Priority Health core plans: HMO, POS, PPO

PriorityPOSSM, PriorityHMOSM and PriorityPPOSM. These three plans are at the heart of every health insurance solution we offer. Use this comparison to determine which core plan best fits your organization. Then research our many plan designs to truly customize your plan.

PriorityHMO

  • Our most popular health coverage option
  • Emphasizes health and wellness while managing medical costs, ensuring employees receive all the services they need, but none that are unnecessary

PriorityPOS

  • For employers who are looking for the flexibility of a traditional health plan but need the cost savings of managed care
  • Same extensive provider network as our HMO and PPO plans

PriorityPPO

  • Offers employees the greatest freedom of choice by providing in-network and out-of-network options

HMO, POS, PPO: side-by-side comparison

Feature

HMO plans

POS plans

PPO plans

Primary care physician (PCP) coordinates care

Each member is required to choose a PCP.

Each member must 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.

Some specialists require referrals from a member's treating physician.

Not required

Not required

If the member doesn't choose a PCP, then the Alternate Benefit1 level applies, even if the specialist is in-network.

Not required

The Non-Network Benefits2 level applies for visits to non-network physicians, even if referred by a network physician.

Provider network

Priority Health HMO network

Priority Health HMO or PPO network

Priority Health PPO and/or partner network

Out-of-network health care (provider visits)

Not covered3

Covered, but members pay higher out-of-network costs.1

Covered, but members pay higher out-of-network costs.2

Out-of-network emergency care

Covered at the in-network benefit level, regardless of the provider's network participation status.

Once patients status is stable, the continued inpatient stay, at any non-participating hospital, requires PH approval for coverage.

Transfer to a participating facility may be required to continue in-network benefit level coverage.

Covered at the preferred in-network benefit level. Includes resulting hospital admissions, regardless of the provider's network participation status.

Once patients status is stable, the continued inpatient stay at any non-participating hospital, requires PH approval for Preferred in-network benefit level coverage.

Transfer to a participating facility may be required to continue Preferred in-network benefit level coverage.

Covered. But if a member is admitted to a facility that does not participate in the network, the inpatient stay is covered at the out-of-network benefit level.

Approved drug list (formulary)

Included

Included

Included

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.

New member continuity of care for the first 90 days4

New-to-Priority Health members can receive services from out-of-network providers at the in-network benefit level for pre-authorized services that were scheduled prior to enrollment with Priority Health. Priority Health nurse care managers help members transition to in-network providers following the above services.

New-to-Priority Health members can receive services from out-of-network providers at the in-network benefit level for pre-authorized services that were scheduled prior to enrollment with Priority Health. Priority Health nurse care managers help members transition to in-network providers following the above services.

N/A

Member cost sharing

Low

Low for in-network; higher out-of-network

Low for in-network; higher out-of-network

1  Our POS plans include 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.
2Our PPO includes two benefit levels: Network (in-network) and Non-Network (out of-network). No primary care physician is required.
3Out-of-network care may be provided at the in-network benefit level if approved by a Priority Health medical director.
4Certain exceptions apply.