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Priority Health

MyPriority Bronze 8700 - Ascension St. John Providence Network

Plan Overview

Combined Medical and Drug Deductible
  • Individual: $8,700
  • Family: $17,400
  • Per Person: $8,700
Combined Medical and Drug Out of Pocket Maximum
  • Individual: $8,700
  • Family: $17,400
  • Per Person: $8,700

Office Visit

Primary Doctor
  • CoPay: $30.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: This plan includes one annual physical/wellness exam at no cost to the member.
Specialist
  • CoPay: No Charge after deductible
  • CoInsurance: Not Applicable
  • Covered: Covered

Prescription Drug Information

Preferred Brand Drugs
  • CoPay: No Charge after deductible
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: Refer to the drug list for quantity limits and other exclusions.
Non Preferred Brand Drugs
  • CoPay: No Charge after deductible
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: Refer to the drug list for quantity limits and other exclusions.
Generic Drugs
  • CoPay: $5.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: Refer to the drug list for quantity limits and other exclusions.
Specialty Drugs
  • CoPay: No Charge after deductible
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: Refer to the drug list for quantity limits and other exclusions.

Inpatient Coverage

Hospital Services
  • CoPay: No Charge after deductible
  • CoInsurance: Not Applicable
  • Covered: Covered
Inpatient Services
  • CoPay: No Charge after deductible
  • CoInsurance: Not Applicable
  • Covered: Covered

Emergency and Urgent Care

Emergency Room
  • CoPay: No Charge after deductible
  • CoInsurance: Not Applicable
  • Covered: Covered
Urgent Care Facility
  • CoPay: $75.00
  • CoInsurance: Not Applicable
  • Covered: Covered

Maternity

Labor and Delivery Hospital Stay
  • CoPay: No Charge after deductible
  • CoInsurance: Not Applicable
  • Covered: Covered
Pre and Postnatal Office Visit
  • CoPay: No Charge
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: Routine care is covered as preventive. Complications of Pregnancy is diagnostic/medical care will be covered as indicated by the SBC document.

Vision

Routine Eye Exams For Children
  • CoPay: No Charge
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Limit Quantity: 1
  • Limit Unit : Exam(s) per Year
  • Benefit Explanation: One exam per year. See SBC for details.

Major Dental Care

Routine Dental Checkups for Children
  • Covered: Not Covered
Routine Dental Checkups for Adults
  • Covered: Not Covered
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