20
Individual & Family Health Insurance Plans MyPriority PPO SM MyPriority HSA SM
Individual & Family Health Insurance Plans
MyPriority PPOSM
MyPriority HSASM
Just right for you Choosing the right health insurance is an important decision. With several plans to choose from and an accident rider, you can have coverage that’s geared to your lifestyle and budget. Priority Health makes it easy, with health insurance designed especially for people like you.
priorityhealth.com Formoreinformationcall855-MyPriority(855-697-7467)
Formoreinformationcall855-MyPriority(855-697-7467)
How MyPriority works for you It’s easy to understand your coverage and what you’ll pay.*
MyPriority PPO
Before you meet your deductible
•Preventivehealthvisitsandproceduresarecoveredinfull*
•You’llpayjust$30everytimeyouseeadoctororgotourgentcare
(upto4visitsperyear)
•Twooptionsforprescriptiondrugcoverage
–we’llcover60%ofbrandorgenericor50%ofgenericsonly.
•Yourcostswilltracktoseparatedeductiblesforin-network
andout-of-networkcare*
Once you meet your deductible
You’llpayjustaportionofthediscountedcostofcoveredservices.
Thepercentagedependsonwhichplanyouselect.*
Accident Rider
Wewaivethedeductibleandyoupayonly20%or30%forcoveredserviceswithin60daysoftheaccident
(dependingontheoptionyouchoose).
MyPriority HSA
•MakedepositstoyourHSAatanytime
•Benefitfromtax-deferredinvestmentaccount
•Withdrawthecashtax-free—noworlater—forqualifiedmedicalexpenses
•Saveaheadforfuturemedicalexpenseswithno“useitorloseit”rules
Before you meet your deductible
•Preventivehealthvisitsandproceduresare100%covered*
•You’llpayforyourprescriptionsandotherhealthservicesusingfunds
fromyourtax-advantagedhealthsavingsaccount.
•You’lltakeadvantageofourin-networkdiscountsonprescriptionsandotherhealthservices.
Once you meet your deductible
In-networkservicesandprescriptionsarecovered100%,andyou’llhave50%coverage
formostout-of-networkservices.
Accident Rider
Wecoverthefirst$1000forallcoveredserviceswithin60daysoftheaccident.
Formoreinformationcall855-MyPriority(855-697-7467)
Apply todayIt’s easy to enjoy the affordable security of MyPriority. Just pick your plan and complete the application.
To learn more:
•Getaninstantquoteatpriorityhealth.com
•Callusformoreinformationtoll-freeat855MyPriority(855697-7467)
•Contactyourlocalagent
We wrote the book on
HSA accounts. Go to
priorityhealth.com to
request your free copy
of “HSAs for Dummies.”
Learn More
Ann
ual d
educ
tible
–
sing
lein
-net
wor
k1
– fa
mily
$1
,000
$2
,000
$2
,500
$5
,000
$3
,500
$7
,000
$5
,000
$1
0,00
0$7
,500
$1
5,00
0$1
0,00
0
$20,
000
$1,0
00
$2,0
00$2
,500
$5
,000
$1,0
00
$2,0
00$3
,000
$6
,000
Ann
ual d
educ
tible
–
sing
leou
t-of
-net
wor
k –
fam
ily$2
,000
$4
,000
$5
,000
$1
0,00
0$7
,000
$1
4,00
0
$10,
000
$2
0,00
0$1
5,00
0
$30,
000
$20,
000
$4
0,00
0$2
,000
$4
,000
$5,0
00
$10,
000
$2,0
00
$4,0
00$6
,000
$1
2,00
0
Coi
nsur
ance
