MyPriority Standard Gold 2000 – Beaumont Health Network

29698MI0540723
Gold
HMO

MyPriority Standard Gold 2000 – Beaumont Health Network is a Gold HMO plan by Priority Health.

IMPORTANT: You are viewing the 2023 version of MyPriority Standard Gold 2000 – Beaumont Health Network 29698MI0540723. You can enroll in this plan during open enrollment 2023, which started November 1st and ends January 15th, 2023, in most states.

Locations

MyPriority Standard Gold 2000 – Beaumont Health Network is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of MyPriority Standard Gold 2000 – Beaumont Health Network 29698MI0540723.
Insurer: Priority Health
Network Type: HMO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 29698MI0540723

Cost-Sharing Overview

MyPriority Standard Gold 2000 – Beaumont Health Network offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for MyPriority Standard Gold 2000 - Beaumont Health Network?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

MyPriority Standard Gold 2000 – Beaumont Health Network offers the following features and referral requirements.

Wellness Program: No
Disease Program: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs
Notice Pregnancy: No
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what MyPriority Standard Gold 2000 – Beaumont Health Network covers when you are out of the service area or out of the country.

Out of Country Coverage: Yes
Out of Country Coverage Description: Emergency Care Only
Out of Service Area Coverage: Yes
Out of Service Area Coverage Description: Urgent/Emergency Care Only
National Network: No

Additional Benefits and Cost-Sharing

MyPriority Standard Gold 2000 – Beaumont Health Network includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Durable Medical Equipment
Covered
25.00% Coinsurance after deductible 100.00%
Hearing Aids
Not Covered
Imaging (CT/PET Scans, MRIs)
Covered
25.00% Coinsurance after deductible 100.00%
Preventive Care/Screening/Immunization
Covered
0.00% 100.00%
Routine Foot Care
Not Covered
Acupuncture
Not Covered
Weight Loss Programs
Covered
25.00% Coinsurance after deductible 100.00%
Routine Eye Exam for Children
Covered
0.00% 100.00%1 Exam(s) per Year
Eye Glasses for Children
Covered
0.00% 100.00%1 Item(s) per Year
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
$30.00 100.00%30 Visit(s) per Year
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$30.00 100.00%30 Visit(s) per Year Combined with chiro.
Well Baby Visits and Care
Covered
0.00% 100.00%
Laboratory Outpatient and Professional Services
Covered
25.00% Coinsurance after deductible 100.00%
X-rays and Diagnostic Imaging
Covered
25.00% Coinsurance after deductible 100.00%
Basic Dental Care – Child
Not Covered
Orthodontia – Child
Not Covered
Major Dental Care – Child
Not Covered
Basic Dental Care – Adult
Not Covered
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Not Covered
Abortion for Which Public Funding is Prohibited
Not Covered
Transplant
Covered
25.00% Coinsurance after deductible 100.00%
Accidental Dental
Not Covered
Dialysis
Covered
25.00% Coinsurance after deductible 100.00%
Allergy Testing
Covered
25.00% Coinsurance after deductible 100.00%
Chemotherapy
Covered
25.00% Coinsurance after deductible 100.00%
Radiation
Covered
25.00% Coinsurance after deductible 100.00%
Diabetes Education
Covered
0.00% 100.00%
Prosthetic Devices
Covered
25.00% Coinsurance after deductible 100.00%
Infusion Therapy
Covered
25.00% Coinsurance after deductible 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
25.00% Coinsurance after deductible 100.00% Coverage includes medical care or services to treat dysfunction or TMJS resulting from a medical cause or injury, Office visits for medical evaluation and treatment, X-rays of the temporomandibular joint including contrast studies, but not dental X-rays, Myofunctional therapy and Surgery to the temporomandibular joint, such as condylectomy, meniscectomy, arthrotomy, and arthrocentesis.
Nutritional Counseling
Covered
0.00% 100.00%6 Visit(s) per Year Dietician Services.
Reconstructive Surgery
Covered
25.00% Coinsurance after deductible 100.00%
Gender Affirming Care
Covered
25.00% Coinsurance after deductible 100.00%
Applied Behavior Analysis Based Therapies
Covered
25.00% Coinsurance after deductible 100.00%
Autism Spectrum Disorders
Covered
25.00% Coinsurance after deductible 100.00% Only covered in relation to Autism Spectrum Disorder.
Primary Care Visit to Treat an Injury or Illness
Covered
$30.00 100.00%
Specialist Visit
Covered
$60.00 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$60.00 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
25.00% Coinsurance after deductible 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
25.00% Coinsurance after deductible 100.00%
Hospice Services
Covered
25.00% Coinsurance after deductible 100.00% Coverage includes inpatient and outpatient hospice care.
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Covered
25.00% Coinsurance after deductible 100.00% Underlying causes only.
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Not Covered
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$45.00 100.00%
Home Health Care Services
Covered
25.00% Coinsurance after deductible 100.00%
Emergency Room Services
Covered
25.00% Coinsurance after deductible 25.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
25.00% Coinsurance after deductible 25.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
25.00% Coinsurance after deductible 100.00%
Inpatient Physician and Surgical Services
Covered
25.00% Coinsurance after deductible 100.00%
Bariatric Surgery
Covered
25.00% Coinsurance after deductible 100.00%1 Procedure(s) per Lifetime
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
25.00% Coinsurance after deductible 100.00%45 Days per Year
Prenatal and Postnatal Care
Covered
No Charge 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
25.00% Coinsurance after deductible 100.00%
Mental/Behavioral Health Outpatient Services
Covered
$30.00 100.00%
Mental/Behavioral Health Inpatient Services
Covered
25.00% Coinsurance after deductible 100.00%
Substance Abuse Disorder Outpatient Services
Covered
$30.00 100.00%
Substance Abuse Disorder Inpatient Services
Covered
25.00% Coinsurance after deductible 100.00%
Generic Drugs
Covered
$15.00 100.00%
Preferred Brand Drugs
Covered
$30.00 100.00%
Non-Preferred Brand Drugs
Covered
$60.00 100.00%
Specialty Drugs
Covered
$250.00 100.00%
Outpatient Rehabilitation Services
Covered
25.00% Coinsurance after deductible 100.00%30 Visit(s) per Year PT/OT/Chiro – combined visits per contract year; 30 ST per contract year; 30 cardiac/pulmonary visits per contract year.
Habilitation Services
Covered
25.00% Coinsurance after deductible 100.00%30 Visit(s) per Year Yearly limits: PT and OT: 30 visits, Speech: 30 visits.
Chiropractic Care
Covered
25.00% Coinsurance after deductible 100.00%30 Visit(s) per Year Limit combined with OT and PT.

Free Preventive Services

There is no copayment or coinsurance for any of the following MyPriority Standard Gold 2000 – Beaumont Health Network preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for MyPriority Standard Gold 2000 – Beaumont Health Network including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for MyPriority Standard Gold 2000 - Beaumont Health Network?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Table of Contents