keep paying your Medicare Part
B premium.
Deductible $0
Maximum plan benefit coverage amount $2,500 for dental services and an additional $150 for eyewear,
per calendar year
Dental services
Delta Dental
®
is the preferred provider for
additional dental services.
Dental services (continued)
$0 copay for one fluoride treatment per year
$0 copay for emergency treatment of dental pain and
anesthesia, no limit
50% of the cost for implants & implant repairs per tooth every 5
years
50% of the cost for surgical extractions, once per tooth per
lifetime
50% of the cost for endodontics, once per tooth, every 24 months
50% of the cost of dentures once every 60 months, denture
relines and repairs and bridge repairs, once every 36 months
50% of the cost of onlays, crowns and associated substructures,
once per tooth, every 60 months
Vision services
In-network vision services must be provided
by an EyeMed
®
“Select” provider. If received
by a non-EyeMed “Select” provider (out-of-
network), you must seek reimbursement. In-
network and out of-network benefits cannot
be combined.
$150 additional eyewear allowance/reimbursement per year
ADDITIONAL MEDICAL BENEFITS COVERED UNDER YOUR PLAN
Benefits and what you should know PriorityMedicare + Kroger (PPO)
Abridge
$0
A smartphone based application that securely records medical
conversations during patient appointments.* Once the recording
is complete the Abridge app will transcribe the conversation and
pull out any key information (prescription refills, follow up
appointments, etc.). The app also allows members to share the
transcripts with caregivers/family as they wish.
*Medical professionals must verbally consent to being recorded.
Acupuncture
Medicare-covered acupuncture for lower chronic back pain
In- and out-of-network: $20 per visit
Non-Medicare covered routine acupuncture for other
conditions
In- and out-of-network: $20 per visit (limit 6 visits each year)
Annual preventive physical exam
You’re free to talk at your annual preventive
exam. When we say no cost, we mean it -
$0 annual physical exam, without the worry
of being charged for an office visit. This is
an opportunity for you and your physician
to discuss any concerns or questions you
have.
In- and out-of-network: $0 for an exam
BrainHQ
Access to online exercises and games that
improve memory, attention, brain speed
and more. Train on any device like a
computer, tablet or smartphone.
$0
Chiropractic care Medicare-covered care
In- and out-of-network: $20 for each visit
Non-Medicare covered routine care
In- and out-of-network: $20 for each visit
$20 for X-ray services performed once per year
Limited to 12 non-Medicare covered routine visits per year
whether done in- or out-of-network.
Dialysis In- and out-of-network: 20% for each service
Home health services
Prior authorization may be required.
In- and out-of-network: $0 for each Medicare-covered service
Benefits and what you should know PriorityMedicare + Kroger (PPO)
Meal benefit
Home-delivered meals, provided through
Mom’s Meals following a discharge from a
hospital (acute or psychiatric) or Skilled
Nursing Facility (SNF) stay.
$0 for 28 meals following a discharge (limit 4 times per year)
Medical equipment and supplies
Examples include diabetic supplies
(shoes/inserts, diabetic test strips), durable
medical equipment (wheelchairs, oxygen,
insulin pumps) and prosthetic devices
(braces, artificial limbs).
Diabetic test strips are limited to JJHCS
and Bayer products when dispensed by a
retail pharmacy or mail-order pharmacy.
Prior authorization may be required.
Diabetes supplies
In- and out-of-network: $0 for each item
Durable medical equipment
In- and out-of-network: 20% for each item
Prosthetic devices
In- and out-of-network: $0-20% for each item, depending on the
device
OTC Plus
Use your OTC Plus card to purchase over-
the-counter drugs and health-related
products that do not need a prescription
such as; allergy medication, eye drops,
cough drops, nasal spray, vitamins and
more.
Members who qualify for Special
Supplemental Benefits for the Chronically Ill
(SSBCI) may also use their OTC Plus card
to purchase healthy foods such as
vegetables, fruits, meats, milk and more.
$25 allowance per month for OTC items and if eligible, healthy
food.
Eligible OTC items and healthy food can be purchased at Krog
er
stores. OTC items may also be purchased online at
PriorityHealth.com/OTC
, by phone or by mail using the plan’s
OTC catalog for home delivery.
Podiatry services
In- and out-of-network: $40 for each visit
$0 for nail debridement and callous removal for members with
specific conditions (up to 6 of each)
Priority Health Travel Pass
Out-of-area travel benefit
You’ll pay in-network prices when seeking care from Medicare-
participating providers anywhere in the U.S. outside of the lower
peninsula of Michigan if your plan has a different cost-share for
in-network and out-of-network benefits/services. Our
partnership with Multiplan
®
can make accessing Medicare-
participating providers even easier.
