Your Priority Health Plan Open Enrollment Benefits Guide
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Access your plan anytime, anywhere. Finding all your important health plan information is easier than ever with a Priority Health member account. With your member account you can: • See what’s covered by your plan. • Find or change your primary care physician. • Replace a lost ID card. • Estimate the cost of care. • Schedule virtual care appointments. • Pay your bill. Download the Priority Health app or go to member.priorityhealth.com to get started.
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Choosing a doctor
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Know your costs 2
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Preventive care
Staying healthy and engaged
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Care options
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Exclusive programs
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Prescription coverage
A primary care provider of your choice Did you know you can use our Find a Doctor tool to search by name, location and specialty to find the primary care provider (PCP) of your choice? Here’s how: • Log in to your Priority Health member account at member.priorityhealth.com or through the app. • Select My Health Care. • Select the Find a Doctor tool. • Search by name, specialty or location. Search results are based on your specific plan and home address, so you’ll only see doctors in your network and your area. You can change locations to find a PCP that’s most convenient for you or change your assigned PCP at any time.
Living or working outside of Michigan? If you have a PriorityPOS or PriorityPPO plan, you can still search for providers and receive out-of-state care.
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Preventive care at no cost to you We believe in the importance of preventive care–finding illnesses before they get serious and fighting them when things are most treatable. That’s why we include preventive health care services such as flu shots and routine physicals in every plan at no cost to you.1 Preventive care can help you avoid health problems, recognize health risks and detect illness early. To see what’s covered in the Preventive Health Care Guidelines of your plan, visit priorityhealth.com/preventive.
FOR CHILDREN • Well-child visits • Vaccines for chickenpox, flu and more
FOR ADULTS • Routine physical exams • Colon screenings
FOR WOMEN • Breast cancer screenings • Pap and HPV tests
• Flu shots • Cholesterol and diabetes screening labs
• Contraceptives2
Most Priority Health plans include preventive health care at no cost to our members. There are a few plans that do not include preventive health care or have special guidelines: 1) Preventive care may be excluded or may include specific costs for certain services if the plan is grandfathered—typically an employer-sponsored plan that hasn’t changed since 2010. 2) Contraceptives may be excluded from benefits for certain religious employers, eligible organizations or closely held for-profit companies with an exemption. 2Religious employers or other eligible organizations my not be required to offer contraceptive coverage. You can find out if your plan includes this service by calling customer service at the number listed on the back of your Priority Health member ID card. 1
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Care options that save you time and money With Priority Health you have options for care—options that can save you time and money. ER and urgent care visits are often time consuming and expensive. If you can’t see your PCP right away, Priority Health’s virtual care services allow you to see a doctor 24/7, including nights, weekends and holidays. Use virtual care to connect with a doctor over the phone, through video chat or by submitting an online questionnaire. Depending on your condition and the type of virtual care you choose, a doctor can: • Develop a treatment plan. • Prescribe a medication and send it to your preferred pharmacy. • Notify your primary care doctor with current information. • Make follow-up recommendations, including next steps with a specialist.
Virtual care is perfect for treating nonemergency issues such as: • Cough
• Pink eye
• Cold and flu
• Allergies
• Fever
• Bites and stings
• Nausea and vomiting
• Rashes and hives
• Sinus infections
When to use urgent care Use urgent care for non-life-threatening conditions that can’t wait for an appointment such as minor broken bones or fractures in fingers or toes, sprains and strains or X-rays and lab tests.
When to use the emergency room Use the emergency room for emergencies or symptoms that can’t wait such as bleeding that won’t stop, pain in the chest or one arm, poisoning or drug overdose, seizures or slurred speech and broken bones.
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Prescription coverage Is my prescription covered? That’s an important question. We know prescription coverage can make a difference in both your health and budget. That’s why we improve our prescription benefits, expand our approved drug list and update you on your options as regularly as possible.
How to check if your prescriptions are covered The easiest way to see if your plan covers your prescriptions is to check the approved drug list, or ADL. You can find it on our website: • Go to priorityhealth.com/formulary/employer. • Check the back of your member ID card to see if you have the traditional or optimized formulary and select the appropriate list. • Search for medications alphabetically by name or by therapeutic class—like antihistamines, for example.
Make sure to pay attention to the prescription tier. Tier 1 drugs will typically be the least expensive drugs available to you. You can also reference the plan documents provided at your open enrollment meeting to help determine your costs.
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Prescription FAQs Click on the question for more information.
What if my drug isn’t on the list?
The ADL says I need prior authorization. What does that mean?
What if my drug isn’t covered and my doctor can’t switch my prescription before my new plan starts?
The ADL says I need step therapy. What does that mean?
Who decides which drugs are on the ADL?
Learn more about the ADL at priorityhealth.com/rx101.
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What will it cost me?
Remove guesswork and reduce costs with Cost Estimator. Did you know the price of a procedure can vary depending on where it’s performed? Want to know what health care services will cost you? You can with our Cost Estimator. It’s a valuable tool in your member account that allows you to see what in-network facilities charge for common services and your out-of-pocket share, based on your plan—This puts you in control of how you spend your money. Find Cost Estimator in your member account. Use it to search by procedure, at locations near you. Stop bracing yourself for the bill; be financially prepared for hundreds of services, doctor’s visits or medical procedures with Cost Estimator. Visit priorityhealth.com/member/getting-care/cost-estimator to learn more.
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Staying healthy and engaged
Your journey to health and wellness starts here. We know that the health and wellness journey can look different for each one of our members. That’s why these programs are designed to support the unique, personalized needs of Priority Health members through experiences that spark interest, encourage engagement and ultimately improve health.
Get personalized support. Learn healthier habits. Get personalized wellness suggestions. Complete nutritional programs. Set goals and track achievements. If it has to do with your health and wellness, you can do it all in the Priority Health Wellbeing Hub, powered by Virgin Pulse. It’s free, easy to access, and customizable to fit your specific interests and needs. Learn more at priorityhealth.com/wellbeing-hub.
Get discounted gym memberships. What’s the best way to break a sweat without breaking the bank? Active&Fit Direct™. It’s a program designed to help you work out at one of our many fitness centers in Michigan—and more than 9,000 centers nationwide. Membership is $25 per month, plus a onetime $25 enrollment fee (plus applicable taxes)1. Learn more at priorityhealth.com/activeandfit.
Get healthy tips and more. Our digital magazine, ThinkHealth, offers the latest stories and information to help you live your healthiest life. Topics include personal wellbeing, nutrition, healthy tips and ways to save on your health care. Learn more at priorityhealth.com/thinkhealth.
Become an Ambassador. As part of our partnership with the National Fitness Campaign (NFC), Priority Health Fitness Courts are being constructed in easily accessible public spaces, with the goal of fighting obesity, improving quality of life and creating equitable access to exercise. Fitness Court Ambassadors are community members who are positive and informed resources for healthy living who want to share their enthusiasm around health and wellness to help others discover it themselves. Learn more about becoming a Fitness Court Ambassador at nationalfitnesscampaign.com/ambassador. Participants must be 18 years of age and have a valid email address. Participants may pay by credit card and are charged in advance on a monthly basis using a recurring payment subscription. This is a per-member fee. Participants commit to three months of membership. If participants choose to cancel, they must provide a 30-day notice of cancellation. All payments are subject to tax, if applicable, based on the participant’s location. Members are encouraged to enroll and pay their fees at the beginning of the month, as fees are charged on a per-calendar-month basis. 1
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Exclusive programs
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Travel the country and be covered.
Get support when managing a chronic condition.
Reduce your risk.
Say what?
There’s more to Priority Health than costs and coverage. A Priority Health plan comes with access to a number of unique, affordable health services. Here are just a few ways you can get the most out of a Priority Health plan through our exclusive, low- or no-cost programs.
Keep mental wellness top of mind.
More for moms.
Save on the brands you love.
Connecting you to the resources you need.
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Simple. Exceptional. Affordable. That’s all part of the plan. Whether you’re continuing your coverage with Priority Health or are a brand-new member, our strong network of providers and hospitals, tools to help you understand you coverage and save money, and personalized solutions to support your health and wellness journey are already in place to make sure you’ll receive quality care and get the most out of your health plan.
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Questions? Call customer service. Did you know our customer service team members have won awards for being helpful, efficient and there when you need them? If you are considering Priority Health but still have questions regarding our services or your health plan, please contact customer service at 800.942.0954. Each representative is located right here in Michigan and is available Mon.–Thurs. 7:30 a.m. to 7 p.m.; Fri. 9:00 a.m. to 5 p.m.; and and Sat. 8:30 a.m. to noon.
