MyPriority Silver 5500 - Off-Marketplace - Spectrum Health Partners
MyPriority® Silver 5500 - Off-Marketplace (full or narrow network) plans are an affordable option for individuals who do not qualify for a federal subsidy, or choose not to use it. It offers a lower monthly premium because you purchase it directly from Priority Health and avoid fees associated with plans offered on the federally run Marketplace.
Highlights of what members get:
- Limited virtual care: 24/7 access to a doctor with a Spectrum Health On-Demand Video Visit
- Prescription drugs: $5 copayment for Tier 1a and $20 copayment for Tier 1b drugs, before deductible
- Primary doctor visits: $30 primary care doctor visits, before deductible
- Urgent care: $75 urgent care visits, before deductible
- Chronic condition management: Services, supplies, and treatments for some of the most common chronic conditions, with cost-share, before deductible
- Cost Estimator: Access to our tool to see prices for hundreds of services and procedures
- Active&Fit Direct™: Discounted prices for gym memberships and more
- Global emergency assistance: If you become ill or injured while traveling more than 100 miles from home, our partner Assist America® can help you get care and even arrange your safe travel home
- Hearing exams and hearing aids: Discounts for you and your extended family with TruHearing®
Spectrum Health Partners: Narrow network option for Kent County residents
Members who choose one of these plans are required to receive care in the Spectrum Health system of doctors and hospitals and their affiliated clinics, outpatient facilities, labs, etc.
- Spectrum Health hospitals (including those outside Kent County with the exception of Spectrum Health Lakeland)
- Spectrum Health Medical Group
- Physicians who denote a Spectrum Health hospital in Grand Rapids as their primary hospital affiliation
- Orthopedic Associates of Michigan (OAM) physicians (procedures must be done at a Spectrum Health facility)
- Ancillary facilities such as Pine Rest Christian Mental Health Services and Forest View Hospital
- All in-network pharmacies
- A narrow network allows members to enjoy a lower monthly premium while getting access to quality care.
- Members who enroll in this plan will see the Spectrum Health Partners network on their ID cards.
- Care received outside of the Spectrum Health Partners network will not be covered and members will be required to cover the full cost for out-of-network care.
You must receive care in the Spectrum Health system of doctors and hospitals and their affiliated clinics, outpatient facilities, labs, etc. Emergency services are covered at the in-network level. Use our Find a Doctor online directory to see if your doctor is in the Spectrum Health Partners network.
The metal level determines how you and your plan share the costs of care. Silver means your health plan pays 70% (on average) and you pay about 30%. Silver level plans offer a good balance of premium and out-of-pocket costs.
The amount you pay for covered health care services before Priority Health begins to pay.
After you've paid your deductible, coinsurance is your portion of the cost for medical services listed as benefits in your insurance plan or prescriptions listed in the approved drug list. For example, if your plan's fee for an office visit is $100 and you've met your deductible, your coinsurance payment of 20% would be $20. Priority Health would pay the rest of the fee, 80%. Preventive health services are covered at 100%.
Your annual maximum cost. The most you’ll pay for health care services including copays and prescription drugs in one year.
Primary doctor, before deductible
Specialist, before deductible
Mental health, before deductible (initial visit covered in full)
Limited virtual care
24/7 access to a doctor with a Spectrum Health On-Demand Video Visit.
Preventive care includes specific health care services that help you avoid potential health problems or find them early when they are most treatable, before you feel sick or have symptoms. Examples of preventive care include flu shots, physical exams, lab tests and some prescriptions. See our Preventive Health Care Guidelines for a list of covered preventive services.
Retail health, urgent care and emergency services
Retail health clinic, before deductible
Urgent care, before deductible
Emergency room, 30% coinsurance after deductible
An illness, injury, symptom or condition that needs immediate care to avoid the worsening of the condition.
Diagnostic tests, lab services, X-rays and radiology services
Diagnostic tests and lab services, before deductible
X-rays and radiology services, after deductible
Tier 1a and Tier 1b drugs
The least expensive prescription drugs available to you. This tier includes low-cost generic drugs—proven to be as safe as brand-name drugs—and, on some formularies, select brand-name drugs.
The features and benefits explained in this section are intended to give you an overview of your coverage and do not include or explain every detail of what is and is not covered. Please refer to the Summary of Benefits and Coverage.
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