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MyPriority individual medical plans

This information is for health care providers.

Individuals looking for individual health insurance coverage should visit the MyPrioritySM plans information for prospective members.

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MyPriority plan features

Priority Health offers three MyPrioritySM individual medical plans.
  • Individuals apply and are underwritten based on their age, gender, tobacco use and health status.
  • Members of MyPriority plans do not choose a PCP.
See each plan's Summary of Benefits document, linked in the chart below, for more details.

Features MyPriority PPO plan MyPriority U31 Plan MyPriority Short-term Plan

Eligible individuals
  • Subscribers: Adults 18-64-1/2
  • Dependents: Spouses, children 1-18 years
    (full-time student dependents to 23 years)
  • Children-only coverage for ages 1-18
 Adults 18-30 Adults 18-64-1/2

Preventive coverage

for services that fall within the
Preventive Health Care Guidelines		 After the 90-day waiting period, services are
covered 100% up to $500 max. per member per year.
After $500 max., members pay coinsurance which applies to their deductible.
After the 90-day waiting period, services are
covered at 30% coinsurance.
Not covered

Office visits &
urgent care visits

 $30 copay before deductible is met
Limited to a combined 4 visits per member per year
After 4 visits, member must meet deductible		 $30 copay before deductible is met
Limited to a combined 4 visits per member per year
After 4 visits, member must meet deductible		 Must meet deductible, then coinsurance applies

Coinsurance

 20% in-network/40% out-of-network
OR
30% in-network/50% out-of-network
20% in-network/40% out-of-network

Deductible

 Varies
Family deductible may be met collectively by 2 or more individuals		 Varies Varies
Family deductible may be met collectively by 2 or more individuals

Rx coverage

 YES YES
  • Generics covered at 50% coinsurance
  • Brand-names not covered, but members will get Priority Health's discount
  • See Drug classes not covered below
NO

Maternity rider available

Call the Provider Help Line to verify if a member has this rider.		 YES
180-day waiting period applies
NO NO

Accident rider available

Call the Provider Help Line to verify if a member has this rider.		 YES
20% coinsurance applies before deductible is met		 YES
20% coinsurance applies before deductible is met		 NO

Services not covered

 Pre-existing conditions
Certain surgeries: Bariatric surgery, blepharoplasty of upper eyelids, breast reduction, panniculectomy, surgical treatment of male gynecomastia and procedures to correct obstructive sleep apnea, orthognathic surgery
Family planning/infertility services: Vasectomy, tubal ligation, diaphragm, infertility counseling, treatment of the underlying cause(s) of infertility
Treatment for TMJ, port wine stain removal		 All services listed for MyPriority PPO, and:
Preventive health, maternity, mental health and dietitian services; transplants

Summary of benefits

 MyPriority PPO Summary of Benefits (200KB PDF) MyPriority U31 Summary of Benefits (329KB PDF) MyPriority Short-term Summary of Benefits (277KB PDF)


Drug classes not covered

The therapeutic classes below are NOT COVERED by MyPriority plans, and the online formulary tool reflects this.
Go to the online formulary
  • Amphetamines
  • Antidepressants
  • Antihistamines
  • Antipsychotics and atypical antipsychotics
  • Antiulcer agents and acid suppressants
  • Contraceptives
  • Estrogen agonist-antagonists
  • Estrogens and antiestrogens
  • Infertility
  • Phosphodiesterase inhibitors
  • Prenatal vitamins
  • Proton-pump inhibitors
  • Psychotherapeutic agents
  • Sexual dysfunction
  • Smoking cessation
  • Stimulants
  • Vasodilating agents


Last modified 06/03/10