In-network
Inpatient hospital
Per admission $0 per stay
Plan-listed inpatient copay $0
● CMS 2026 plan record
PriorityMedicare PPO No RX EGWP Calendar (PPO)
Choose and order benefitsSelections are saved only on this device.
Emergency transport
Ambulance
Ground · in-network20% coinsurance
Air · in-network20% coinsurance
Emergency services
Emergency room
20% coinsurance
Waived if admitted within 24 hours
Medical maximum
Maximum out-of-pocket
In-network$6,800
Combined in + out$10,000
Skilled care at home
Home health
In-networkCost share not reported
Out-of-network20% coinsurance
Monthly cost
Premium & giveback
Part C premiumNot reported
Consolidated C + DNot reported
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Primary care physician
In: 20% coinsurance · Out: 20% coinsurance
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Specialist
In: 20% coinsurance · Out: 20% coinsurance
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Preventive care
In: Cost share not reported · Out: 20% coinsurance
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Diagnostic procedures & tests
In: 20% coinsurance · Out: 20% coinsurance
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Laboratory services
In: 20% coinsurance · Out: 20% coinsurance
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X-rays & standard imaging
In: 20% coinsurance · Out: 20% coinsurance
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MRI, CT & PET imaging
In: 20% coinsurance · Out: 20% coinsurance
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Urgent care
In: Cost share not reported · Out: Not separately reported
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Emergency room
In: 20% coinsurance · Out: Not separately reported
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Ground ambulance
In: 20% coinsurance · Out: 20% coinsurance
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Air ambulance
In: 20% coinsurance · Out: 20% coinsurance
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Outpatient hospital
In: 20% coinsurance · Out: 20% coinsurance
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Outpatient surgery / ASC
In: 20% coinsurance · Out: 20% coinsurance
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Home health
In: Cost share not reported · Out: 20% coinsurance
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Skilled nursing facility
In: Cost share not reported · Out: Not separately reported
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Cardiac & pulmonary rehabilitation
In: 20% coinsurance · Out: 20% coinsurance
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Occupational therapy
In: 20% coinsurance · Out: 20% coinsurance
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Physical & speech therapy
In: 20% coinsurance · Out: 20% coinsurance
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Mental health services
In: 20% coinsurance · Out: 20% coinsurance
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Substance use treatment
In: 20% coinsurance · Out: 20% coinsurance
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Podiatry
In: 20% coinsurance · Out: 20% coinsurance
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Chiropractic
In: 20% coinsurance · Out: 20% coinsurance
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Dental
In: 20% coinsurance · Out: 20% coinsurance
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Vision
In: 20% coinsurance · Out: 20% coinsurance
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Hearing
In: 20% coinsurance · Out: 20% coinsurance
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Transportation
In: Cost share not reported · Out: 20% coinsurance
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Fitness & wellness
In: Cost share not reported · Out: 20% coinsurance
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Over-the-counter allowance
Not reported in this CMS export
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Meals
In: Cost share not reported · Out: 20% coinsurance
Plan details
All plan benefits
No benefits match that search.
Medical care3 benefits
Primary care physician
In-network20% coinsurance
Out-of-network20% coinsurance
Specialist
In-network20% coinsurance
Out-of-network20% coinsurance
Preventive care
In-networkCost share not reported
Out-of-network20% coinsurance
Diagnostics & imaging4 benefits
Diagnostic procedures & tests
In-network20% coinsurance
Out-of-network20% coinsurance
Laboratory services
In-network20% coinsurance
Out-of-network20% coinsurance
X-rays & standard imaging
In-network20% coinsurance
Out-of-network20% coinsurance
MRI, CT & PET imaging
In-network20% coinsurance
Out-of-network20% coinsurance
Urgent & hospital care6 benefits
Urgent care
In-networkCost share not reported
Out-of-networkNot separately reported
Emergency room
In-network20% coinsurance
Out-of-networkNot separately reported
Ground ambulance
In-network20% coinsurance
Out-of-network20% coinsurance
Air ambulance
In-network20% coinsurance
Out-of-network20% coinsurance
Outpatient hospital
In-network20% coinsurance
Out-of-network20% coinsurance
Outpatient surgery / ASC
In-network20% coinsurance
Out-of-network20% coinsurance
Recovery & therapy5 benefits
Home health
In-networkCost share not reported
Out-of-network20% coinsurance
Skilled nursing facility
In-networkCost share not reported
Out-of-networkNot separately reported
Cardiac & pulmonary rehabilitation
In-network20% coinsurance
Out-of-network20% coinsurance
Occupational therapy
In-network20% coinsurance
Out-of-network20% coinsurance
Physical & speech therapy
In-network20% coinsurance
Out-of-network20% coinsurance
Behavioral health2 benefits
Mental health services
In-network20% coinsurance
Out-of-network20% coinsurance
Substance use treatment
In-network20% coinsurance
Out-of-network20% coinsurance
Specialty care2 benefits
Podiatry
In-network20% coinsurance
Out-of-network20% coinsurance
Chiropractic
In-network20% coinsurance
Out-of-network20% coinsurance
Supplemental benefits7 benefits
Dental
In-network20% coinsurance
Out-of-network20% coinsurance
Vision
In-network20% coinsurance
Out-of-network20% coinsurance
Hearing
In-network20% coinsurance
Out-of-network20% coinsurance
Transportation
In-networkCost share not reported
Out-of-network20% coinsurance
Fitness & wellness
In-networkCost share not reported
Out-of-network20% coinsurance
Over-the-counter allowance
Not reported in this CMS exportNot reported in this CMS export
Meals
In-networkCost share not reported
Out-of-network20% coinsurance
Plan costs & rulesCoverage overview
Premium & Part B giveback
Part C premium not reported · Part B giveback not separately reported
Maximum out-of-pocket (MOOP)
In-network$6,800
Combined in + out$10,000
Medical deductibles
In-networkNot reported
Out-of-networkNot reported
Network & referrals
Local PPO · Referrals: Required for some services · Out-of-network coverage: Yes
Prescription drugs0 tiers
Part D deductible
This plan is not present in the public CMS Landscape release
Using this plan
Understand H4875-805-000
Plain-language context built from this plan’s 2026 CMS record. It is a guide to the reported benefits, not a personalized cost estimate.
