Understand your MPSERS plan
Have questions about your Priority Health coverage? Find answers below.
We encourage our members to create a MyHealth account. Your account is accessible online and on the go with our MyHealth app available on the App Store and Google Play, and gives you access to everything you need including your deductible balances, claims information, prescriptions and more!
Priority Health covers preventive care services that you receive from an in-network provider.
We encourage all our members to take advantage of their preventive care coverage by having regular physical exams, mammograms, colonoscopies and immunizations like the flu shot or the shingles vaccine.
Review our Preventive Health Care Guidelines to find a list of preventive care services.
With our plans you don’t need a referral to see an in-network specialist. Some specialists may require a referral from your doctor before they’ll see you, but there’s no approval needed from Priority Health.
Finding doctors, hospitals and pharmacies
While you're in the Priority Health service area, we ask that you use participating doctors and hospitals. You can search for providers in the network by using our online Find a Doctor directory.
Under your MPSERS prescription coverage, you'll pay:
- $10 copayment for generic medications (you may still take advantage of the free or low-cost generic programs your pharmacy offers)
- $40 copayment for most brand-name drugs
- $70 copayment for non-preferred brand-name drugs
- 20% coinsurance (up to $100 per prescription) for specialty medications
You can search for participating pharmacies, including all the national chains, using our online Find a Doctor directory.
You may use our online Approved Drug List to see if your current prescriptions are covered by your plan. The approved drug list, also known as a formulary, determines how prescriptions will be covered. Find out how to use the online Approved Drug List.
Priority Health also offers a voluntary prescription mail order service, through Express Scripts. Log in or register your MyHealth account to learn more.
We recognize that our members like to travel, and we want to make sure you're covered while you do. In the case of a medical emergency, your coverage is the same whether you're here at home, in another state, or even another country. If you need routine services while you're outside of the Priority Health service area, you can take advantage of your travel benefits anywhere in the United States.
Common health insurance terms
Health insurance can be confusing! Here are definitions of common terms to help you understand your coverage.
Deductible: The amount you pay each contract year for the health care services your plan covers, before we begin to pay. For example, if your deductible is $1,000, your plan won’t pay anything until you’ve spent $1,000 for covered health care services that apply to the deductible. Not all health care costs will count towards your deductible.
Coinsurance: Your share of the cost of a covered health care service. This is usually calculated as a percent (for example, 10%) of the amount we allow providers to share for the service. You pay coinsurance plus any deductibles you owe. For example, if your plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your coinsurance payment of 10% would be $10. Priority Health would pay the rest of the allowed amount, 90% or $90.
Copayment: A fixed amount (for example $25) you pay for a covered health care service, usually when you receive the service, after you have met your deductible. Copayments may also apply when you get your prescriptions filled. The amount can vary by the type of covered health care service.
Out-of-pocket maximum: The most you’ll pay, in a contract year for covered services, before Priority Health begins paying 100% of the costs for covered services. This amount may include deductibles, coinsurance and copayments. This amount doesn’t include premiums, out-of-network or non-participating provider costs and costs for non-covered services. Your coverage documents list any costs that don’t apply toward you out-of-pocket limit.