PriorityMedicare Merit (PPO) 2026 Plan Details for Berrien County, Michigan Residents
PriorityMedicare Merit (PPO) 2026 Plan Details for Berrien County, Michigan Residents
When selecting a Medicare Advantage plan in Berrien County for 2026, it's important to compare all your options. PriorityMedicare Merit (PPO) is among the plans you can review side-by-side with others, ensuring you find the coverage that suits your needs. You can easily enroll online or reach out to a licensed agent for personalized guidance.
Based on the most recent CMS data, plan enrollments topped 7,826 members, with 109 in Berrien County, Michigan.
PriorityMedicare Merit Overview
| Plan ID H4875-016-5 Overview | |
|---|---|
| Health Plan ID: | H4875-016-5 |
| Medicare Advantage Plan Type: | PPO |
| Plan Year: | 2026 |
| Monthly Premium: | $83.00 Plus your Medicare Part B premium. |
| Health Plan Deductible: | $0.00 |
| Annual Out-of-Pocket Maximum: | $4200.00 (In-Network) |
| Part B Give Back: | Not offered |
| Part D Drug Plan Benefit: | Enhanced, $0.00 deductible |
| Additional Benefits: | Dental, Vision, Hearing |
| Availability: | Berrien County, MI |
| Insured By: | Priority Health Medicare |
Why Choose PriorityMedicare Merit?
This Medicare Advantage MAPD PPO plan combines hospital, medical, and prescription drug coverage with the flexibility to see providers in or out of the plan’s network. With a monthly premium of $83.00, PriorityMedicare Merit includes all the core benefits of Medicare Part A and Part B, plus built-in drug coverage to help manage your prescriptions. The annual Part D deductible is $0.00.
Primary care visits have a $0 copay | Out-of-network: 30% coinsurance, while seeing a specialist comes with a $0-$45 copay | Out-of-network: 30% coinsurance. Urgent care services carry a $55 copay, and ground ambulance transportation is $270 copay | Out-of-network: $270 copay. These costs apply toward the plan’s annual maximum out-of-pocket (MOOP) limit of $4200.00 — and once that’s reached, all in-network services are fully covered for the rest of the year.
This plan is registered with CMS under ID H4875-016-5. Below, you’ll find a summary of cost sharing for key services. Still have questions? Check the FAQ section for more details.
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Cost-Sharing Overview
PriorityMedicare Merit 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 H4875-016-5.
Find out the costs for visiting your primary care doctor and specialists, as well as coverage for wellness and preventive programs.
| Service | Enrollee Cost (in-network) |
|---|---|
| Primary: | In-network: $0 copay | Out-of-network: 30% coinsurance |
| Specialist: | In-network: $0-$45 copay | Out-of-network: 30% coinsurance |
Medicare Advantage plans often include preventive and wellness benefits designed to help members stay healthy, identify risks early, and maintain an active lifestyle.
| Service | Enrollee Cost (in-network) |
|---|---|
| Annual wellness exam: | In-network: $0 copay |
| Telehealth benefit: | In-network: $0 copay |
| Routine chiropractic: | Not covered |
| Fitness benefits: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Health education: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Counseling services: | Not covered |
| Over the counter drug benefits: | Not covered |
| Health transportation (non-emergency): | Not covered |
Review the costs for emergency services, urgent care, ambulance services, inpatient hospital stays, and skilled nursing facility care.
| Service | Enrollee Cost |
|---|---|
| Emergency room care: | $130 copay |
| Wordwide emergency care: | $130 copay |
| Urgent care: | $55 copay |
| Inpatient hospital care: | In-network: | Tier 1 | $275 per day for days 1-6 | $0 per day for days 7-90 | $275 Lifetime Reserve Days for days 1-6 | $0 Lifetime Reserve Days for days 7-60 | $0 per stay | Out-of-network: | 30% per stay |
| Skilled Nursing Facility: | In-network: | Tier 1 | $0 per day for days 1-20 | $218 per day for days 21-100 | Out-of-network: | 30% per stay |
| Ground ambulance: | In-network: $270 copay | Out-of-network: $270 copay |
This section explains the costs for mental health services, including individual and group therapy, and inpatient care.
| Service | Enrollee Cost (in-network) |
|---|---|
| Outpatient individual therapy: | In-network: $20 copay | Out-of-network: 30% coinsurance |
| Outpatient group therapy: | In-network: $20 copay | Out-of-network: 30% coinsurance |
| Inpatient psychiatric hospital care: | In-network: | Tier 1 | $275 per day for days 1-6 | $0 per day for days 7-90 | $275 Lifetime Reserve Days for days 1-6 | $0 Lifetime Reserve Days for days 7-60 | $0 per stay | Out-of-network: | 30% per stay |
See the cost details for rehabilitation services, including physical therapy, speech therapy, and occupational therapy.
