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Plans

 

 

Michigan HMO/POS/PPO group health plan comparison

FeaturePriorityHMOSMPriorityPOSSMPriorityPPOSM
Primary care physician or other primary care provider (PCP) selection Each member is required to choose a PCP.
Each member is required to choose a PCP. (Preferred Benefits1 level)

Not required (Alternate Benefits1 level)		 Not required
Specialist referrals Priority Health doesn't require that members have referrals to see specialists in our network. But, some specialists require referrals from a member's treating physician.
Not required.
Note: If the member has not selected a primary care physician (PCP), then the Alternate Benefit1 level applies, even if the specialist is in-network.
Not required. But, the Non-Network Benefits2 level applies for visits to non-network physicians, even if referred by a network physician.
Provider network Priority Health network Priority Health network Priority Health and/or partner network
Out-of-network health care provider visits No Yes Yes
Deductibles 

 Optional Optional (Preferred Benefits1 level)

Yes (Alternate Benefits1 level)
Optional (Network Benefits2 level)

Yes (Non-Network Benefits2 level)
Coinsurance Optional Optional (Preferred Benefit level)

Yes (Alternate Benefits level)		 Optional (Network Benefits2 level)

Yes (Non-Network Benefits2 level)
Prescription drug coverage Included 
Included
Included 
Maximum annual benefit None None. But the Out-of-Network maximum is usually $1.25 million Yes. Maximum is typically $2 million or $5 million.
Reasonable & customary limits on charges No Yes (Alternate Benefits1 level) Yes (Non-Network Benefits2 level)
HealthyEncountersSMwellness & other classes Free at PH offices Free at PH offices Free at PH offices
Approved drug list (formulary) Included Included Included
Funding options 
  • Fully funded
  • Shared funding (with PriorityEPOSM)
  • Self-funded (with PriorityEPOSM)
  • Fully funded
  • Shared funding
    Self-funded
  • Fully funded
  • Shared funding
    Self-funded
National coverage For urgent and emergency care.
For urgent and emergency care, at the Alternate Benefits level for out-of-network care and the Preferred Benefit level for in-network care.
For urgent and emergency care, at the Non-Network Benefits level for out-of-network care. Care provided in-network is covered at the Network Benefits level.

Monthly premium costs

 $$3 $$$3 $$$3

1 PriorityPOS includes two benefit levels: Preferred (in-network) and Alternate (out of-network). A member is required to have a primary care physician in order to receive the Preferred Benefits level.
2PriorityPPO includes two benefit levels: Network (in-network) and Non-Network (out of-network). No primary care physician is required.
3Actual premiums are based on an employer group's demographic information and plan design.
Last modified: 2/2/2012
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