MyPriority Silver 5500 - Off Marketplace - Spectrum Health Partners
MyPriority® Silver 5500 - Off-Marketplace 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.
Your health is our top priority
Earning 4 out of 5 stars* on healthcare.gov, Priority Health gives you more for your money and does more to improve your health.
Highlights of what members get:
- On-demand mental health support: Included in your plan is myStrength, a mental health and wellness online tool that helps you live your best life.
- Chronic condition management: Access to a variety of medications, supplies and services to help keep your chronic conditions under control—covered in full or with a low cost share, before deductible
- Diabetes management: Our plans provide coverage for diabetes management services, supplies and treatments for no cost, before deductible when furnished by a participating medical equipment and supplies provider. Diabetes prescriptions and testing procedures are covered before deductible, with cost share.
- Global emergency assistance: If you or your dependents 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
A narrow network offered to individuals who live in Kent, Barry, Mecosta, Newaygo, Ottawa counties and a portion of Allegan County.*
Members who choose a Spectrum Health Partners plan are required to receive care in the Spectrum Health system of doctors and hospitals and their affiliated clinics, outpatient facilities, labs, etc.
This network includes:
Hospitals: All Spectrum Health hospitals (with the exception of Spectrum Health Lakeland)
Physicians (primary care and specialist) network:
- Spectrum Health Medical Group
- Physicians who denote a Spectrum Health hospital as their primary hospital affiliation
- Orthopedic Associates of Michigan (OAM) physicians
- All ancillary facilities in the Priority Health network will be available in the Spectrum Health network as well. Examples include 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
- No referral needed to see an in-network specialist
- 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
*ZIP codes in Allegan County where the Spectrum Health Partners narrow network is offered: 49070, 49311, 49314, 49323, 49328, 49335, 49344, 49348, 49406, 49408, 49416, 49419, 49423, 49453
You must receive care in the Spectrum Health Partners network of doctors and hospitals and their affiliated clinics, outpatient facilities, labs, etc. Care received outside of the Spectrum Health Partners network will not be covered and members will be required to cover the full cost of out-of-network care.
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 met your deductible, coinsurance is the percentage of the cost for medical services you have to pay. 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, office visits (evaluation only), before deductible
Specialist, office visits (evaluation only), before deductible
Mental health, office visits only, before deductible
Tier 1a and Tier 1b drugs
Tier 1 includes low-cost generic drugs—proven to be as safe as brand-name drugs—and, on some formularies, select brand-name drugs.
Retail health, urgent care and emergency services
Retail health clinic, office visits (evaluation only), before deductible
Urgent care, office visits (evaluation only), before deductible
Emergency room (waived if admitted); 30% coinsurance, after deductible
When you seek treatment for an illness, injury, symptom or condition that needs immediate care.
Limited virtual care
24/7 access to a provider with a Spectrum Health On-Demand virtual urgent care.
Preventive services help you avoid potential health problems or find them early when they are most treatable before you feel sick or have symptoms. See our Preventive Health Care Guidelines for a list of covered preventive services.
Routine prenatal and postnatal care, before deductible
Diagnostic tests, lab services, X-rays and radiology services
Diagnostic tests and lab services, before deductible
X-rays and radiology services, after deductible
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.