You may stay enrolled in the plan when outside of the service
area for up to 12 months, as long as your permanent residency
remains in your plans service area.
Worldwide urgent and emergent care
Unlimited worldwide emergent and urgent care coverage.
Benefits and what you should know PriorityMedicare + Kroger (PPO)
Priority Health Travel Pass (continued)
Worldwide travel assistance program
$0 for emergency travel assistance services through Assist
America
®
when you’re more than 100 miles from home or in a
foreign country. Assist America
®
provides pre-trip assistance to
help you prepare for your travel, including finding a doctor or a
pharmacy to fill your prescriptions at your destination but also
assistance while on your trip should a medical travel emergency
arise, like needing help replacing lost or forgotten prescriptions
(costs may apply for the prescriptions drugs), retrieval of
vehicles or other valuable property left stranded because of a
medical situation and more, at no extra cost to you.
You will still pay for benefits covered by Priority Health
Medicare, such as emergency, urgent care or prescription drug
copays.
Rehabilitation services Cardiac, pulmonary rehabilitation services and supervised
exercise therapy (SET) services
In- and out-of-network: $20 for each service
Physical therapy, occupational therapy and speech therapy
services
In- and out-of-network: $40 for each service
SilverSneakers
®
Fitness membership
$0 membership at thousands of participating SilverSneakers
fitness centers nationwide. Plus, options for working out from
the comfort of your home with access to members-only virtual
exercise classes and online workshops with the SilverSneaker
GO
™
fitness app or SilverSneakers home fitness kits.
You can also sign up for Tuition Rewards
®
through
SilverSneakers to earn money towards college tuition for family
members.
The SilverSneakers
®
program is provided by Tivity Health
®
. All
programs and services may not be available in all areas.
Virtual care
Online care you receive from the comfort of
your home, or wherever you may be, with a
virtual visit via video on your computer,
smart phone or tablet.
In-network: $0 virtual visits with primary care, specialist and
behavioral health providers.
Available 24/7, virtual visits let you see a provider for, and get
treatment for, non-emergency care.
Out-of-network: Not covered
PREMIUMS AND BENEFITS | Monthly Premiums
Counties PriorityMedicare + Kroger (PPO)
Genesse, Ingham, Livingston, Macomb, Oakland,
Saginaw, Washtenaw and Wayne
$0
8
Before making an enrollment decision, it is important
that you fully understand our benets and rules.
If you have any questions, you can call and speak to a
Medicare expert at 888.356.1369 from 8 a.m. to 8 p.m.,
seven days a week (TTY 711).
Pre-enrollment
checklist
Understanding the benets
The Evidence of Coverage (EOC) provides a complete list of all coverage and
services. It is important to review plan coverage, costs, and benets before you
enroll. Visit prioritymedicare.com or call 888.356.1369 to view a copy of the EOC.
Review the provider directory (or ask your doctor) to make sure the doctors you
see now are in the network. If they are not listed, it means you will likely have to
select a new doctor.
Review the pharmacy directory to make sure the pharmacy you use for any
prescription medicines is in the network. If the pharmacy is not listed, you will
likely have to select a new pharmacy for your prescriptions.
Review the formulary to make sure your drugs are covered.
Understanding important rules
In addition to your monthly plan premium, you must continue to pay your
Medicare Part B premium. This premium is normally taken out of your Social
Security check each month.
Benets, premiums and/or copayments/co-insurance may change on
January 1, 2024.
Our plan allows you to see providers outside of our network (non-contracted
providers). However, while we will pay for certain covered services for HMO-POS
plans that are provided by a non-contracted provider, the provider must agree to
treat you. Except in an emergency or urgent situations, non-contracted providers
may deny care. In addition, you may pay a higher copay for services received by
non-contracted providers.
Priority Health’s pharmacy network includes limited lower-cost, preferred pharmacies in Michigan. The lower costs advertised in our plan materials for these
pharmacies may not be available at the pharmacy you use. For up-to-date information about our network pharmacies, including whether there are any lower-
cost preferred pharmacies in your area, please call 888.389.6648, TTY users call 711, or consult the online pharmacy directory at prioritymedicare.com.
Out-of-network/non-contracted providers are under no obligation to treat Priority Health members, except in emergency situations. Please call our customer
service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.
Priority Health has HMO-POS and PPO plans with a Medicare contract. Enrollment in Priority Health Medicare depends on contract renewal.
H4875_100010992303_M CMS-accepted 09142022 ©2023 Priority Health MR044 12529D1 5/23
