MyPriority Premier Silver – HMO
Network type: HMO
Coverage tier: Silver
Primary care visit: $30 copay
Specialist visit: $65 copay
Urgent care visit: $75 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $5,500 per person $5,500 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 | $65 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 |
| Non-preferred Brand | $125 copay |
| 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 | $10 copay |
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/8ADACD938DDA4BDBBDB3CDB27B9E7F38.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 |
