MyPriority Telehealth PCP Silver 5500 - Off-Marketplace

Telehealth PCP: a plan option with access to virtual and in-person care.

Three important things to know about a Telehealth PCP plan:

  1. Every visit starts with a virtual appointment; you will need a smartphone or computer: When you need care, you make a virtual appointment with your assigned Doctor On Demand provider and connect with them via the app or online portal.
  2. This plan offers all types of 'virtual first' care: The virtual PCP acts as a primary care doctor, urgent care, behavioral health, preventive health and chronic care provider.
  3. You'll need a referral to seek in-person care with a PCP or specialist: This is a 'virtual first' plan. Referrals from your assigned telehealth doctor are required to seek care in a traditional office setting. In-person claims that do not have a referral from a Doctor On Demand provider will be denied.

Members who choose a Priority Health Telehealth PCP plan will have a doctor from our virtual care partner, Doctor On Demand. You can have appointments and consultations with this doctor just like you would in person. If your Doctor On Demand physician refers you to an in-person facility for health care services, you have access to the Priority Health broad network.

Highlights of what members get:

  • Telehealth PCP: All visits with your doctor will take place virtually, all you need is a device with an internet connection
  • Doctor On Demand visits: $10 primary care doctor, urgent care & mental health visits before, deductible
  • Prescription drugs: $5 Tier 1a and $20 Tier 1b drugs, before deductible
  • Chronic condition management: Services, supplies, and treatments for some of the most common chronic conditions, with cost-share, before deductible
  • Active&Fit Direct™: Discounted prices for gym memberships and more

Details:

  • A Telehealth PCP plan allows you to have appointments and consultations with your doctor from the comfort and safety of your home
  • If your virtual PCP from Doctor on Demand determines that you need in-person health care services, they will provide a referral within the broad Priority Health HMO network

Network

HMO

With a Telehealth PCP plan, your primary care provider will be a Doctor on Demand provider and you will receive care virtually. When services cannot be provided virtually, Doctor on Demand will work to provide you with a referral within the broad Priority Health HMO Network.

Metal level

Silver

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. 

Deductible

$5,500
Individual
$11,000
Family

The amount you pay for covered health care services before Priority Health begins to pay.

Coinsurance

70%
Plan pays
30%
You 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%.

Out-of-pocket limit

$8,700
Individual 
$17,400
Family

Your annual maximum cost. The most you’ll pay for health care services including copays and prescription drugs in one year.

Virtual office visits

$10 copayment
Primary doctor, before deductible 
$10 copayment
Urgent care, before deductible 
$10 copayment
Mental health, before deductible

Office visits provided virtually by Doctor on Demand. Referral needed from Doctor on Demand to seek in person care from another provider.

Preventive care

Covered in full

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.

Emergency services

$250 copayment
After deductible, waived if admitted
30%
Coinsurance

An illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm.

Diagnostic tests, X-rays, lab services and radiology services 

$10 copay
Diagnostic tests and lab services, before deductible
30% coinsurance
X-rays and radiology services, after deductible

Referral needed from Doctor on Demand.

Tier 1a and Tier 1b drugs

$5 copayment
Tier 1a,
before deductible
$20 copayment
Tier 1b,
before deductible

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.