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Priority Health complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Priority Health does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. Priority Health: Provides free aids and services to people with disabilities to communicate effectively with us, such as: • Qualified sign language interpreters • Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: • Qualified interpreters • Information written in other languages If you need these services, contact Priority Health customer service by calling the number on the back of your member ID card (TTY users call 711). If you believe that Priority Health has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with: Priority Health Compliance Department Attention: Civil Rights Coordinator 1231 E. Beltline Ave. NE Grand Rapids, MI 49525-4501 Toll free: 866.807.1931 (TTY users call 711) Fax: 616.975.8850
[email protected] You can file a grievance in person or by mail, fax or email. If you need help filing a grievance, the Priority Health civil rights coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at ocrportal.hhs.gov or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Ave. SW Room 509F, HHH Building Washington, DC 20201 800.368.1019, 800.537.7697 (TDD) Complaint forms are available at hhs.gov/ocr/office/file/index.html.
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ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia en su idioma. Consulte al número de Servicio al Cliente que está en la parte de atrás de su tarjeta de identificación de miembro. (TTY: 711).
يرجى االتصال برقم خدمة العمالء على. فإن خدمات المساعدة اللغوية تتوافر لك بالمجان، إذا كنت تتحدث العربية:مالحظة .)711: (رقم هاتف الصم والبكم.الجانب الخلفي من بطاقة عضويتك الشخصية 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請撥打會員卡背面的客服電話 (TTY: 711）。
ܵ ܲ ܵ ܵ ܵ ܲ ܲ ܵ ܵ ܣܘ ܬܘܢ ܬܘܢ ܸܠ ܵܫ ܵܢܐ ܼ ܼ ܸ ܚܬܘܢ ܹܟܐ ܼܗ ܼ ܡܨ ܼܝ، )ܪܝ ܵܝܐ (ܐܬܘܪ ܵܝܐ ܼ ܡܙܡ ܼܝ ܼ ܐܢ ܼܐ ܸ :ܢܘܗܪܐ ܵ ܲ ܵ ܵ ܲ ܵ ܲ ܲ ܲ ܲ ܵ ܲ ܲ ܠܚܖ ܸܡܢ .ܕܗ ܼܝܪܬܐ ܒ ܸܠܫܢܐ ܼܡܓܢܐ ܼܝܬ ܼܲܩܒܠ ܼܝ ܼ ܠܘܟ ܼܘܢ ܩܪܘܢ ܼ ܐܢ ܼܒ ܼ ܵ ܬܘܢ ܸܚ ܼ ܠܡ ܹܬܐ ܼ ܣܡ ܼ ܸ ܲ ܵ ܖܦ ܵ ܠܡ ܹܬܐ ܼܲܥܠ ܸܡ ܵܢܝ ܵܢܐ ܖܐ ܼܝ ܹܠܗ ܟܬ ܼܝ ܼܵܒܐ ܝܘ ܵܬܐ ܼܲܗ ܵܖ ܹܡܐ ܼ ܲ ܖܚ ܸ ܡܗ ܼܝܪ ܹܢܐ ܼ ܬܩܐ ܖܗ ܼܵܝ ܸ ܠܚ ܵܨܐ ܼ ܵ ܖܗ ܵܖ ܲ (TTY: 711). ܡܘܬܐ ܼ ܼ CHÚ Ý: Nếu quý vị nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho quý vị. Xin hãy gọi tới số điện thoại của bộ phận dịch vụ khách hàng có ở mặt sau thẻ ID thành viên của quý vị. (TTY: 711). KUJDES: Nëse flisni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Ju lutem kontaktoni qendrën e shërbimit për klient në pjesën e pasme të ID kartës tuaj të anëtaresimit
(TTY: 711).
주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 멤버쉽 ID카드의 뒷면에 있는 고객 서비스 번호로 전화해 주십시오. (TTY: 711)
লক্ষ্য করুনঃ আপনন বাাংলায় কথা বলতে পারতল আপনার জনয ননঃখরচায় ভাষা সহায়ো সসবা সুলভ রতয়তে। অনুগ্রহ কতর আপনার সদসযপদ আইনি কাতিের সপেতন থাকা গ্রাহক সসবা নম্বতর কল করুন। (TTY: 711) UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer telefonicznej obsługi klienta wskazany na odwrocie Twojej legitymacji członkowskiej (TTY: 711). ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienste zur Verfügung. Bitte rufen Sie die Kundendienstnummer auf der Rückseite Ihrer Mitgliedskarte an. (TTY:
711).
ATTENZIONE: se parla italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero sul retro della tessera identificativa di membro. (TTY: 711). 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。メンバーシップIDカードの 裏面にあるお客様サービスセンターの番号までお電話にてご連絡ください。(TTY: 711). ВНИМАНИЕ! Если Вы говорите на русском языке, то Вам доступны услуги бесплатной языковой поддержки. Пожалуйста, позвоните в службу поддержки клиентов по номеру, указанному на обратной стороне Вашей идентификационной карточки участника (телетайп (TTY: 711). OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Molimo nazovite broj službe za korisnike na pozadini vaše članske iskaznice (TTY: 711). PAUNAWA: Kung nagsasalita ka ng Tagalog,mga serbisyo ng tulong sa wika, ng libre, ay available para sa iyo. Pakitawan ang numero ng customer service sa likod ng iyong ID card ng pagiging miyembro.
(TTY: 711).
9338C _ Nondiscrimination and Language assistance Section 1557 notice
PH116 10/16
Priority Health has HMO-POS and PPO plans with a Medicare contract. Enrollment in Priority Health Medicare depends on contract renewal. NCMS_4000_4001_1726Z 10202016 MH – N2002-20 Approved 10272016 ©2016 Priority Health 9338C PH116 11/16
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Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 05/01/2023 - 04/30/2024 LEPPINKS INC : Copay Aligned HMO HRA $5000 80% Coverage for: Subscriber/Dependent | Plan Type: HMO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. Note: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage or to get a copy of the complete terms of coverage, visit us at PriorityHealth.com or call the number on back of your Priority Health ID card. For general definitions of common terms, such as allowed amount, balance billing, co-insurance, co-payment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary/ or call the number on back of your Priority Health ID card to request a copy. Important Questions Answers What is the overall deductible?
$5,000 person /$10,000family.
Are there services covered before you meet Yes, the deductible doesn't apply to preventive care. your deductible? Are there other deductibles for specific services?
No.
person / $17,100 family. What is the out-of-pocket $8,550 Your plan also has a co-insurance maximum. limit for this plan? $2,000 person / $4,000 family.
Why this Matters Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/. You don’t have to meet deductibles for specific services. The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own outof-pocket limits until the overall family out-of-pocket limit has been met.
What is not included in the out-of-pocket limit?
Premiums, balance-billed charges, health care this plan doesn't cover, Even though you pay these expenses, they don't count toward the out-of-pocket and services that exceed an annual day/visit limit. limit. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, Will you pay less if you Yes. See PriorityHealth.com or call the number on back of your Priority and you might receive a bill from a provider for the difference between the use a network provider? Health ID card for a list of participating providers. provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to No. You can see the in-network specialist you choose without a referral. see a specialist?
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Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 05/01/2023 - 04/30/2024 LEPPINKS INC : Copay Aligned HMO HRA $5000 80% Coverage for: Subscriber/Dependent | Plan Type: HMO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. Note: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage or to get a copy of the complete terms of coverage, visit us at PriorityHealth.com or call the number on back of your Priority Health ID card. For general definitions of common terms, such as allowed amount, balance billing, co-insurance, co-payment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary/ or call the number on back of your Priority Health ID card to request a copy. Important Questions Answers What is the overall deductible?
$5,000 person /$10,000family.
Are there services covered before you meet Yes, the deductible doesn't apply to preventive care. your deductible? Are there other deductibles for specific services?
No.
person / $17,100 family. What is the out-of-pocket $8,550 Your plan also has a co-insurance maximum. limit for this plan? $2,000 person / $4,000 family.
Why this Matters Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/. You don’t have to meet deductibles for specific services. The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own outof-pocket limits until the overall family out-of-pocket limit has been met.
What is not included in the out-of-pocket limit?
Premiums, balance-billed charges, health care this plan doesn't cover, Even though you pay these expenses, they don't count toward the out-of-pocket and services that exceed an annual day/visit limit. limit. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, Will you pay less if you Yes. See PriorityHealth.com or call the number on back of your Priority and you might receive a bill from a provider for the difference between the use a network provider? Health ID card for a list of participating providers. provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to No. You can see the in-network specialist you choose without a referral. see a specialist?