– P
lan
Pay
s:(u
nles
s ot
herw
ise
note
d)
• 8
0% in
-net
wor
k•
60%
out
-of-
netw
ork
• 7
0% in
-net
wor
k•
50%
out
-of-
netw
ork
• 7
0% in
-net
wor
k•
50%
out
-of-
netw
ork
Ann
ual i
n-ne
twor
k
– si
ngle
ou
t-of
-poc
ket
max
imum
2 –
fam
ily$3
,000
$6
,000
$4
,500
$9
,000
$5
,500
$1
1,00
0$7
,000
$1
4,00
0$9
,500
$1
9,00
0$1
2,00
0
$24,
000
$4,0
00
$8,0
00$6
,500
$1
3,00
0$3
,000
$6
,000
$9,0
00
$18,
000
Ann
ual o
ut-o
f-ne
twor
k
– si
ngle
ou
t-of
-poc
ket
max
imum
2 –
fam
ily$1
0,00
0
$20,
000
$13,
000
$2
6,00
0 $1
5,00
0
$30,
000
$18,
000
$3
6,00
0 $2
3,00
0
$46,
000
$28,
000
$5
6,00
0$1
2,00
0
$24,
000
$15,
000
$3
0,00
0$1
2,00
0
$24,
000
$16,
000
$3
2,00
0
Ann
ual b
enefi
t m
axim
um(fo
r in
and
out
-of-
netw
ork
serv
ices
co
mb
ined
)
$2 m
illio
n$2
mill
ion
$2 m
illio
n
Ben
efit
Wha
t yo
u pa
y
Pre
vent
ive
care
3
• $0
; 100
% c
over
ed•
$0; 1
00%
cov
ered
• $0
; 100
% c
over
ed
Doc
tor'
s of
fice
visi
ts4
• $3
0 co
pay
befo
re d
educ
tible
• $3
0 co
pay
befo
re d
educ
tible
• $3
0 co
pay
befo
re d
educ
tible
Urg
ent
care
4
Em
erge
ncy
room
5•
$150
cop
ay•
30%
coi
nsur
ance
in-n
etw
ork
afte
r de
duct
ible
• 30
% c
oins
uran
ce o
ut-o
f-ne
twor
k af
ter
dedu
ctib
le
• $1
50 c
opay
• 30
% c
oins
uran
ce in
-net
wor
k af
ter d
educ
tible
• 30
% c
oins
uran
ce o
ut-o
f-ne
twor
k af
ter d
educ
tible
• $1
50 c
opay
•
40%
in-n
etw
ork
coin
sura
nce
afte
r ded
uctib
le•
40%
out
-of-
netw
ork
coin
sura
nce
afte
r ded
uctib
le
Am
bul
ance
•
30%
coi
nsur
ance
in-n
etw
ork
afte
r de
duct
ible
• 30
% c
oins
uran
ce o
ut-o
f-ne
twor
k af
ter
dedu
ctib
le•
30%
coi
nsur
ance
in-n
etw
ork
afte
r ded
uctib
le•
30%
coi
nsur
ance
out
-of-
netw
ork
afte
r ded
uctib
le
• 40
% in
-net
wor
k co
insu
ranc
e af
ter d
educ
tible
• 40
% o
ut-o
f-ne
twor
k co
insu
ranc
e af
ter d
educ
tible
Out
pat
ient
lab
/X-r
ay•
20%
coi
nsur
ance
in-n
etw
ork
afte
r de
duct
ible
• 40
% c
oins
uran
ce o
ut-o
f-ne
twor
k af
ter
dedu
ctib
le•
30%
coi
nsur
ance
in-n
etw
ork
afte
r ded
uctib
le•
50%
coi
nsur
ance
out
-of-
netw
ork
afte
r ded
uctib
le
• 30
% c
oins
uran
ce in
-net
wor
k af
ter d
educ
tible
• 50
% c
oins
uran
ce o
ut-o
f-ne
twor
k af
ter d
educ
tible
Out
pat
ient
sur
gery
Hos
pita
lizat
ion
Out
pat
ient
sp
eech
the
rap
y6
Out
pat
ient
occ
upat
iona
l the
rap
y6
Out
pat
ient
phy
sica
l the
rap
y/
spin
al m
anip
ulat
ion6
Car
dia
c re
hab
6
Ski
lled
nur
sing
; Sub
acut
e; In
pat
ient
re
hab
; Hos
pic
e7
Hom
e he
alth
car
e8
Sub
stan
ce a
bus
e9
Die
titia
n se
rvic
es10
DM
E; P
&O
11•
50%
coi
nsur
ance
aft
er d
educ
tible
•
50%
coi
nsur
ance
afte
r de
duct
ible
• 50
% c
oins
uran
ce a
fter
dedu
ctib
le
Pre
scrip
tion
dru
g co
vera
ge12
• 40
% c
opay
for
gene
rics
and
bran
d dr
ugs
befo
re d
educ
tible
• In
clud
es o
ral c
ontr
acep
tives
. •
40%
cop
ay fo
r gen
eric
s an
d br
and
drug
s be
fore
de
duct
ible
• In
clud
es o
ral c
ontr
acep
tives
.
