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MyPriority Standard Silver 5800 – Spectrum Health Partners (Allegan, Barry)

29698MI0540744
Silver
HMO

MyPriority Standard Silver 5800 – Spectrum Health Partners (Allegan, Barry) is a Silver HMO plan by Priority Health.

IMPORTANT: You are viewing the 2023 version of MyPriority Standard Silver 5800 – Spectrum Health Partners (Allegan, Barry) 29698MI0540744. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

MyPriority Standard Silver 5800 – Spectrum Health Partners (Allegan, Barry) is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of MyPriority Standard Silver 5800 – Spectrum Health Partners (Allegan, Barry) 29698MI0540744.
Insurer: Priority Health
Network Type: HMO
Metal Type: Silver
HSA Eligible?: No
Plan ID: 29698MI0540744

Cost-Sharing Overview

MyPriority Standard Silver 5800 – Spectrum Health Partners (Allegan, Barry) 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 Silver 5800 - Spectrum Health Partners (Allegan, Barry)?

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 Silver 5800 – Spectrum Health Partners (Allegan, Barry) offers the following features and referral requirements.

Wellness Program: No
Disease Program:
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 Silver 5800 – Spectrum Health Partners (Allegan, Barry) 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 Silver 5800 – Spectrum Health Partners (Allegan, Barry) includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
$40.00 100.00%
Specialist Visit
Covered
$80.00 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$80.00 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
40.00% Coinsurance after deductible 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
40.00% Coinsurance after deductible 100.00%
Hospice Services
Covered
40.00% Coinsurance after deductible 100.00% Coverage includes inpatient and outpatient hospice care.
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Covered
40.00% 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
$60.00 100.00%
Home Health Care Services
Covered
40.00% Coinsurance after deductible 100.00%
Emergency Room Services
Covered
40.00% Coinsurance after deductible 40.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
40.00% Coinsurance after deductible 40.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
40.00% Coinsurance after deductible 100.00%
Inpatient Physician and Surgical Services
Covered
40.00% Coinsurance after deductible 100.00%
Bariatric Surgery
Covered
40.00% Coinsurance after deductible 100.00%1 Procedure(s) per Lifetime
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
40.00% 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
40.00% Coinsurance after deductible 100.00%
Mental/Behavioral Health Outpatient Services
Covered
$40.00 100.00%
Mental/Behavioral Health Inpatient Services
Covered
40.00% Coinsurance after deductible 100.00%
Substance Abuse Disorder Outpatient Services
Covered
$40.00 100.00%
Substance Abuse Disorder Inpatient Services
Covered
40.00% Coinsurance after deductible 100.00%
Generic Drugs
Covered
$20.00 100.00%
Preferred Brand Drugs
Covered
$40.00 100.00%
Non-Preferred Brand Drugs
Covered
$80.00 Copay after deductible 100.00%
Specialty Drugs
Covered
$350.00 Copay after deductible 100.00%
Outpatient Rehabilitation Services
Covered
40.00% 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
40.00% Coinsurance after deductible 100.00%30 Visit(s) per Year Yearly limits: PT and OT: 30 visits, Speech: 30 visits.
Chiropractic Care
Covered
40.00% Coinsurance after deductible 100.00%30 Visit(s) per Year Limit combined with OT and PT.
Durable Medical Equipment
Covered
40.00% Coinsurance after deductible 100.00%
Hearing Aids
Not Covered
Imaging (CT/PET Scans, MRIs)
Covered
40.00% 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
40.00% Coinsurance after deductible 100.00%
Routine Eye Exam for Children
Covered
No Charge 100.00%1 Exam(s) per Year
Eye Glasses for Children
Covered
No Charge 100.00%1 Item(s) per Year
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
$40.00 100.00%30 Visit(s) per Year
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$40.00 100.00%30 Visit(s) per Year Combined with chiro.
Well Baby Visits and Care
Covered
No Charge 100.00%
Laboratory Outpatient and Professional Services
Covered
40.00% Coinsurance after deductible 100.00%
X-rays and Diagnostic Imaging
Covered
40.00% 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
40.00% Coinsurance after deductible 100.00%
Accidental Dental
Not Covered
Dialysis
Covered
40.00% Coinsurance after deductible 100.00%
Allergy Testing
Covered
40.00% Coinsurance after deductible 100.00%
Chemotherapy
Covered
40.00% Coinsurance after deductible 100.00%
Radiation
Covered
40.00% Coinsurance after deductible 100.00%
Diabetes Education
Covered
No Charge 100.00%
Prosthetic Devices
Covered
40.00% Coinsurance after deductible 100.00%
Infusion Therapy
Covered
40.00% Coinsurance after deductible 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
40.00% 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
No Charge 100.00%6 Visit(s) per Year Dietician Services.
Reconstructive Surgery
Covered
40.00% Coinsurance after deductible 100.00%
Gender Affirming Care
Covered
40.00% Coinsurance after deductible 100.00%
Applied Behavior Analysis Based Therapies
Covered
40.00% Coinsurance after deductible 100.00%
Autism Spectrum Disorders
Covered
40.00% Coinsurance after deductible 100.00% Only covered in relation to Autism Spectrum Disorder.

Free Preventive Services

There is no copayment or coinsurance for any of the following MyPriority Standard Silver 5800 – Spectrum Health Partners (Allegan, Barry) 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 Silver 5800 – Spectrum Health Partners (Allegan, Barry) 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 Silver 5800 - Spectrum Health Partners (Allegan, Barry)?

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

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