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All co-payment and co-insurance costs shown in this chart are after your deductible has been met, if a deductible applies. What You Will Pay Common Services You May Non-Participating Limitations, Exceptions & Other Important Information Participating Provider Medical Event Need Provider (You will pay the least) (You will pay the most) Primary care visit to treat $30 co-pay/ visit Not covered Deductible does not apply. an injury or illness $45 co-pay/ visit Not covered Deductible does not apply. If you visit a health Specialist visit Preventive care services are those listed in Priority Health's Preventive care provider's Preventive Health Care Guidelines. Deductible does not apply. office or clinic care/screening/ No charge Not covered You may have to pay for services that aren’t preventive. Ask your provider immunization if the services needed are preventive. Then check what your plan will pay for. Diagnostic test (x-ray, 20% co-insurance Not covered Prior Authorization may be required. blood work) If you have a test Prior Authorization required. Imaging (CT/PET scans, $150 co-pay Not covered Co-pay waived if performed while confined in a hospital as an inpatient. MRIs) Deductible does not apply.
* For more information about limitations and exceptions, see the plan or policy document at PriorityHealth.com.
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All co-payment and co-insurance costs shown in this chart are after your deductible has been met, if a deductible applies. What You Will Pay Common Services You May Non-Participating Limitations, Exceptions & Other Important Information Participating Provider Medical Event Need Provider (You will pay the least) (You will pay the most) Primary care visit to treat $30 co-pay/ visit Not covered Deductible does not apply. an injury or illness $45 co-pay/ visit Not covered Deductible does not apply. If you visit a health Specialist visit Preventive care services are those listed in Priority Health's Preventive care provider's Preventive Health Care Guidelines. Deductible does not apply. office or clinic care/screening/ No charge Not covered You may have to pay for services that aren’t preventive. Ask your provider immunization if the services needed are preventive. Then check what your plan will pay for. Diagnostic test (x-ray, 20% co-insurance Not covered Prior Authorization may be required. blood work) If you have a test Prior Authorization required. Imaging (CT/PET scans, $150 co-pay Not covered Co-pay waived if performed while confined in a hospital as an inpatient. MRIs) Deductible does not apply.
* For more information about limitations and exceptions, see the plan or policy document at PriorityHealth.com.
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Common Medical Events
Services You May Need
Generic drugs If you need drugs to (Tier 1) treat your illness or condition Preferred brand drugs (Tier 2) More information about prescription drug coverage is available at Non-preferred brand https://www.priorityhea drugs (Tier 3) lth.com/prog/pharmacy /pharmacy.cgi Preferred specialty drugs (Tier 4) Non-Preferred specialty drugs (Tier 5) Facility fee (e.g., ambulatory surgery If you have outpatient surgery center) Physician/surgeon fees
What You Will Pay Non-Participating Participating Provider Provider (You will pay the least) (You will pay the most)
$15 co-pay/ retail prescription $30 co-pay/ mail order prescription $50 co-pay/ retail prescription $100 co-pay/ mail order prescription $80 co-pay/ retail prescription $160 co-pay/ mail order prescription 20% co-insurance/ retail prescription 20% co-insurance/ retail prescription
If you need immediate medical attention
Not covered
Not covered
Not covered Not covered Not covered
20% co-insurance/ visit
Not covered
Emergency medical transportation
$150 co-pay
Urgent care
$75 co-pay/ visit
Covers up to a 31-day supply (retail prescription); Covers up to a 90-day supply (mail order prescription, excluding Specialty Drugs) 50% co-insurance/ prescription for infertility drugs. Deductible does not apply.
Not covered
20% co-insurance/ visit
Emergency room services $250 co-pay/ visit
Limitations, Exceptions & Other Important Information
Covered at the In-Network benefit level; R&C limitations apply Covered at the In-Network benefit level; R&C limitations apply Covered at the in-network benefit level when obtained outside of the Service Area; R&C limitations apply
The maximum co-pay for preferred specialty drugs is $150 per fill. The maximum co-pay for non-preferred specialty drugs is $300 per fill. Deductible does not apply. Including outpatient care, observation care and ambulatory surgery center care. Prior Authorization may be required. Co-pay waived if you become confined in a Hospital as an inpatient. Deductible does not apply. Deductible does not apply. Deductible does not apply.
* For more information about limitations and exceptions, see the plan or policy document at PriorityHealth.com.
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Common Medical Events
Services You May Need
Generic drugs If you need drugs to (Tier 1) treat your illness or condition Preferred brand drugs (Tier 2) More information about prescription drug coverage is available at Non-preferred brand https://www.priorityhea drugs (Tier 3) lth.com/prog/pharmacy /pharmacy.cgi Preferred specialty drugs (Tier 4) Non-Preferred specialty drugs (Tier 5) Facility fee (e.g., ambulatory surgery If you have outpatient surgery center) Physician/surgeon fees
What You Will Pay Non-Participating Participating Provider Provider (You will pay the least) (You will pay the most)
$15 co-pay/ retail prescription $30 co-pay/ mail order prescription $50 co-pay/ retail prescription $100 co-pay/ mail order prescription $80 co-pay/ retail prescription $160 co-pay/ mail order prescription 20% co-insurance/ retail prescription 20% co-insurance/ retail prescription
If you need immediate medical attention
Not covered
Not covered
Not covered Not covered Not covered
20% co-insurance/ visit
Not covered
Emergency medical transportation
$150 co-pay
Urgent care
$75 co-pay/ visit
Covers up to a 31-day supply (retail prescription); Covers up to a 90-day supply (mail order prescription, excluding Specialty Drugs) 50% co-insurance/ prescription for infertility drugs. Deductible does not apply.
Not covered
20% co-insurance/ visit
Emergency room services $250 co-pay/ visit
Limitations, Exceptions & Other Important Information
Covered at the In-Network benefit level; R&C limitations apply Covered at the In-Network benefit level; R&C limitations apply Covered at the in-network benefit level when obtained outside of the Service Area; R&C limitations apply
The maximum co-pay for preferred specialty drugs is $150 per fill. The maximum co-pay for non-preferred specialty drugs is $300 per fill. Deductible does not apply. Including outpatient care, observation care and ambulatory surgery center care. Prior Authorization may be required. Co-pay waived if you become confined in a Hospital as an inpatient. Deductible does not apply. Deductible does not apply. Deductible does not apply.
* For more information about limitations and exceptions, see the plan or policy document at PriorityHealth.com.
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Common Medical Events If you have a hospital stay
Services You May Need
Facility fee (e.g., hospital 20% co-insurance/ visit room) Physician/surgeon fee 20% co-insurance/ visit
If you need mental Outpatient services health, behavioral health, or substance abuse services Inpatient services Routine prenatal and postnatal care If you are pregnant
What You Will Pay Non-Participating Participating Provider Provider (You will pay the least) (You will pay the most) Not covered Not covered
$30 co-pay/ visit
Not covered
20% co-insurance/ visit
Not covered
No charge
Not covered
Delivery professional fees 20% co-insurance/ visit
Not covered
Delivery facility fees
Not covered
20% co-insurance/ visit
Limitations, Exceptions & Other Important Information
Prior Authorization is required except in emergencies. No charge for first three mental visits with a participating provider within 90 days of discharge from a participating hospital for mental health inpatient care. Deductible does not apply. Except in an emergency, Prior Authorization required. Routine prenatal and postnatal visits are covered under your Preventive Health Care Services benefit. Appropriate office visit charge may apply to physician office services for complications of pregnancy. Except in an emergency, Prior Authorization required.
* For more information about limitations and exceptions, see the plan or policy document at PriorityHealth.com.
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Common Medical Events If you have a hospital stay
Services You May Need
Facility fee (e.g., hospital 20% co-insurance/ visit room) Physician/surgeon fee 20% co-insurance/ visit
If you need mental Outpatient services health, behavioral health, or substance abuse services Inpatient services Routine prenatal and postnatal care If you are pregnant
What You Will Pay Non-Participating Participating Provider Provider (You will pay the least) (You will pay the most) Not covered Not covered
$30 co-pay/ visit
Not covered
20% co-insurance/ visit
Not covered
No charge
Not covered
Delivery professional fees 20% co-insurance/ visit
Not covered
Delivery facility fees
Not covered
20% co-insurance/ visit
Limitations, Exceptions & Other Important Information
Prior Authorization is required except in emergencies. No charge for first three mental visits with a participating provider within 90 days of discharge from a participating hospital for mental health inpatient care. Deductible does not apply. Except in an emergency, Prior Authorization required. Routine prenatal and postnatal visits are covered under your Preventive Health Care Services benefit. Appropriate office visit charge may apply to physician office services for complications of pregnancy. Except in an emergency, Prior Authorization required.