• G
ener
ic d
rugs
cov
ered
at
50%
bef
ore
dedu
ctib
le
• In
clud
es o
ral c
ontr
acep
tives
• B
rand
s at
Prio
rity
Hea
lth
disc
ount
ed p
rice
befo
re
dedu
ctib
le
Med
ical
sp
ecia
lty d
rugs
13•
20%
coi
nsur
ance
in-n
etw
ork
afte
r de
duct
ible
• 40
% c
oins
uran
ce o
ut-o
f net
wor
k af
ter
dedu
ctib
le•
30%
coi
nsur
ance
in-n
etw
ork
afte
r ded
uctib
le•
50%
coi
nsur
ance
out
-of-
netw
ork
af
ter d
educ
tible
• 50
% c
oins
uran
ce a
fter
dedu
ctib
le
Tran
spla
nts14
• A
t des
igna
ted
tran
spla
nt fa
cilit
y•
At d
esig
nate
d tr
ansp
lant
fa
cilit
y•
At d
esig
nate
d tr
ansp
lant
fa
cilit
y
Op
tiona
l Cov
erag
e
Acc
iden
t rid
er15
• 20
% c
oins
uran
ce in
-net
wor
k be
fore
ded
uctib
le•
40%
coi
nsur
ance
out
-of-
netw
ork
befo
re d
educ
tible
• 30
% c
oins
uran
ce in
-net
wor
k be
fore
ded
uctib
le•
50%
coi
nsur
ance
out
-of-
netw
ork
befo
re d
educ
tible
• 30
% c
oins
uran
ce in
-net
wor
k be
fore
ded
uctib
le•
50%
coi
nsur
ance
out
-of-
netw
ork
befo
re d
educ
tible
Not
cov
ered
(for
all
ded
uctib
le o
ptio
ns)
• C
erta
in s
urge
ries
— b
aria
tric
sur
gery
, ble
phar
opla
sty
of u
pper
eye
lids,
bre
ast r
educ
tion,
pan
nicu
lect
omy,
sur
gica
l tre
atm
ent o
f m
ale
gyne
com
astia
and
pro
cedu
res
to c
orre
ct o
bstr
uctiv
e sl
eep
apne
a.
• Fa
mily
pla
nnin
g/in
fert
ility
ser
vice
s —
vas
ecto
my,
tuba
l liti
gatio
n, d
iaph
ragm
, inf
ertil
ity c
ouns
elin
g an
d tr
eatm
ent o
f und
erly
ing
ca
use
of in
fert
ility
•
TMJ,
por
t win
e st
ains
, ort
hogn
athi
c su
rger
y
90-d
ay w
aitin
g p
erio
d (f
or a
ll d
educ
tible
op
tions
)
Sur
gerie
s su
bjec
t to
the
90 d
ay w
aitin
g pe
riod
incl
ude:
Ton
sille
ctom
y, A
deno
idec
tom
y, H
emor
rhoi
dect
omy,
Hys
tere
ctom
y an
d B
unio
nect
omy,
S
urgi
cal t
reat
men
t of t
he fo
llow
ing
cond
ition
s ar
e al
so s
ubje
ct to
the
90 d
ay w
aitin
g pe
riod:
Cys
toce
le, E
nter
ocel
e, R
ecto
cele
, Ure
thro
cele
, U
terin
e P
rola
pse,
Ingu
inal
Her
nia
(oth
er th
an s
tran
gula
ted
or in
carc
erat
ed),
Car
pal T
unne
l Syn
drom
e an
d Va
ricos
e Ve
ins.
Pre
-exi
stin
g co
nditi
on e
xclu
sion
Ben
efits
will
be
excl
uded
fo
r ea
ch Il
lnes
s o
r In
jury
or
cond
itio
n no
t d
iscl
ose
d o
n th
e ap
plic
atio
n, f
or
whi
ch, d
urin
g t
he s
ix m
ont
h p
erio
d
prio
r to
the
eff
ectiv
e d
ate,
med
ical
ad
vice
, dia
gno
sis,
car
e o
r tr
eatm
ent
reco
mm
end
ed b
y o
r re
ceiv
ed f
rom
a H
ealth
Pro
fess
iona
l. F
or
pur
po
ses
of
this
lim
itatio
n, “
trea
tmen
t” in
clud
es t
he u
se o
f p
resc
riptio
n d
rug
s.
Thi
s P
re-E
xist
ing
Co
nditi
on
excl
usio
n w
ill a
pp
ly u
ntil
the
end
of
the
twel
ve m
ont
h p
erio
d b
egin
ning
on
the
effe
ctiv
e d
ate
und
er t
he p
olic
y.
