MyPriority Enhanced Gold Trinity Health East Network
Priority Health
Plan overview
Medical deductible
Individual: $0
Family: $0
Per Person: $0
Prescription drug deductible
Individual: $0
Family: $0
Per Person: $0
Combined medical and drug out of pocket maximum
Individual: $9200
Family: $18400
Per Person: $9200
Office visit
Primary Doctor
CoPay: $20.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: This plan includes one annual physical/wellness exam at no cost to the member.
Specialist
CoPay: $45.00
CoInsurance: Not Applicable
Covered: Covered
Prescription drug information
Preferred brand drugs
CoPay: $75.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: Refer to the drug list for quantity limits and other exclusions.
Non preferred brand drugs
CoPay: $100.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: Refer to the drug list for quantity limits and other exclusions.
Generic drugs
CoPay: $5.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: Refer to the drug list for quantity limits and other exclusions.
Specialty drugs
CoPay: Not Applicable
CoInsurance: 50.00%
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: Refer to the drug list for quantity limits and other exclusions. In accordance with state law, the maximum copayment per 30-day fill for orally administered chemotherapy drugs are capped at $250 or less. Deductible may apply.
Inpatient coverage
Hospital services
CoPay: $1000.00 Copay per Day
CoInsurance: Not Applicable
Covered: Covered
Inpatient services
CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Emergency and urgent care
Emergency room
CoPay: $250.00
CoInsurance: Not Applicable
Covered: Covered
Urgent care facility
CoPay: $75.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation:
Maternity
Labor and delivery hospital stay
CoPay: $1,000.00
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
CoPay:
CoInsurance:
Covered: Not Covered
Limit Quantity:
Limit Unit:
Routine dental checkups for adults
CoPay:
CoInsurance:
Covered: Not Covered
Limit Quantity:
Limit Unit:
Benefit Explanation:
These policies have exclusions, limitations, reduction of benefits, terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company (whichever is applicable).