MyPriority plan documents
MyPrioritySM plan documents are listed by plan name and by effective date (the "start date" of your plan).
Jump down to find documents for:
Document types:
Policy: The complete legal agreement and explanation of what your plan covers
Schedule of Benefits: An overview of the dollar amounts and percentages that the plan pays and that you will pay for services that are covered by the plan
Accident coverage rider: An option available under some plans at an extra cost that covers part of the expenses due to an accident or injury (such as a broken leg) before you meet your deductible.
Maternity coverage rider: An option available under the MyPriority PPO plan that covers part of the expenses for prenatal care and vaginal or elective Caesarean delivery of a baby.
MyPriority PPO plan documents
Coverage for individuals and families.
| Document | Versions by effective date |
|---|
| MyPriority PPO Policy |
|
Schedule of Benefits
80% in-network, 60% out-of-network coinsurance
$1,000 single/$2,000 family deductible |
|
Schedule of Benefits
80% in-network, 60% out-of-network coinsurance
$2,500 single/$5,000 family deductible |
|
Schedule of Benefits
80% in-network, 60% out-of-network coinsurance
$3,500 single/$7,000 family deductible |
|
Schedule of Benefits
80% in-network, 60% out-of-network coinsurance
$5,000 single/$10,000 family deductible |
|
Schedule of Benefits
70% in-network, 50% out-of-network coinsurance
$1,000 single/$2,000 family deductible |
|
Schedule of Benefits
70% in-network, 50% out-of-network coinsurance
$2,500 single/$5,000 family deductible |
|
Schedule of Benefits
80% in-network, 60% out-of-network coinsurance
$7,500 single/$15,000 family deductible |
|
Schedule of Benefits
80% in-network, 60% out-of-network coinsurance
$10,000 single/$20,000 family deductible |
|
Schedule of Benefits
70% in-network, 50% out-of-network coinsurance
$1,000 single/$2,000 family deductible
Generic drug coverage only |
|
Schedule of Benefits
70% in-network, 50% out-of-network coinsurance
$3,000 single/$6,000 family deductible
Generic drug coverage only |
|
| Accident rider |
|
MyPriority U31 plan documents
These plans are now listed above in the MyPriority PPO section.
MyPriority Short-term plan documents
Coverage for individuals and families for 1-6 months.
| Document | Versions by effective date |
|---|
| MyPriority Short-term policy |
|
Schedule of Benefits
80% in-network, 60% out-of-network coinsurance
$500 single/$1,000 family deductible |
|
Schedule of Benefits
80% in-network, 60% out-of-network coinsurance
$1,000 single/$2,000 family deductible |
|
Schedule of Benefits
80% in-network, 60% out-of-network coinsurance
$2,500 single/$5,000 family deductible |
|
MyPriority HSA plan documents
Coverage for individuals and families.
| Document | Versions by effective date |
|---|
| MyPriority HSA Policy |
|
Schedule of Benefits
100% in-network, 50% out-of-network coinsurance
$2,000 single/$4,000 family deductible |
|
Schedule of Benefits
100% in-network, 50% out-of-network coinsurance
$4,000 single/$8,000 family deductible |
|
Schedule of Benefits
100% in-network, 50% out-of-network coinsurance
$5,000 single/$10,000 family deductible |
|
| $1,000 Accident rider |
|