Plan at a glance
A quick read on this plan
PriorityMedicare PPO No RX EGWP Calendar (PPO) is a 2026 Local PPO offered by Priority Health Medicare in National. The CMS record indicates out-of-network coverage, although member costs may differ from in-network care. Referrals are required for some services. Its listed inpatient copay stages total $0 across null charged days.
Common benefit costs
What you may pay
These are individual in-network benefit amounts. A real visit may involve more than one separately billed service.
Routine care
- Primary care physician
- 20% coinsurance
- Specialist
- 20% coinsurance
- Laboratory services
- 20% coinsurance
Separate visits or services; costs are not added together.
Tests & outpatient care
- Diagnostic procedures & tests
- 20% coinsurance
- MRI, CT & PET imaging
- 20% coinsurance
- Outpatient hospital
- 20% coinsurance
The service setting and billing details can change what you pay.
Emergency & hospital care
- Emergency room
- 20% coinsurance
- Listed inpatient stages
- $0 total
null charged inpatient days are included in the calculated total. Actual costs depend on the care received and plan rules.
Helpful context
Terms worth knowing
Maximum out-of-pocket (MOOP)
This is the most you generally pay during the plan year for covered Part A and Part B medical services under the applicable network limit. Premiums and prescription drug costs generally do not count toward it.
Availability
Who can enroll
- Service area
- National (AK, AL, AR, AZ, CA, CO, CT, DC, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY)
- Plan type
- Local PPO
- Contract / plan
- H4875-805
- Coverage year
- 2026
Enrollment is limited to people eligible through the sponsoring employer or group. Confirm eligibility and the exact service area with the plan before enrolling.
Supplemental coverage
Extra benefits reported
Availability is summarized here; allowances, frequency limits, networks, and prior-authorization rules may apply.
Dental20% coinsurance
Vision20% coinsurance
Hearing20% coinsurance
Fitness & wellnessCost share not reported
TransportationCost share not reported
MealsCost share not reported
Plan-specific answers
Frequently asked questions
Where is H4875-805-000 available?
PriorityMedicare PPO No RX EGWP Calendar (PPO) is listed for National (AK, AL, AR, AZ, CA, CO, CT, DC, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY). Enrollment is limited to people eligible through the sponsoring employer or group.
What is the in-network maximum out-of-pocket limit for H4875-805-000?
The 2026 CMS record lists an in-network medical maximum out-of-pocket limit of $6,800. Prescription drug spending generally does not count toward this medical limit.
What does an emergency room visit cost on H4875-805-000?
The plan record lists 20% coinsurance, waived when an admission meets the plan's stated timing rule.
Does H4875-805-000 report extra benefits?
Yes. CMS reports dental, vision, hearing, fitness & wellness, transportation, and other supplemental benefits. See the detailed benefit rows and official plan documents for limits and conditions.
Source trail
Official CMS, Contract Year 2026
Plan identity and benefits come from CMS PBP data. Premium and MOOP figures are cross-checked against the August 2026 Landscape release; county identity is sourced from segment-level Landscape rows and stable codes are enriched from the aligned MA contract service-area release where matched. Quick-reference values should be confirmed in 2026 official plan documents.
Plan context
Where H4875-805-000 fits
- Full CMS plan ID
H4875-805-000- Contract
H4875- Base plan code
H4875-805- Segment
000- Carrier
- Priority Health Medicare
- Plan type
- Local PPO
- Service area
- National (AK, AL, AR, AZ, CA, CO, CT, DC, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VT, WA, WI, WV, WY)
43 additional service-area states listed in the CMS record.
County/service-area foundation
CMS service-area entries
These named entries come from a CMS contract-level service-area file. They describe the contract's published geography and must not be treated as proof that every segment has identical county-level rules.
- Aleutians East, AK · employer/group only
- Aleutians West, AK · employer/group only
- Anchorage, AK · employer/group only
- Bethel, AK · employer/group only
- Bristol Bay, AK · employer/group only
- Chugach, AK · employer/group only
- Copper River, AK · employer/group only
- Denali, AK · employer/group only
- Dillingham, AK · employer/group only
- Fairbanks North Star, AK · employer/group only
- Haines, AK · employer/group only
- Hoonah-Angoon, AK · employer/group only
3135 additional service-area entries are retained in the data record.
About this code
What H4875-805-000 identifies
H4875-805-000 is a Contract Year 2026 Medicare plan segment code. Searches written as H4875-805, H4875 805, or the compact full CMS ID H4875805000 refer to this plan or its base plan code.
Medicare Plan Lookup uses official CMS data as a quick reference. Benefit details, eligibility, service-area rules, and cost sharing should be confirmed in the current Summary of Benefits or Evidence of Coverage.