The
Pre
-Exi
stin
g C
ond
itio
n ex
clus
ion
do
es n
ot
app
ly t
o a
new
bo
rn w
ho b
eco
mes
a C
ove
red
Dep
end
ent
und
er t
his
Po
licy
with
in 3
1 d
ays
afte
r th
e b
irth.
*For
com
ple
te p
lan
det
ails
go
to p
riorit
yhea
lth.c
om
80%
Med
ical
60%
Bra
nd/G
ener
ic D
rug
70%
Med
ical
60%
Bra
nd/G
ener
icD
rug
70%
Med
ical
50%
Gen
eric
Dru
gs O
nly
Sum
mar
y of
ben
efits
MyP
rio
rity
PP
O
Ann
ual d
educ
tible
–
sing
lein
-net
wor
k1
– fa
mily
$1
,000
$2
,000
$2
,500
$5
,000
$3
,500
$7
,000
$5
,000
$1
0,00
0$7
,500
$1
5,00
0$1
0,00
0
$20,
000
$1,0
00
$2,0
00$2
,500
$5
,000
$1,0
00
$2,0
00$3
,000
$6
,000
Ann
ual d
educ
tible
–
sing
leou
t-of
-net
wor
k –
fam
ily$2
,000
$4
,000
$5
,000
$1
0,00
0$7
,000
$1
4,00
0
$10,
000
$2
0,00
0$1
5,00
0
$30,
000
$20,
000
$4
0,00
0$2
,000
$4
,000
$5,0
00
$10,
000
$2,0
00
$4,0
00$6
,000
$1
2,00
0
Coi
nsur
ance
– P
lan
Pay
s:(u
nles
s ot
herw
ise
note
d)
• 8
0% in
-net
wor
k•
60%
out
-of-
netw
ork
• 7
0% in
-net
wor
k•
50%
out
-of-
netw
ork
• 7
0% in
-net
wor
k•
50%
out
-of-
netw
ork
Ann
ual i
n-ne
twor
k
– si
ngle
ou
t-of
-poc
ket
max
imum
2 –
fam
ily$3
,000
$6
,000
$4
,500
$9
,000
$5
,500
$1
1,00
0$7
,000
$1
4,00
0$9
,500
$1
9,00
0$1
2,00
0
$24,
000
$4,0
00
$8,0
00$6
,500
$1
3,00
0$3
,000
$6
,000
$9,0
00
$18,
000
Ann
ual o
ut-o
f-ne
twor
k
– si
ngle
ou
t-of
-poc
ket
max
imum
2 –
fam
ily$1
0,00
0
$20,
000
$13,
000
$2
6,00
0 $1
5,00
0
$30,
000
$18,
000
$3
6,00
0 $2
3,00
0
$46,
000
$28,
000
$5
6,00
0$1
2,00
0
$24,
000
$15,
000
$3
0,00
0$1
2,00
0
$24,
000
$16,
000
$3
2,00
0
Ann
ual b
enefi
t m
axim
um(fo
r in
and
out
-of-
netw
ork
serv
ices
co
mb
ined
)
$2 m
illio
n$2
mill
ion
$2 m
illio
n
Ben
efit
Wha
t yo
u pa
y
Pre
vent
ive
care
3
• $0
; 100
% c
over
ed•
$0; 1
00%
cov
ered
• $0
; 100
% c
over
ed
Doc
tor'
s of
fice
visi
ts4
• $3
0 co
pay
befo
re d
educ
tible
• $3
0 co
pay
befo
re d
educ
tible
• $3
0 co
pay
befo
re d
educ
tible
Urg
ent
care
4
Em
erge
ncy
room
5•
$150
cop
ay•
30%
coi
nsur
ance
in-n
etw
ork
afte
r de
duct
ible
• 30
% c
oins
uran
ce o
ut-o
f-ne
twor
k af
ter
dedu
ctib
le
• $1
50 c
opay
• 30
% c
oins
uran
ce in
-net
wor
k af
ter d
educ
tible
• 30
% c
oins
uran
ce o
ut-o
f-ne
twor
k af
ter d
educ
tible
• $1
50 c
opay
•
40%
in-n
etw
ork
coin
sura
nce
afte
r ded
uctib
le•
40%
out
-of-
netw
ork
coin
sura
nce
afte
r ded
uctib
le
Am
bul
ance
•
30%
coi
nsur
ance
in-n
etw
ork
afte
r de
duct
ible
• 30
% c
oins
uran
ce o
ut-o
f-ne
twor
k af
ter
dedu
ctib
le•
30%
coi
nsur
ance
in-n
etw
ork
afte
r ded
uctib
le•
30%
coi
nsur
ance
out
-of-
netw
ork
afte
r ded
uctib
le
• 40
% in
-net
wor
k co
insu
ranc
e af
ter d
educ
tible
• 40
% o
ut-o
f-ne
twor
k co
insu
ranc
e af
ter d
educ
tible
Out
pat
ient
lab
/X-r
ay•
20%
coi
nsur
ance
in-n
etw
ork
afte
r de
duct
ible
• 40
% c
oins
uran
ce o
ut-o
f-ne
twor
k af