| Service | Enrollee Cost (in-network) |
|---|---|
| Physical therapy and speech and language therapy: | In-network: $35 copay | Out-of-network: 30% coinsurance |
| Occupational therapy: | In-network: $35 copay | Out-of-network: 30% coinsurance |
Learn about the costs associated with medical equipment and supplies, including diabetes supplies, durable medical equipment, and prosthetics.
| Service | Enrollee Cost (in-network) |
|---|---|
| Diabetes supplies: | In-network: $0 copay | Out-of-network: 30% coinsurance |
| Durable medical equipment: | In-network: 20% coinsurance | Out-of-network: 30% coinsurance |
| Prosthetics: | In-network: 0%-20% coinsurance | Out-of-network: 30% coinsurance |
This section outlines the costs for diagnostic services, lab tests, x-rays, and other imaging services.
| Service | Enrollee Cost (in-network) |
|---|---|
| Diagnostic radiology services: | In-network: $125 copay | Out-of-network: 30% coinsurance |
| Lab services: | In-network: $0-$20 copay | Out-of-network: 0%-30% coinsurance |
| Outpatient x-rays: | In-network: $35 copay | Out-of-network: 30% coinsurance |
| Diagnostic tests and procedures: | In-network: $20 copay | Out-of-network: 30% coinsurance |
Review the cost-sharing details for chemotherapy and other Medicare Part B-covered drugs.
| Service | Enrollee Cost (in-network) |
|---|---|
| Chemotherapy: | In-network: 0%-20% coinsurance | Out-of-network: 0%-20% coinsurance |
| Other Part B drugs (Medicare-covered): | In-network: 0%-20% coinsurance | Out-of-network: 0%-20% coinsurance |
This section details the dental services covered under your plan including Medicare-covered preventive dental, oral exams, x-rays, dental cleanings, and comprehensive dental.
| Service | Member Cost (in-network) |
|---|---|
| Oral exam: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Dental x-rays: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Cleaning: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Periodontics: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Endodontics: | Not covered |
| Restorative services: | Not covered |
| Implant services: | Not covered |
| Orthodontics: | Not covered |
| Oral/Maxillofacial surgery: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
This section outlines the coverage for hearing-related services, including exams, fittings, and hearing aids.
| Service | Member Cost (in-network) |
|---|---|
| Hearing exam: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Fitting/evaluation: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Prescription hearing aids: | In-network: $295-$1495 copay | Out-of-network: $295-$1495 copay |
| OTC hearing aids: | Not covered |
Learn about the costs for vision-related services, including eye exams, eyeglasses, and contact lenses.
| Service | Member Cost (in-network) |
|---|---|
| Routine eye exam: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Contact lenses: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Eyeglass frames only: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Eyeglass lenses only: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Eyeglasses (frames & lenses): | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| Upgrades: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
Medicare Advantage plans may include extra benefits and special needs services designed to support members with chronic conditions, mobility limitations, or other complex health needs.
| Service | Enrollee Cost (in-network) |
|---|---|
| Adult day health services: | Not covered |
| Home based palliative care: | Not covered |
| Personal emergency response system: | Not covered |
| Weight management programs: | Not covered |
| 'Wigs for chemotherapy hair loss: | Not covered |
| Alternative therapies: | Not covered |
| Massage therapy: | Not covered |
| Home/bathroom safety devices: | Not covered |
Certain preventive services are covered 100% by PriorityMedicare Merit as a Part B benefit.
Part D Prescription Drug Costs & Benefits
PriorityMedicare Merit 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
The Part D prescription drug plan premium is included in your overall Medicare Advantage plan cost. However, additional expenses or subsidies may apply through the Low-Income Subsidy (LIS) program, also known as Extra Help. LIS, provided by Social Security, helps those with limited income and resources to lower or eliminate Part D costs. LIS benefits are not part of Medicare Advantage coverage.
| Basic Part D Premium: | $74.60 |
|---|---|
| Supplemental Part D Premium: | $0.00 |
| Total Part D Premium: | $74.60 |
| Low-Income Premium Subsidy: | $8.75 |
| Low-Income Premium Subsidy Paid by CMS: | $8.80 |
| Low-Income Subsidy Premium: | $65.80 |
For more details, visit the Social Security Extra Help program.
Prescription Drug Plan Deductible
This plan has a $0.00 annual Part D deductible. You'll pay this deductible at the pharmacy before Priority Health Medicare starts contributing towards your prescription costs.
