MyPriority Balanced Silver Trinity Health East Network – HMO

Description

This plan has 87% cost sharing reduction [Popular Plan]

Health Care Plan Details

Network type	HMO
Deductible	$500 per person $500 per person
Out-of-pocket max	$2,800 per person $5,600 per family
Metal tier	Silver

Visit Copay

Primary care visit	$10 copay
Specialist visit	$45 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$75 copay
Emergency room	20% coinsurance after deductible
Ambulance	20% coinsurance after deductible
Hospital stay (facility)	20% coinsurance after deductible
Hospital stay (physician)	20% coinsurance after deductible
Outpatient procedure (facility)	$1000 copay after deductible, 20% coinsurance after deductible
Outpatient procedure (physician)	20% coinsurance after deductible
Physical rehabilitation	20% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	20% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$5 copay
Brand	$30 copay after deductible
Non-preferred Brand	$50 copay after deductible
Specialty	50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	20% coinsurance after deductible
Imaging (CT/PET/MRI)	20% coinsurance after deductible
Blood work	20% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	$10 copay
Psychiatric hospital stay	20% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.priorityhealth.com/-/media/165C28F5D48B4284801FF0E510AB9740.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