* For more information about limitations and exceptions, see the plan or policy document at PriorityHealth.com.
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Common Medical Events
Services You May Need Home health care
No charge
Not covered
Rehabilitation services
$30 co-pay/ visit
Not covered
If you need help recovering or have other special health Habilitation services needs
If your child needs dental or eye care
What You Will Pay Non-Participating Participating Provider Provider (You will pay the least) (You will pay the most)
•$30 co-pay/ visit for Physical, Occupational and Speech Therapy •20% co-insurance/ visit for Not covered Applied Behavior Analysis (ABA) services
Limitations, Exceptions & Other Important Information Including hospice care services; excluding rehabilitation and habilitation services. Prior Authorization required, except for hospice care. Physical and occupational therapy limited to a combined 50 visits per contract year. Osteopathic and chiropractic manipulation limited to a combined 24 visits per contract year. Speech therapy limited to 50 visits per contract year. Cardiac and pulmonary rehabilitation limited to a combined 50 visits per contract year. Deductible does not apply. Prior Authorization required for Applied Behavior Analysis (ABA). Multiple charges may apply during one day of service. Deductible does not apply to flat dollar co-pays. Services limited to a combined 45 days per contract year. Prior Authorization required, except for hospice care. Including rental, purchase or repair. Prior Authorization required for equipment over $1,000 and all rentals. This benefit applies to hospice services provided in the home only. Any hospice services provided in a facility will be subject to the appropriate facility benefit.
Skilled nursing care
20% co-insurance/ visit
Not covered
Durable medical equipment (DME)
No charge
Not covered
Hospice service
No charge
Not covered
Child eye exam
Not covered
Not covered
Not covered
Child glasses
Not covered
Not covered
Not covered
Child dental check-up
Not covered
Not covered
Not covered
* For more information about limitations and exceptions, see the plan or policy document at PriorityHealth.com.
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Common Medical Events
Services You May Need Home health care
No charge
Not covered
Rehabilitation services
$30 co-pay/ visit
Not covered
If you need help recovering or have other special health Habilitation services needs
If your child needs dental or eye care
What You Will Pay Non-Participating Participating Provider Provider (You will pay the least) (You will pay the most)
•$30 co-pay/ visit for Physical, Occupational and Speech Therapy •20% co-insurance/ visit for Not covered Applied Behavior Analysis (ABA) services
Limitations, Exceptions & Other Important Information Including hospice care services; excluding rehabilitation and habilitation services. Prior Authorization required, except for hospice care. Physical and occupational therapy limited to a combined 50 visits per contract year. Osteopathic and chiropractic manipulation limited to a combined 24 visits per contract year. Speech therapy limited to 50 visits per contract year. Cardiac and pulmonary rehabilitation limited to a combined 50 visits per contract year. Deductible does not apply. Prior Authorization required for Applied Behavior Analysis (ABA). Multiple charges may apply during one day of service. Deductible does not apply to flat dollar co-pays. Services limited to a combined 45 days per contract year. Prior Authorization required, except for hospice care. Including rental, purchase or repair. Prior Authorization required for equipment over $1,000 and all rentals. This benefit applies to hospice services provided in the home only. Any hospice services provided in a facility will be subject to the appropriate facility benefit.
Skilled nursing care
20% co-insurance/ visit
Not covered
Durable medical equipment (DME)
No charge
Not covered
Hospice service
No charge
Not covered
Child eye exam
Not covered
Not covered
Not covered
Child glasses
Not covered
Not covered
Not covered
Child dental check-up
Not covered
Not covered
Not covered
* For more information about limitations and exceptions, see the plan or policy document at PriorityHealth.com.
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Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan documents for more information and a list of any other excluded services.) • Hearing aids • Non-emergency care when traveling outside the U.S. • Acupuncture • Long-term care • Private-duty nursing • Cosmetic surgery • Routine eye care (Adult & Child) • Dental care (Adult & Child) • Routine foot care Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan documents.) • Infertility treatment - diagnostic, counseling and • Bariatric surgery • Weight loss programs planning services for the underlying cause of • Chiropractic care infertility Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Insurance and Financial Services (DIFS) at 1-877-999-6442 or
[email protected]; the Department of Health and Human Services, Center for Consumer Information and Insurance Oversight at 1-877-267-2323 x61565 or www.cciio.cms.gov; or the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596. Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact the number on back of your Priority Health ID card or www.priorityhealth.com; the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform; or the Department of Insurance and Financial Services (DIFS) at 1-877-999-6442 or
[email protected]. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP) at 1-877-999-6442 or
[email protected]. Does this plan provide Minimum Essential Coverage? Yes. Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet Minimum Value Standards? Yes. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Language Access Services: Spanish (Español): Para obtener asistencia en español, llame al número que figura en el reverso de su tarjeta de identificación de salud prioritaria. Tagalog (Tagalog): Kung kailangan mo ng tulong sa Tagalog, tawagan ang numero sa likod ng iyong Priority Health ID card. Chinese (中文): 如果您需要中文帮助，请拨打优先健康身份证背面的电话. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne'. ----------------------To see examples of how this plan might cover costs for a sample medical situation, see the next section---------------------PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1146. The time required to complete this information collection is estimated to average 0.08 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
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Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan documents for more information and a list of any other excluded services.) • Hearing aids • Non-emergency care when traveling outside the U.S. • Acupuncture • Long-term care • Private-duty nursing • Cosmetic surgery • Routine eye care (Adult & Child) • Dental care (Adult & Child) • Routine foot care Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan documents.) • Infertility treatment - diagnostic, counseling and • Bariatric surgery • Weight loss programs planning services for the underlying cause of • Chiropractic care infertility Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Insurance and Financial Services (DIFS) at 1-877-999-6442 or
[email protected]; the Department of Health and Human Services, Center for Consumer Information and Insurance Oversight at 1-877-267-2323 x61565 or www.cciio.cms.gov; or the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596. Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact the number on back of your Priority Health ID card or www.priorityhealth.com; the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform; or the Department of Insurance and Financial Services (DIFS) at 1-877-999-6442 or
[email protected]. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP) at 1-877-999-6442 or
[email protected]. Does this plan provide Minimum Essential Coverage? Yes. Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet Minimum Value Standards? Yes. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Language Access Services: Spanish (Español): Para obtener asistencia en español, llame al número que figura en el reverso de su tarjeta de identificación de salud prioritaria. Tagalog (Tagalog): Kung kailangan mo ng tulong sa Tagalog, tawagan ang numero sa likod ng iyong Priority Health ID card. Chinese (中文): 如果您需要中文帮助，请拨打优先健康身份证背面的电话. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne'. ----------------------To see examples of how this plan might cover costs for a sample medical situation, see the next section---------------------PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1146. The time required to complete this information collection is estimated to average 0.08 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
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About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, co-payments, and co-insurance) and excluded services under this plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.
Peg is Having a Baby
Managing Joe’s type 2 Diabetes
Mia’s Simple Fracture
(9 months of in-network pre-natal care and a hospital delivery)
(a year of routine in-network care of a wellcontrolled condition)
(in-network emergency room visit and follow up care)
◼ The plan’s overall deductible ◼ Specialist co-payment ◼ Hospital (facility) co-insurance ◼ Other co-insurance
$2,000 $50 10% 10%
◼ The plan’s overall deductible ◼ Specialist co-payment ◼ Hospital (facility) co-insurance ◼ Other co-insurance
$2,000 $50 10% 50%
◼ The plan’s overall deductible ◼ Specialist co-payment ◼ Hospital (facility) co-insurance ◼ Other co-insurance
$2,000 $50 10% 50%
This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia)
This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter)
This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy)
Total Example Cost
Total Example Cost
Total Example Cost
In this example, Peg would pay: Cost Sharing Deductibles Co-payments Co-insurance What isn’t covered Limits or exclusions The total Peg would pay is
$12,700
$2,000 $0 $2,300 $60 $4,360
In this example, Joe would pay: Cost Sharing Deductibles Co-payments Co-insurance What isn’t covered Limits or exclusions The total Joe would pay is
$5,600
$2,000 $1,200 $300 $60 $2,560
In this example, Mia would pay: Cost Sharing Deductibles Co-payments Co-insurance What isn’t covered Limits or exclusions The total Mia would pay is
The plan would be responsible for the other costs of these EXAMPLE covered services.