Prescription Drug Plan Out-of-Pocket Costs
Beyond premiums and deductibles, PriorityMedicare Merit may have additional costs at pharmacies. The table below outlines out-of-pocket expenses by drug tier.
| Drug Tier | Retail | Mail Order |
|---|---|---|
| Preferred Generic | $2.00 copay | Coming soon |
| Generic | $10.00 copay | Coming soon |
| Preferred Brand | 25% coinsurance | Coming soon |
| Non-Preferred Drug | 32% coinsurance | Coming soon |
| Specialty Tier | 33% coinsurance | Coming soon |
| *Deductible does not apply. | ||
How CMS Star Ratings Guide Your Choice
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 |
|---|---|
| 2026 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 |
If you are new to Medicare or Medicare Advantage plans, the following information will help you understand the enrollment process and restrictions.
Am I Eligible for PriorityMedicare Merit?
To enroll in PriorityMedicare Merit, you must meet the following criteria:
- Be eligible for Medicare Part A and Part B.
- Reside in the plan’s service area.
If you meet these requirements, you are eligible to enroll in PriorityMedicare Merit and benefit from its comprehensive coverage options.
When Can I Enroll in PriorityMedicare Merit?
To ensure you don’t miss your chance to enroll in PriorityMedicare Merit, be aware of these important enrollment periods:
- Initial Enrollment Period (IEP): Your IEP offers a seven-month window around your 65th birthday to sign up for Medicare.
- Annual Enrollment Period (AEP): The AEP, occurring from October 15 to December 7 each year, allows you to enroll in or make changes to your Medicare Advantage plan if you are currently enrolled in a Medicare Advantage plan.
- Medicare Advantage Open Enrollment Period (MA OEP): From January 1 to March 31, the MA OEP provides an opportunity to switch Medicare Advantage plans or return to Original Medicare.
- Special Enrollment Periods (SEPs): Certain life changes, like moving or losing insurance coverage, may qualify you for a SEP, giving you a chance to make adjustments outside the standard periods.
Need help figuring out the right time to enroll? Call HealthCompare (our trusted enrollment partner) at 1-833-748-3201 (TTY 711) to get assistance from a licensed insurance agent.
Steps to Enroll in PriorityMedicare Merit
Joining PriorityMedicare Merit is straightforward. Here are the steps you can take:
- Online: Use our online enrollment partner's Secure Online Enrollment Form to sign up.
- By Phone: Reach out to HealthCompare (our trusted enrollment partner) at 1-833-748-3201 (TTY 711). A licensed insurance agent will help you with the enrollment process and answer any questions you might have.
- Through Medicare.gov: Enroll directly through the official Medicare website. Visit Medicare.gov, log in or create an account, and follow the steps to join PriorityMedicare Merit.
- Direct Enrollment: You can also choose to enroll directly with PriorityMedicare Merit. The contact information can be found below in the "Contact" section.
Make sure you enroll during the appropriate period to activate your coverage as soon as possible.
Here are some of the most frequently asked questions people have about plan ID H4875-016-5:
What’s the monthly premium for PriorityMedicare Merit (PPO)?
Members pay their Part B premium and the plan's of $83.00 per month to be in this 2026 plan.
How high can my costs go in a worst-case year?
For 2026, the maximum you’d spend out-of-pocket in-network is $4200.00.
How much do I pay before drug coverage starts?
You’ll pay the first $0.00 in drug costs before coinsurance kicks in.
Is this a 4-star or 5-star plan?
CMS rates it ★4.0 out of 5 stars for 2026.
How many members does PriorityMedicare Merit have?
As of last month, about 7,826 beneficiaries are enrolled.
Contact Priority Health Medicare
| Contact Type | Details |
|---|---|
| Website: | Priority Health Medicare Plan Page |
| New Members: | 1-888-384-1695 |
| Existing Members: | 1-888-389-6648 |
| Plan Address: | 1231 East Beltline NE | Grand Rapids, MI 49525 |
If you're eligible for Medicare but haven't enrolled or need to verify your enrollment status, visit the Social Security Administration website. For more information about Medicare Advantage, visit medicare.gov.
- CMS.gov, Landscape Source Files — Last accessed September 26, 2025
- CMS.gov, Medicare Part C & D Performance — Last accessed October 10, 2025
- CMS.gov, Plan Benefits Package — Last accessed October 14, 2025
- CMS.gov, Monthly Enrollment by Contract/Plan/State/County — Last accessed October 13, 2025
Learn more about how we use CMS data.
- Priority Health Medicare, http://www.prioritymedicare.com — Last accessed October 13, 2025
- Medicare.gov, "Compare types of Medicare Advantage Plans" — Last accessed 25 May, 2025
- AARP.org, "The Big Choice: Original Medicare vs. Medicare Advantage" — Last accessed 25 May, 2025
- Medicare.gov, "Explore your Medicare coverage options" — Last accessed 25 May, 2025
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Data provenance documentation is maintained in alignment with the U.S. Core Data for Interoperability (USCDI) Provenance standard.
Page content managed by David Bynon, Medicare Analyst.
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