| Summary of Benefits: What your MyPriority PPO plan covers |
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| Service |
Coinsurance |
Notes |
| Preventive care services |
Plan pays: You pay: |
Covered services are listed in the Priority Health Preventive Health Care Guidelines |
| Doctor's office and urgent care visits |
For 4 visits a year, the plan pays: You pay: |
- Covers 4 visits (office & urgent care combined) per member each year
- After the 4 visits you must meet your annual deductible.
- After you meet your deductible, you and the plan pay coinsurance for these services for the rest of the year.
|
| Emergency room services |
Before you meet your deductible, you pay: - $150 copay AND
- 100% of the emergency room charges
After you meet your deductible, the plan pays: - 70% in-network and out-of-network
You pay: - $150 copay AND
- 30% in-network and out-of-network
|
- If you are admitted to the hospital within 24 hours of your ER visit, you don't have to pay the ER copay.
|
| Ambulance services |
After you meet your deductible, the plan pays: - 70% in-network and out-of-network
You pay: - 30% in-network and out-of-network
|
|
Most services, including: - Outpatient lab
- Outpatient x-ray
- Outpatient surgery
- Hospitalization
|
After you meet your deductible, the plan pays: - 80% or 70% in-network, 60% or 50% out-of-network
You pay: - 20% or 30% in-network, 40% or 50% out-of-network
|
- Coinsurance depends on which plan design you choose.
|
Therapy services - Outpatient speech therapy
- Outpatient occupational therapy
- Outpatient physical therapy & spinal manipulation
- Cardiac rehabilitation
|
After you meet your deductible, the plan pays: - 80% or 70% in-network, 60% or 50% out-of-network
You pay: - 20% or 30% in-network, 40% or 50% out-of-network
|
- Limited to a combined maximum of $3,000 in therapy costs per member per year
- Coinsurance depends on which plan design you choose.
|
Inpatient and hospice care - Skilled nursing home care
- Subacute hospital care
- Inpatient rehabilitation care
- Hospice care
|
After you meet your deductible, the plan pays: - 80% or 70% in-network, 60% or 50% out-of-network
You pay: - 20% or 30% in-network, 40% or 50% out-of-network
|
- Limited to a combined maximum of of 60 days per member each year.
- Coinsurance depends on which plan design you choose.
|
| Home health care |
After you meet your deductible, the plan pays: - 80% or 70% in-network, 60% or 50% out-of-network
You pay: - 20% or 30% in-network, 40% or 50% out-of-network
|
- Limited to a maximum of 60 visits per member each year.
- Coinsurance depends on which plan design you choose.
|
| Substance abuse services |
After you meet your deductible, the plan pays: - 80% or 70% in-network, 60% or 50% out-of-network
You pay: - 20% or 30% in-network, 40% or 50% out-of-network
|
- Coinsurance depends on which plan design you choose.
|
| Dietitian services |
After you meet your deductible, the plan pays: - 80% or 70% in-network, 60% or 50% out-of-network
You pay: - 20% or 30% in-network, 40% or 50% out-of-network
|
- Coinsurance depends on which plan design you choose.
|
Durable medical equipment,
including prosthetics and orthotics |
After you meet your deductible, the plan pays: |
- Plan pays a maximum per member each year of $2,000 for in-network services and $2,000 for out-of-network services.
- After you meet your deductible, you and the plan pay coinsurance up to a $2,000 maximum per member each year.
|
| Prescription drugs |
Before AND after you meet your deductible, plan pays: - 60% or 50% of the discounted cost for prescription drugs covered by your plan
You pay: - 40% or 50% of the discounted cost for prescription drugs covered by your plan
|
- Some plans cover only generic drugs
- Oral contraceptives are covered
- Priority Health negotiates a discount on drugs from pharmacies in our network that averages 16% on most brand name drugs and 58% or more on generic drugs. You pay coinsurance on our discounted price.
- Coinsurance depends on which plan design you choose.
- The coinsurance you pay does not apply to your deductible or your out-of-pocket maximum.
|
| Medical specialty drugs |
After you meet your deductible, the plan pays: - 80% or 70% in-network, 60% or 50% out-of-network
You pay: - 20% or 30% in-network, 40% or 50% out-of-network
|
- "Specialty drugs" treat complex or rare conditions, such as multiple sclerosis, rheumatoid arthritis, hepatitis C, and hemophilia. They need special handling or administration.
- Note: Few specialty drugs are available in generic versions.
- Coinsurance depends on which plan design you choose.
- Plan pays a maximum per member per year of $25,000 for drugs received out-of-network.
|
Services covered after a 90-day waiting period: - Tonsils
- Adenoids
- Bunions
- Hemorrhoids
- Varicose veins
- Inguinal hernias (other than strangulated or incarcerated)
- Carpal tunnel surgery
- Elective hysterectomy (unless the condition is life-threatening) and treatment for other female reproductive conditions
|
After you meet your deductible, the plan pays: - 80% or 70% in-network, 60% or 50% out-of-network
You pay: - 20% or 30% in-network, 40% or 50% out-of-network
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- Coinsurance begins for these services after you have been covered for 90 days AND have met your deductible.
- Coinsurance depends on which plan design you choose.
|
| Pre-existing condition exclusion |
- The plan does not cover, or pay coinsurance on, charges for services needed to treat a pre-existing illness, injury or condition until you have been continuously insured under the plan for 12 months, if the pre-existing condition was not disclosed on your application.
- After the 12-month waiting period, the plan pays for covered services for a pre-existing condition unless the condition is specifically excluded from coverage.
- For details see the MyPriority PPO plan policy on our Plan documents page.
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- Exclusion does not apply to anyone under age 19.
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| Services not covered |
- Maternity services
- Certain surgeries: Bariatric surgery, blepharoplasty of the upper eyelids, breast reduction, orthognathic surgery, panniculectomy, surgical treatment of male gynecomastia, removal of port wine stains
- Procedures to correct obstructive sleep apnea
- Family planning and infertility services: Contraceptives (other than oral), vasectomy, tubal ligation, diaphragm, infertility counseling, treatment of the underlying causes of infertility
- Treatment for temporomandibular joint disorder (TMJ)
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| Optional coverage for additional cost |
| Accident rider: |
Before you meet your deductible, the plan pays: - 80% or 70% in-network, 60% or 50% out-of-network
You pay: - 20% or 30% in-network, 40% or 50% out-of-network
|
- May be added at sign-up and after 12 months
- Covers services to treat injuries due to an accident within 60 days of the accident
- Your deductible is waived and the plan pays coinsurance for accident-related services
- After the 60 days, you will have to meet your annual deductible before the plan begins to pay coinsurance for covered services.
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