$2,800
$2,000 $0 $300 $0 $2,300
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About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, co-payments, and co-insurance) and excluded services under this plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.
Peg is Having a Baby
Managing Joe’s type 2 Diabetes
Mia’s Simple Fracture
(9 months of in-network pre-natal care and a hospital delivery)
(a year of routine in-network care of a wellcontrolled condition)
(in-network emergency room visit and follow up care)
◼ The plan’s overall deductible ◼ Specialist co-payment ◼ Hospital (facility) co-insurance ◼ Other co-insurance
$2,000 $50 10% 10%
◼ The plan’s overall deductible ◼ Specialist co-payment ◼ Hospital (facility) co-insurance ◼ Other co-insurance
$2,000 $50 10% 50%
◼ The plan’s overall deductible ◼ Specialist co-payment ◼ Hospital (facility) co-insurance ◼ Other co-insurance
$2,000 $50 10% 50%
This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia)
This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter)
This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy)
Total Example Cost
Total Example Cost
Total Example Cost
In this example, Peg would pay: Cost Sharing Deductibles Co-payments Co-insurance What isn’t covered Limits or exclusions The total Peg would pay is
$12,700
$2,000 $0 $2,300 $60 $4,360
In this example, Joe would pay: Cost Sharing Deductibles Co-payments Co-insurance What isn’t covered Limits or exclusions The total Joe would pay is
$5,600
$2,000 $1,200 $300 $60 $2,560
In this example, Mia would pay: Cost Sharing Deductibles Co-payments Co-insurance What isn’t covered Limits or exclusions The total Mia would pay is
The plan would be responsible for the other costs of these EXAMPLE covered services.
$2,800
$2,000 $0 $300 $0 $2,300
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Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period:05/01/2023 - 04/30/2024 LEPPINKS INC : Priority HSA HMO $3000 70% Coverage for: Subscriber/Dependent | Plan Type: HMO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. Note: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage or to get a copy of the complete terms of coverage, visit us at PriorityHealth.com or call the number on the back of your Priority Health ID card. For general definitions of common terms, such as allowed amount, balance billing, co-insurance, co-payment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary/ or call the number on the back of your Priority Health ID card to request a copy. Important Questions Answers What is the overall deductible?
$3,000 person / $6,000 family.
Are there services covered before you meet your deductible?
Yes, the deductible doesn't apply to preventive care.
Are there other deductibles for specific services?
No.
Why this Matters Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/. You don't have to meet deductibles for specific services.
The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own outof-pocket limits until the overall family out-of-pocket limit has been met. What is not included in Premiums, balance-billed charges, health care this plan doesn't cover, Even though you pay these expenses, they don't count toward the out-of-pocket the out-of-pocket limit? and services that exceed an annual day/visit limit. limit. This plan uses a provider network. You will pay the most if you use an out-ofnetwork provider, and you might receive a bill from a provider for the difference Will you pay less if you Yes. See PriorityHealth.com or call the number on the back of your between the provider’s charge and what your plan pays (balance billing). Be use a network provider? Priority Health ID card for a list of participating providers. aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to No. You can see the in-network specialist you choose without a referral. see a specialist? What is the out-of-pocket $6,000 person / $12,000 family. limit for this plan?
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Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period:05/01/2023 - 04/30/2024 LEPPINKS INC : Priority HSA HMO $3000 70% Coverage for: Subscriber/Dependent | Plan Type: HMO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. Note: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage or to get a copy of the complete terms of coverage, visit us at PriorityHealth.com or call the number on the back of your Priority Health ID card. For general definitions of common terms, such as allowed amount, balance billing, co-insurance, co-payment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary/ or call the number on the back of your Priority Health ID card to request a copy. Important Questions Answers What is the overall deductible?
$3,000 person / $6,000 family.
Are there services covered before you meet your deductible?
Yes, the deductible doesn't apply to preventive care.
Are there other deductibles for specific services?
No.
Why this Matters Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/. You don't have to meet deductibles for specific services.
The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own outof-pocket limits until the overall family out-of-pocket limit has been met. What is not included in Premiums, balance-billed charges, health care this plan doesn't cover, Even though you pay these expenses, they don't count toward the out-of-pocket the out-of-pocket limit? and services that exceed an annual day/visit limit. limit. This plan uses a provider network. You will pay the most if you use an out-ofnetwork provider, and you might receive a bill from a provider for the difference Will you pay less if you Yes. See PriorityHealth.com or call the number on the back of your between the provider’s charge and what your plan pays (balance billing). Be use a network provider? Priority Health ID card for a list of participating providers. aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to No. You can see the in-network specialist you choose without a referral. see a specialist? What is the out-of-pocket $6,000 person / $12,000 family. limit for this plan?
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All co-payment and co-insurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event
Services You May Need Primary care visit to treat an injury or illness Specialist visit
What You Will Pay Participating Provider Non-Participating Provider (You will pay the least) (You will pay the most)
Limitations, Exceptions & Other Important Information
30% co-insurance/ visit
Not covered
-----------none-----------
30% co-insurance/ visit If you visit a health care provider's office or clinic Preventive care/screening/ No charge immunization
Not covered
-----------none----------Preventive care services are those listed in Priority Health's Preventive Health Care Guidelines. Deductible does not apply. You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.
If you have a test
Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRIs)
Not covered
30% co-insurance
Not covered
Prior Authorization may be required.
30% co-insurance
Not covered
Prior Authorization required.
* For more information about limitations and exceptions, see the plan or policy document at PriorityHealth.com.
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All co-payment and co-insurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event
Services You May Need Primary care visit to treat an injury or illness Specialist visit
What You Will Pay Participating Provider Non-Participating Provider (You will pay the least) (You will pay the most)
Limitations, Exceptions & Other Important Information
30% co-insurance/ visit
Not covered
-----------none-----------
30% co-insurance/ visit If you visit a health care provider's office or clinic Preventive care/screening/ No charge immunization
Not covered
-----------none----------Preventive care services are those listed in Priority Health's Preventive Health Care Guidelines. Deductible does not apply. You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.
If you have a test
Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRIs)
Not covered
30% co-insurance
Not covered
Prior Authorization may be required.
30% co-insurance
Not covered
Prior Authorization required.
* For more information about limitations and exceptions, see the plan or policy document at PriorityHealth.com.
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Common Medical Events
If you need drugs to treat your illness or condition More information about prescription drug coverage is available at https://www.priorityhealt h.com/prog/pharmacy/p harmacy.cgi
If you have outpatient surgery
What You Will Pay Services You May Need
Participating Provider (You will pay the least) $15 co-pay/ retail Generic drugs prescription (Tier 1) $30 co-pay/ mail order prescription $50 co-pay/ retail Preferred brand drugs prescription (Tier 2) $100 co-pay/ mail order prescription $80 co-pay/ retail Non-preferred brand drugs prescription (Tier 3) $160 co-pay/ mail order prescription Preferred specialty drugs 20% co-insurance/ retail (Tier 4) prescription Non-Preferred specialty 20% co-insurance/ retail drugs (Tier 5) prescription Facility fee (e.g., ambulatory 30% co-insurance/ visit surgery center) Physician/surgeon fees
30% co-insurance/ visit
Emergency room services
30% co-insurance/ visit
medical If you need immediate Emergency transportation medical attention Urgent care
30% co-insurance 30% co-insurance/ visit
Non-Participating Provider (You will pay the most)
Limitations, Exceptions & Other Important Information
Not covered
Not covered
Covers up to a 31-day supply (retail prescription); Covers up to a 90-day supply (mail order prescription, excluding Specialty Drugs) 50% co-insurance/ prescription for infertility drugs.
Not covered Not covered Not covered Not covered Not covered Covered at the in-network benefit level; R&C limitations apply Covered at the in-network benefit level; R&C limitations apply Covered at the in-network benefit level when obtained outside of the Service Area; R&C limitations apply
* For more information about limitations and exceptions, see the plan or policy document at PriorityHealth.com.
The maximum co-pay for preferred specialty drugs is $150 per fill. The maximum co-pay for non-preferred specialty drugs is $300 per fill. Including outpatient care, observation care and ambulatory surgery center care. Prior Authorization may be required. -----------none---------------------none----------Urgent Care services received from a Non-Participating Provider who is located in our Service Area are not Covered.
