MyPriority Balanced Silver – HMO

Description

Health Care Plan Details

Network type	HMO
Deductible	$3,600 per person $3,600 per person
Out-of-pocket max	$9,400 per person $18,800 per family
Metal tier	Silver

Visit Copay

Primary care visit	$30 copay
Specialist visit	$85 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$75 copay
Emergency room	$250 copay after deductible, 30% coinsurance after deductible
Ambulance	$250 copay after deductible, 30% coinsurance after deductible
Hospital stay (facility)	30% coinsurance after deductible
Hospital stay (physician)	30% coinsurance after deductible
Outpatient procedure (facility)	$1000 copay after deductible, 30% coinsurance after deductible
Outpatient procedure (physician)	30% coinsurance after deductible
Physical rehabilitation	30% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	30% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$5 copay
Brand	$75 copay after deductible
Non-preferred Brand	$100 copay after deductible
Specialty	50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	30% coinsurance after deductible
Imaging (CT/PET/MRI)	$150 copay after deductible, 30% coinsurance after deductible
Blood work	30% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	$30 copay
Psychiatric hospital stay	30% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.priorityhealth.com/-/media/1A56C1E301D8443FB28EF2DC3A9194F0.pdf
Drug and medication plan formulary	https://www.priorityhealth.com/formulary
Search doctor list	https://web.healthsparq.com/healthsparq/public/#/one/insurerCode=PH_I&brandCode=PH