Options for your
deductible and out-of-pocket maximum |
Available options: - $500 single /$1,000 family deductible
$1,500 single/$3,000 family
in-network out-of-pocket maximum
OR
- $1,000 single/$2,000 family deductible
$2,000 single/$4,000 family
in-network out-of-pocket maximum
OR
- $2,500 single/$5,000 family deductible
$3,500 single/$7,000 family
in-network out-of-pocket maximum
|
Your deductible: - You pay the full cost of covered services until you meet your deductible.
- You can meet your family deductible with the expenses of 2 or more individuals in the family.
Your out-of-pocket maximum: - The out-of-pocket maximum is the most you will pay for covered services.
- It includes your deductible and the coinsurance you pay.
- There is no out-of-pocket maximum on services you get out-of-network.
|
Coinsurance
for covered services |
Plan pays: - 80% in-network, 60% out-of-network
You pay: - 20% in-network, 40% out-of-network
|
- Coinsurance is the percentage you and the plan each pay for covered services you receive.
- You begin paying coinsurance after you meet your deductible each year.
|
| Annual benefit maximum |
$2 million |
- This is the most the plan will pay for covered services that you and your family get, in-network and out-of-network combined, each year.
|
Covered services |
| Doctor visits |
Plan pays: - 80% in-network, 60% out-of-network
You pay: - 20% in-network, 40% out-of-network
|
- After you meet your deductible each year, you and the plan pay coinsurance.
|
| Urgent care visits |
Plan pays: - 80% in-network, 60% out-of-network
You pay: - 20% in-network, 40% out-of-network
|
- After you meet your deductible each year, you and the plan pay coinsurance.
|
| Emergency room care |
Plan pays: - 70% in-network, 70% out-of-network
You pay: - 30% in-network, 30% out-of-network
|
- After you meet your deductible each year, you and the plan pay coinsurance.
|
Ambulance services
|
Plan pays: - 70% in-network, 70% out-of-network
You pay: - 30% in-network, 30% out-of-network
|
- After you meet your deductible each year, you and the plan pay coinsurance.
|
Most services, including: - Outpatient lab tests and x-rays
- Outpatient surgery
- Hospitalization
|
Plan pays: - 80% in-network, 60% out-of-network
You pay: - 20% in-network, 40% out-of-network
|
- After you meet your deductible each year, you and the plan pay coinsurance.
|
Therapy services - Outpatient speech therapy
- Outpatient occupational therapy
- Outpatient physical therapy & spinal manipulation
- Cardiac rehabilitation
|
Plan pays: - 80% in-network, 60% out-of-network
You pay: - 20% in-network, 40% out-of-network
|
- After you meet your deductible, you and the plan pay coinsurance for all these services up to a combined maximum of $1,000 per member each year.
|
Skilled nursing care
Subacute hospital care
Inpatient rehabilitation
Hospice care |
Plan pays: - 80% in-network, 60% out-of-network
You pay: - 20% in-network, 40% out-of-network
|
- After you meet your deductible, you and the plan pay coinsurance for all these services up to a combined maximum of of 30 days per member each year.
|
| Home health care |
Plan pays: - 80% in-network, 60% out-of-network
You pay: - 20% in-network, 40% out-of-network
|
- After you meet your deductible, you and the plan pay coinsurance for up to a maximum of 30 visits per member each year.
|
| Substance abuse services |
Plan pays: - 80% in-network, 60% out-of-network
You pay: - 20% in-network, 40% out-of-network
|
- After you meet your deductible, you and the plan pay coinsurance up to the state-required minimum.
|
Durable medical equipment,
including prosthetics and orthotics |
You pay: 50% coinsurance |
- After you meet your deductible, you and the plan pay coinsurance up to a $2,000 maximum per member each year.
|
| Prescription drugs |
You pay: - 100% of Priority Health's discounted price
|
- 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 our discounted price.
- Your costs do not apply to your deductibleor out-of-pocket maximum.
|
| Medical specialty drugs |
You pay: - 50% of Priority Health's discounted price
|
- $25,000 maximum per member per year
|
Services not covered- Maternity services
- Pre-existing conditions
- Transplants
- Cosmetic surgeries: Bariatric, blepharoplasty of the upper eyelids, breast reduction, orthognathic surgery, panniculectomy, port wine stain removal, surgical treatment of male gynecomastia
- Procedures to correct obstructive sleep apnea
- Family planning and infertility services: Contraceptives, vasectomy, tubal ligation, diaphragm, infertility counseling, treatment of the underlying causes of infertility
- Treatment for temporomandibular joint disorder (TMJ)
- 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 other female reproductive conditions
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