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Common Medical Events
If you need drugs to treat your illness or condition More information about prescription drug coverage is available at https://www.priorityhealt h.com/prog/pharmacy/p harmacy.cgi
If you have outpatient surgery
What You Will Pay Services You May Need
Participating Provider (You will pay the least) $15 co-pay/ retail Generic drugs prescription (Tier 1) $30 co-pay/ mail order prescription $50 co-pay/ retail Preferred brand drugs prescription (Tier 2) $100 co-pay/ mail order prescription $80 co-pay/ retail Non-preferred brand drugs prescription (Tier 3) $160 co-pay/ mail order prescription Preferred specialty drugs 20% co-insurance/ retail (Tier 4) prescription Non-Preferred specialty 20% co-insurance/ retail drugs (Tier 5) prescription Facility fee (e.g., ambulatory 30% co-insurance/ visit surgery center) Physician/surgeon fees
30% co-insurance/ visit
Emergency room services
30% co-insurance/ visit
medical If you need immediate Emergency transportation medical attention Urgent care
30% co-insurance 30% co-insurance/ visit
Non-Participating Provider (You will pay the most)
Limitations, Exceptions & Other Important Information
Not covered
Not covered
Covers up to a 31-day supply (retail prescription); Covers up to a 90-day supply (mail order prescription, excluding Specialty Drugs) 50% co-insurance/ prescription for infertility drugs.
Not covered Not covered Not covered Not covered Not covered Covered at the in-network benefit level; R&C limitations apply Covered at the in-network benefit level; R&C limitations apply Covered at the in-network benefit level when obtained outside of the Service Area; R&C limitations apply
* For more information about limitations and exceptions, see the plan or policy document at PriorityHealth.com.
The maximum co-pay for preferred specialty drugs is $150 per fill. The maximum co-pay for non-preferred specialty drugs is $300 per fill. Including outpatient care, observation care and ambulatory surgery center care. Prior Authorization may be required. -----------none---------------------none----------Urgent Care services received from a Non-Participating Provider who is located in our Service Area are not Covered.
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Common Medical Events
Services You May Need
Facility fee (e.g., hospital If you have a hospital room) stay Physician/surgeon fee If you need mental health, behavioral health, or substance abuse services
If you are pregnant
What You Will Pay Participating Provider Non-Participating Provider (You will pay the least) (You will pay the most) 30% co-insurance/ visit
Not covered
30% co-insurance/ visit
Not covered
Outpatient services
30% co-insurance/ visit
Not covered
Inpatient services
30% co-insurance/ visit
Not covered
Routine prenatal and postnatal care
No charge
Not covered
Delivery professional fees Delivery facility fees
30% co-insurance/ visit 30% co-insurance/ visit
Not covered Not covered
* For more information about limitations and exceptions, see the plan or policy document at PriorityHealth.com.
Limitations, Exceptions & Other Important Information Prior Authorization is required except in emergencies. No charge for first three mental health visits with a participating provider within 90 days of discharge from a participating hospital for mental health inpatient care. Except in an emergency, Prior Authorization required. Routine prenatal and postnatal visits are covered under your Preventive Health Care Services benefit. Appropriate office visit charge may apply to physician office services for complications of pregnancy. Except in an emergency, Prior Authorization required.
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Common Medical Events
Services You May Need
Facility fee (e.g., hospital If you have a hospital room) stay Physician/surgeon fee If you need mental health, behavioral health, or substance abuse services
If you are pregnant
What You Will Pay Participating Provider Non-Participating Provider (You will pay the least) (You will pay the most) 30% co-insurance/ visit
Not covered
30% co-insurance/ visit
Not covered
Outpatient services
30% co-insurance/ visit
Not covered
Inpatient services
30% co-insurance/ visit
Not covered
Routine prenatal and postnatal care
No charge
Not covered
Delivery professional fees Delivery facility fees
30% co-insurance/ visit 30% co-insurance/ visit
Not covered Not covered
* For more information about limitations and exceptions, see the plan or policy document at PriorityHealth.com.
Limitations, Exceptions & Other Important Information Prior Authorization is required except in emergencies. No charge for first three mental health visits with a participating provider within 90 days of discharge from a participating hospital for mental health inpatient care. Except in an emergency, Prior Authorization required. Routine prenatal and postnatal visits are covered under your Preventive Health Care Services benefit. Appropriate office visit charge may apply to physician office services for complications of pregnancy. Except in an emergency, Prior Authorization required.
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Common Medical Events
If you need help recovering or have other special health needs
If your child needs dental or eye care
What You Will Pay Services You May Need Participating Provider Non-Participating Provider (You will pay the least) (You will pay the most)
Limitations, Exceptions & Other Important Information
Durable medical equipment No charge (DME)
Not covered
Hospice service
30% co-insurance/ visit
Not covered
Child eye exam
Not covered
Not covered
Including hospice care services; excluding rehabilitation and habilitation services. Prior Authorization required, except for hospice care. Physical and occupational therapy limited to 50 visits per contract year. Osteopathic and chiropractic manipulation limited to a combined 24 visits per contract year. Speech therapy limited to 50 visits per contract year. Cardiac and pulmonary rehabilitation limited to a combined 50 visits per contract year. Prior Authorization required for Applied Behavior Analysis (ABA). Covered services include Physical, Occupational, Speech Therapy and Applied Behavior Analysis (ABA). Multiple charges may apply during one day of service. Services limited to a combined 45 days per contract year. Prior Authorization required, except for hospice care. Including rental, purchase or repair. Prior Authorization required for equipment over $1,000 and all rentals. This benefit applies to hospice services provided in the home only. Any hospice services provided in a facility will be subject to the appropriate facility benefit. Not covered
Child glasses
Not covered
Not covered
Not covered
Child dental check-up
Not covered
Not covered
Not covered
Home health care
30% co-insurance/ visit
Not covered
Rehabilitation services
30% co-insurance/ visit
Not covered
Habilitation services
30% co-insurance/ visit
Not covered
Skilled nursing care
30% co-insurance/ visit
Not covered
* For more information about limitations and exceptions, see the plan or policy document at PriorityHealth.com.
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Common Medical Events
If you need help recovering or have other special health needs
If your child needs dental or eye care
What You Will Pay Services You May Need Participating Provider Non-Participating Provider (You will pay the least) (You will pay the most)
Limitations, Exceptions & Other Important Information
Durable medical equipment No charge (DME)
Not covered
Hospice service
30% co-insurance/ visit
Not covered
Child eye exam
Not covered
Not covered
Including hospice care services; excluding rehabilitation and habilitation services. Prior Authorization required, except for hospice care. Physical and occupational therapy limited to 50 visits per contract year. Osteopathic and chiropractic manipulation limited to a combined 24 visits per contract year. Speech therapy limited to 50 visits per contract year. Cardiac and pulmonary rehabilitation limited to a combined 50 visits per contract year. Prior Authorization required for Applied Behavior Analysis (ABA). Covered services include Physical, Occupational, Speech Therapy and Applied Behavior Analysis (ABA). Multiple charges may apply during one day of service. Services limited to a combined 45 days per contract year. Prior Authorization required, except for hospice care. Including rental, purchase or repair. Prior Authorization required for equipment over $1,000 and all rentals. This benefit applies to hospice services provided in the home only. Any hospice services provided in a facility will be subject to the appropriate facility benefit. Not covered
Child glasses
Not covered
Not covered
Not covered
Child dental check-up
Not covered
Not covered
Not covered
Home health care
30% co-insurance/ visit
Not covered
Rehabilitation services
30% co-insurance/ visit
Not covered
Habilitation services
30% co-insurance/ visit
Not covered
Skilled nursing care
30% co-insurance/ visit
Not covered
* For more information about limitations and exceptions, see the plan or policy document at PriorityHealth.com.