ter
dedu
ctib
le•
30%
coi
nsur
ance
in-n
etw
ork
afte
r ded
uctib
le•
50%
coi
nsur
ance
out
-of-
netw
ork
afte
r ded
uctib
le
• 30
% c
oins
uran
ce in
-net
wor
k af
ter d
educ
tible
• 50
% c
oins
uran
ce o
ut-o
f-ne
twor
k af
ter d
educ
tible
Out
pat
ient
sur
gery
Hos
pita
lizat
ion
Out
pat
ient
sp
eech
the
rap
y6
Out
pat
ient
occ
upat
iona
l the
rap
y6
Out
pat
ient
phy
sica
l the
rap
y/
spin
al m
anip
ulat
ion6
Car
dia
c re
hab
6
Ski
lled
nur
sing
; Sub
acut
e; In
pat
ient
re
hab
; Hos
pic
e7
Hom
e he
alth
car
e8
Sub
stan
ce a
bus
e9
Die
titia
n se
rvic
es10
1
Fam
ily d
educ
tible
may
be
met
col
lect
ivel
y b
y 2
or m
ore
ind
ivid
uals
in t
he fa
mily
2
Exc
lud
es c
opay
s, in
clud
es c
oins
uran
ce a
nd d
educ
tible
3
With
in P
riorit
y H
ealth
Pre
vent
ive
Hea
lth C
are
Gui
del
ines
4
4 co
mb
ined
vis
its p
er m
emb
er a
nnua
lly –
aft
er t
he 4
vis
its, c
over
ed c
harg
es
app
ly t
owar
ds
ded
uctib
le a
nd c
oins
uran
ce.
5
Cop
ay w
aive
d if
ad
mitt
ed w
ithin
24
hour
s
6
$3,0
00 c
omb
ined
ann
ual m
ax p
er m
emb
er
7
60-d
ay c
omb
ined
ann
ual m
ax p
er m
emb
er
8
60 v
isits
ann
ual m
ax p
er m
emb
er
DM
E; P
&O
11•
50%
coi
nsur
ance
aft
er d
educ
tible
•
50%
coi
nsur
ance
afte
r de
duct
ible
• 50
% c
oins
uran
ce a
fter
dedu
ctib
le
Pre
scrip
tion
dru
g co
vera
ge12
• 40
% c
opay
for
gene
rics
and
bran
d dr
ugs
befo
re d
educ
tible
• In
clud
es o
ral c
ontr
acep
tives
. •
40%
cop
ay fo
r gen
eric
s an
d br
and
drug
s be
fore
de
duct
ible
• In
clud
es o
ral c
ontr
acep
tives
.
• G
ener
ic d
rugs
cov
ered
at
50%
bef
ore
dedu
ctib
le
• In
clud
es o
ral c
ontr
acep
tives
• B
rand
s at
Prio
rity
Hea
lth
disc
ount
ed p
rice
befo
re
dedu
ctib
le
Med
ical
sp
ecia
lty d
rugs
13•
20%
coi
nsur
ance
in-n
etw
ork
afte
r de
duct
ible
• 40
% c
oins
uran
ce o
ut-o
f net
wor
k af
ter
dedu
ctib
le•
30%
coi
nsur
ance
in-n
etw
ork
afte
r ded
uctib
le•
50%
coi
nsur
ance
out
-of-
netw
ork
af
ter d
educ
tible
• 50
% c
oins
uran
ce a
fter
dedu
ctib
le
Tran
spla
nts14
• A
t des
igna
ted
tran
spla
nt fa
cilit
y•
At d
esig
nate
d tr
ansp
lant
fa
cilit
y•
At d
esig
nate
d tr
ansp
lant
fa
cilit
y
Op
tiona
l Cov
erag
e
Acc
iden
t rid
er15
• 20
% c
oins
uran
ce in
-net
wor
k be
fore
ded
uctib
le•
40%
coi
nsur
ance
out
-of-
netw
ork
befo
re d
educ
tible
• 30
% c
oins
uran
ce in
-net
wor
k be
fore
ded
uctib
le•
50%
coi
nsur
ance
out
-of-
netw
ork
befo
re d
educ
tible
• 30
% c
oins
uran
ce in
-net
wor
k be
fore
ded
uctib
le•
50%
coi
nsur
ance
out
-of-
netw
ork
befo
re d
educ
tible
Not
cov
ered
(for
all
ded
uctib
le o
ptio
ns)
• C
erta
in s
urge
ries
— b
aria
tric
sur
gery
, ble
phar
opla
sty
of u
pper
eye
lids,
bre
ast r
educ
tion,
pan
nicu
lect
omy,
sur
gica
l tre
atm
ent o
f m
ale
gyne
com
astia
and
pro
cedu
res
to c
orre
ct o
bstr
uctiv
e sl
eep
apne
a.
