MyPriority Enhanced Gold Southeast Michigan Network

Health Insurance Plan Details (2024 Plan)

Monthly Premium

HMO
$ubsidy
Gold
Deductible
$0 /yr
Max Out-of-Pocket
$9,400 /yr

Details

Deductible (per individual) $0 /yr
Deductible (per family) $0 /yr
Max Out-of-Pocket (per individual) $9,400 /yr
Max Out-of-Pocket (per family) $18,800 /yr
Drug Deductible (per individual) Included in Medical
Drug Deductible (per family) Included in Medical
Drug Max Out-of-Pocket (per individual) Included in Medical
Drug Max Out-of-Pocket (per family) Included in Medical
Plan Type HMO
Includes Child Dental? No
Includes Adult Dental? No
Medical Services
Preventive Care No Charge
Primary Care Visit $20 Copay
Specialist Visit $45 Copay
Emergency Room $250 Copay
Inpatient Facility $1000 Copay per Day
Inpatient Physician No Charge
Drug Costs
Generic Drugs $5 Copay
Preferred Brand Drugs $75 Copay
Non-preferred Brand Drugs $100 Copay
Specialty Drugs 50% Coinsurance

Plan Documents

Summary of Benefits and Coverage SBC doc
Provider Directory Doctor lookup
Drug Formulary List drug list

* Figures shown are only for in-network medical costs

** Please check with insurance company if Copay and Coinsurance rates are before or after the deductible


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