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Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan documents for more information and a list of any other excluded services.) • Hearing aids • Non-emergency care when traveling outside the U.S. • Acupuncture • Long-term care • Private-duty nursing • Cosmetic surgery • Routine eye care (Adult & Child) • Dental care (Adult & Child) • Routine foot care Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan documents.) • Infertility treatment - diagnostic, counseling and • Bariatric surgery • Weight loss programs planning services for the underlying cause of • Chiropractic care infertility Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Insurance and Financial Services (DIFS) at 1-877-999-6442 or
[email protected]; the Department of Health and Human Services, Center for Consumer Information and Insurance Oversight at 1-877-267-2323 x61565 or www.cciio.cms.gov; or the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596. Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact the number on the back of your Priority Health ID card or www.priorityhealth.com; the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform; or the Department of Insurance and Financial Services (DIFS) at 1-877-999-6442 or
[email protected]. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP) at 1-877-999-6442 or
[email protected]. Does this plan provide Minimum Essential Coverage? Yes. Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet Minimum Value Standards? Yes. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Language Access Services: Spanish (Español): Para obtener asistencia en español, llame al número que figura en el reverso de su tarjeta de identificación de salud prioritaria. Tagalog (Tagalog): Kung kailangan mo ng tulong sa Tagalog, tawagan ang numero sa likod ng iyong Priority Health ID card. Chinese (中文): 如果您需要中文帮助，请拨打优先健康身份证背面的电话. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne'. ----------------------To see examples of how this plan might cover costs for a sample medical situation, see the next section---------------------PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1146. The time required to complete this information collection is estimated to average 0.08 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
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Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan documents for more information and a list of any other excluded services.) • Hearing aids • Non-emergency care when traveling outside the U.S. • Acupuncture • Long-term care • Private-duty nursing • Cosmetic surgery • Routine eye care (Adult & Child) • Dental care (Adult & Child) • Routine foot care Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan documents.) • Infertility treatment - diagnostic, counseling and • Bariatric surgery • Weight loss programs planning services for the underlying cause of • Chiropractic care infertility Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Insurance and Financial Services (DIFS) at 1-877-999-6442 or
[email protected]; the Department of Health and Human Services, Center for Consumer Information and Insurance Oversight at 1-877-267-2323 x61565 or www.cciio.cms.gov; or the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596. Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact the number on the back of your Priority Health ID card or www.priorityhealth.com; the Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform; or the Department of Insurance and Financial Services (DIFS) at 1-877-999-6442 or
[email protected]. Additionally, a consumer assistance program can help you file your appeal. Contact the Michigan Health Insurance Consumer Assistance Program (HICAP) at 1-877-999-6442 or
[email protected]. Does this plan provide Minimum Essential Coverage? Yes. Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit. Does this plan meet Minimum Value Standards? Yes. If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. Language Access Services: Spanish (Español): Para obtener asistencia en español, llame al número que figura en el reverso de su tarjeta de identificación de salud prioritaria. Tagalog (Tagalog): Kung kailangan mo ng tulong sa Tagalog, tawagan ang numero sa likod ng iyong Priority Health ID card. Chinese (中文): 如果您需要中文帮助，请拨打优先健康身份证背面的电话. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne'. ----------------------To see examples of how this plan might cover costs for a sample medical situation, see the next section---------------------PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1146. The time required to complete this information collection is estimated to average 0.08 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
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About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, co-payments, and co-insurance) and excluded services under this plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.
Peg is Having a Baby
Managing Joe’s type 2 Diabetes
Mia’s Simple Fracture
(9 months of in-network pre-natal care and a hospital delivery)
(a year of routine in-network care of a wellcontrolled condition)
(in-network emergency room visit and follow up care)
◼ The plan’s overall deductible ◼ Specialist co-insurance ◼ Hospital (facility) co-insurance ◼ Other co-insurance
$3,000 20% 20% 20%
◼ The plan’s overall deductible ◼ Specialist co-insurance ◼ Hospital (facility) co-insurance ◼ Other co-insurance
$3,000 20% 20% 20%
◼ The plan’s overall deductible ◼ Specialist co-insurance ◼ Hospital (facility) co-insurance ◼ Other co-insurance
$3,000 20% 20% 20%
This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia)
This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter)
This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy)
Total Example Cost
Total Example Cost
Total Example Cost
In this example, Peg would pay: Cost Sharing Deductibles Co-payments Co-insurance What isn’t covered Limits or exclusions The total Peg would pay is
$12,700
$3,000 $60 $2,500 $60 $5,620
In this example, Joe would pay: Cost Sharing Deductibles Co-payments Co-insurance What isn’t covered Limits or exclusions The total Joe would pay is
$5,600
$1,800 $1,100 $1,100 $60 $4,060
In this example, Mia would pay: Cost Sharing Deductibles Co-payments Co-insurance What isn’t covered Limits or exclusions The total Mia would pay is
The plan would be responsible for the other costs of these EXAMPLE covered services.
$2,800
$1,500 $0 $400 $0 $1,900
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About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, co-payments, and co-insurance) and excluded services under this plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.
Peg is Having a Baby
Managing Joe’s type 2 Diabetes
Mia’s Simple Fracture
(9 months of in-network pre-natal care and a hospital delivery)
(a year of routine in-network care of a wellcontrolled condition)
(in-network emergency room visit and follow up care)
◼ The plan’s overall deductible ◼ Specialist co-insurance ◼ Hospital (facility) co-insurance ◼ Other co-insurance
$3,000 20% 20% 20%
◼ The plan’s overall deductible ◼ Specialist co-insurance ◼ Hospital (facility) co-insurance ◼ Other co-insurance
$3,000 20% 20% 20%
◼ The plan’s overall deductible ◼ Specialist co-insurance ◼ Hospital (facility) co-insurance ◼ Other co-insurance
$3,000 20% 20% 20%
This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia)
This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter)
This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy)
Total Example Cost
Total Example Cost
Total Example Cost
In this example, Peg would pay: Cost Sharing Deductibles Co-payments Co-insurance What isn’t covered Limits or exclusions The total Peg would pay is
$12,700
$3,000 $60 $2,500 $60 $5,620
In this example, Joe would pay: Cost Sharing Deductibles Co-payments Co-insurance What isn’t covered Limits or exclusions The total Joe would pay is
$5,600
$1,800 $1,100 $1,100 $60 $4,060
In this example, Mia would pay: Cost Sharing Deductibles Co-payments Co-insurance What isn’t covered Limits or exclusions The total Mia would pay is
The plan would be responsible for the other costs of these EXAMPLE covered services.
$2,800
$1,500 $0 $400 $0 $1,900
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Plan ID 739705
HMO PriorityHSA
Coverage period: 05.01.2023 to 04.30.2024
Empowering members to take greater control of their health care spending LEPPINK'S INC This document is intended to be an easy-to-read summary to provide a general overview of your benefits. It is not a contract or legal document. Additional limitations and exclusions may apply to covered services. This plan has a specific network of providers, so check the Provider Directory prior to receiving services. Prior authorizations for certain services may apply. A complete description of benefits is contained in the Certificate of Coverage, Schedule or Agreement as applicable. Member cost-sharing Embedded Deductible The amount you pay before we begin to pay.
$3,000 individual/$6,000 family Deductible costs don't apply towards your coinsurance maximum. Out-of-network services not covered.
Coinsurance Your share of the costs of a covered health care service.
30% coinsurance for services after deductible is met, except where noted. Out-of-network services not covered.
Coinsurance maximum The most coinsurance cost share you’ll pay for covered services in a contract year. Your coinsurance cost share counts toward your out-of -pocket limit. Out-of-pocket limit The most you’ll pay in a contract year for covered services before we begin to pay 100% of the costs. Office visits
Not applicable
$6,000 individual/$12,000 family
Primary care provider (PCP) 30% coinsurance after deductible Specialists
30% coinsurance after deductible
Urgent care
30% coinsurance after deductible
Virtual Care Services For medical and behavioral health visits
Covered in full after deductible
Allergy testing, serum and injections
30% coinsurance after deductible
30% coinsurance after deductible Retail health clinic Located in a retail center, like a supermarket or pharmacy and provides care for common illnesses and services (examples: ear aches, sore throats, flu shots) Mental and behavioral health Inpatient hospital
30% coinsurance after deductible
Outpatient office visits
30% coinsurance after deductible
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© Priority Health 8892E 11/20
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continued
Plan ID 739705
Prescription drug coverage Visit priorityhealth.com and search Optimized or Traditional in the Approved Drug list to see coverage and pricing information. Formulary
Traditional
Tier 1
$15 copayment; after deductible
Tier 2
$50 copayment; after deductible
Tier 3
$80 copayment; after deductible
Tier 4
20% coinsurance, $150 max; after deductible
Tier 5
20% coinsurance, $300 max; after deductible
Mail Order Preventive care
Tier 1/2/3 = 2x, after deductible
Preventive care, immunizations
Covered in full; includes women's preventative health care services, well-child visits, flu shots and routine physical exams. Get the most up-to-date list of all the care that's recommended in our Preventative Health Care Guidelines when you login to your online account at PriorityHealth.com
Laboratory and X-ray Radiology
30% coinsurance after deductible
Advanced imaging (CT/ PET/MRI)
30% coinsurance after deductible
Laboratory
30% coinsurance after deductible
Emergency services Emergency room Emergency transportation/ ambulance services Hospital care
30% coinsurance after deductible 30% coinsurance after deductible
Inpatient hospital physician 30% coinsurance after deductible services 30% coinsurance after deductible; exceptions apply Surgery and/or facility fee Bariatric surgery
30% coinsurance after deductible; covered once per lifetime
Outpatient care Skilled nursing services and residential treatment Outpatient surgery
30% coinsurance after deductible; Up to 45 days covered per member each contract year
In-home and hospice care
30% coinsurance after deductible
30% coinsurance after deductible
Rehabilitation services and devices Physical and occupational 30% coinsurance after deductible Combined maximum 50 visits per member per contract year therapy Chiropractic care
30% coinsurance after deductible Maximum 24 visits per member per contract year
Speech therapy
30% coinsurance after deductible; Maximum 50 visits per member per contract year
Covered in full after deductible Prosthetic and orthotic support Durable medical equipment Covered in full after deductible (DME) Family planning and maternity care 50% coinsurance after deductible Family planning Routine prenatal and postpartum care
Covered in full for evaluation and management; see Preventative Health Care Guidelines for recommendations and services
Maternity delivery and nursery care
30% coinsurance after deductible
Tubal ligation
Covered in full for physicians services and outpatient facility Note: Hospital inpatient charges are subject to deductible and coinsurance when in connection with delivery or other covered inpatient surgery 30% coinsurance after deductible
Vasectomy
Quote: 109280 | 03/03/2023 at 8:53 am
© Priority Health 8892E 11/20
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continued
Plan ID 739705
Riders Embedded deductible (HSA only)
Oral and non-oral treatments for sexual dysfunction, 50% copay IRS-allowed chronic condition services, supplies and prescription drugs Durable medical equipment Prosthetics and orthotics Minimum Abortion Rider Rehabilitative medicine Chiropractic visits
Includes embedded deductible and embedded TrOOP. The deductible/TrOOP paid by all members will be combined to satisfy the family deductible/TrOOP. One member cannot contribute more than the individual deductible/TrOOP. Deductible $3,000 per member, $6,000 per family per contract year TrOOP $6,000 per member, $12,000 per family per contract year Must be filled by participating pharmacy. These must be authorized. Coverage is limited to: oral tablets, injectable, and intra-urethral. Covers a limited number of medical services, supplies, and medications identified by the IRS as eligible for pre-deductible coverage. Member cost-share still applies. 100% coverage 100% coverage Adds in "abortion coverage in the event of rape or incest" that was removed from the standard medical policy due to the Abortion Opt Out Act 20 additional visits from the standard 30 visits. Does not include chiropractic visits. 24 visits
Cost estimator: Calculates specific costs for hundreds of procedures, based on where you’re at with your deductible, coinsurance, etc. If a selected procedure is above fair market price, the tool will provide a list of nearby facilities where it’s offered at a lower cost. Travel assistance: If you become ill or injured while traveling more than 100 miles from home, AssistAmerica® coverage is included in your plan. Receive help with medical care, coordinating prescriptions, assistance with lost luggage, and even arrange your travel back home.
Quote: 109280 | 03/03/2023 at 8:53 am
© Priority Health 8892E 11/20
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Plan ID 739706
HMO Copay Align HRA
Coverage period: 05.01.2023 to 04.30.2024
Offering the most coverage available before deductible LEPPINK'S INC This document is intended to be an easy-to-read summary to provide a general overview of your benefits. It is not a contract or legal document. Additional limitations and exclusions may apply to covered services. This plan has a specific network of providers, so check the Provider Directory prior to receiving services. Prior authorizations for certain services may apply. A complete description of benefits is contained in the Certificate of Coverage, Schedule or Agreement as applicable. Member cost-sharing Deductible The amount you pay before we begin to pay.
$5,000 individual/$10,000 family Deductible costs don't apply towards your coinsurance maximum. Out-of-network services not covered.
Coinsurance Your share of the costs of a covered health care service.
20% coinsurance for services after deductible is met, except where noted. Out-of-network services not covered.
Coinsurance maximum The most coinsurance cost share you’ll pay for covered services in a contract year. Your coinsurance cost share counts toward your out-of -pocket limit. Out-of-pocket limit The most you’ll pay in a contract year for covered services before we begin to pay 100% of the costs. Office visits
$2,000 individual/$4,000 family
$8,550 individual/$17,100 family
Primary care provider (PCP) $30 copayment, deductible doesn't apply Specialists
$45 copayment, deductible doesn't apply
Urgent care
$75 copayment, deductible doesn't apply
Virtual Care Services For medical and behavioral health visits
Covered in full
Allergy testing, serum and injections
Covered in full
$75 copayment, deductible doesn't apply Retail health clinic Located in a retail center, like a supermarket or pharmacy and provides care for common illnesses and services (examples: ear aches, sore throats, flu shots) Mental and behavioral health Inpatient hospital
20% coinsurance after deductible
Outpatient office visits
$30 copayment, deductible doesn't apply
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© Priority Health 8892E 11/20
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continued
Plan ID 739706
Prescription drug coverage Visit priorityhealth.com and search Optimized or Traditional in the Approved Drug list to see coverage and pricing information. Formulary
Traditional
Tier 1
$15 copayment; deductible N/A
Tier 2
$50 copayment; deductible N/A
Tier 3
$80 copayment; deductible N/A
Tier 4
20% coinsurance, $150 max; deductible N/A
Tier 5
20% coinsurance, $300 max; deductible N/A
Mail Order Preventive care
Tier 1/2/3 = 2x, deductible N/A
Preventive care, immunizations
Covered in full; includes women's preventative health care services, well-child visits, flu shots and routine physical exams. Get the most up-to-date list of all the care that's recommended in our Preventative Health Care Guidelines when you login to your online account at PriorityHealth.com
Laboratory and X-ray Radiology
20% coinsurance after deductible
Advanced imaging (CT/ PET/MRI)
$150 copayment, deductible doesn't apply
Laboratory
20% coinsurance after deductible
Emergency services Emergency room Emergency transportation/ ambulance services Hospital care
$250 copayment, deductible doesn't apply $150 copayment, deductible doesn't apply
Inpatient hospital physician 20% coinsurance after deductible services 20% coinsurance after deductible; exceptions apply Surgery and/or facility fee Bariatric surgery
20% coinsurance after deductible; covered once per lifetime
Outpatient care Skilled nursing services and residential treatment Outpatient surgery
20% coinsurance after deductible; Up to 45 days covered per member each contract year
In-home and hospice care
Covered in full after deductible
20% coinsurance after deductible
Rehabilitation services and devices Physical and occupational $30 copayment, deductible doesn't apply Combined maximum 50 visits per member per contract year therapy Chiropractic care
$30 copayment, deductible doesn't apply Maximum 24 visits per member per contract year
Speech therapy
$30 copayment, deductible doesn't apply; Maximum 50 visits per member per contract year
Covered in full after deductible Prosthetic and orthotic support Durable medical equipment Covered in full after deductible (DME) Family planning and maternity care 50% coinsurance after deductible Family planning Routine prenatal and postpartum care
Covered in full for evaluation and management; see Preventative Health Care Guidelines for recommendations and services
Maternity delivery and nursery care
20% coinsurance after deductible
Tubal ligation
Covered in full for physicians services and outpatient facility Note: Hospital inpatient charges are subject to deductible and coinsurance when in connection with delivery or other covered inpatient surgery Covered in full when performed in physician's office or in connection with other surgery
Vasectomy
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Plan ID 739706
Riders Oral and non-oral treatments for sexual dysfunction, 50% copay Durable medical equipment Prosthetics and orthotics Minimum Abortion Rider Rehabilitative medicine Chiropractic visits
Must be filled by participating pharmacy. These must be authorized. Coverage is limited to: oral tablets, injectable, and intra-urethral. 100% coverage 100% coverage Adds in "abortion coverage in the event of rape or incest" that was removed from the standard medical policy due to the Abortion Opt Out Act 20 additional visits from the standard 30 visits. Does not include chiropractic visits. 24 visits
Cost estimator: Calculates specific costs for hundreds of procedures, based on where you’re at with your deductible, coinsurance, etc. If a selected procedure is above fair market price, the tool will provide a list of nearby facilities where it’s offered at a lower cost. Travel assistance: If you become ill or injured while traveling more than 100 miles from home, AssistAmerica® coverage is included in your plan. Receive help with medical care, coordinating prescriptions, assistance with lost luggage, and even arrange your travel back home.
Quote: 109280 | 03/03/2023 at 8:53 am
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