• Fa
mily
pla
nnin
g/in
fert
ility
ser
vice
s —
vas
ecto
my,
tuba
l liti
gatio
n, d
iaph
ragm
, inf
ertil
ity c
ouns
elin
g an
d tr
eatm
ent o
f und
erly
ing
ca
use
of in
fert
ility
•
TMJ,
por
t win
e st
ains
, ort
hogn
athi
c su
rger
y
90-d
ay w
aitin
g p
erio
d (f
or a
ll d
educ
tible
op
tions
)
Sur
gerie
s su
bjec
t to
the
90 d
ay w
aitin
g pe
riod
incl
ude:
Ton
sille
ctom
y, A
deno
idec
tom
y, H
emor
rhoi
dect
omy,
Hys
tere
ctom
y an
d B
unio
nect
omy,
S
urgi
cal t
reat
men
t of t
he fo
llow
ing
cond
ition
s ar
e al
so s
ubje
ct to
the
90 d
ay w
aitin
g pe
riod:
Cys
toce
le, E
nter
ocel
e, R
ecto
cele
, Ure
thro
cele
, U
terin
e P
rola
pse,
Ingu
inal
Her
nia
(oth
er th
an s
tran
gula
ted
or in
carc
erat
ed),
Car
pal T
unne
l Syn
drom
e an
d Va
ricos
e Ve
ins.
Pre
-exi
stin
g co
nditi
on e
xclu
sion
Ben
efits
will
be
excl
uded
fo
r ea
ch Il
lnes
s o
r In
jury
or
cond
itio
n no
t d
iscl
ose
d o
n th
e ap
plic
atio
n, f
or
whi
ch, d
urin
g t
he s
ix m
ont
h p
erio
d
prio
r to
the
eff
ectiv
e d
ate,
med
ical
ad
vice
, dia
gno
sis,
car
e o
r tr
eatm
ent
reco
mm
end
ed b
y o
r re
ceiv
ed f
rom
a H
ealth
Pro
fess
iona
l. F
or
pur
po
ses
of
this
lim
itatio
n, “
trea
tmen
t” in
clud
es t
he u
se o
f p
resc
riptio
n d
rug
s.
Thi
s P
re-E
xist
ing
Co
nditi
on
excl
usio
n w
ill a
pp
ly u
ntil
the
end
of
the
twel
ve m
ont
h p
erio
d b
egin
ning
on
the
effe
ctiv
e d
ate
und
er t
he p
olic
y.
The
Pre
-Exi
stin
g C
ond
itio
n ex
clus
ion
do
es n
ot
app
ly t
o a
new
bo
rn w
ho b
eco
mes
a C
ove
red
Dep
end
ent
und
er t
his
Po
licy
with
in 3
1 d
ays
afte
r th
e b
irth.
*For
com
ple
te p
lan
det
ails
go
to p
riorit
yhea
lth.c
om
9
Up
to
the
stat
e-m
and
ated
ben
efit
10
6 vi
sits
per
mem
ber
per
yea
r
11
$2,0
00 m
ax p
er m
emb
er e
ach
year
for
in-n
etw
ork
serv
ices
;
$2,0
00 m
ax p
er m
emb
er e
ach
year
for
out-
of-n
etw
ork
serv
ices
12
Thes
e ex
pen
ses
do
not
go t
owar
ds
your
ded
uctib
le o
r ou
t-of
-poc
ket
max
imum
.
13
$25,
000
max
imum
per
mem
ber
eac
h ye
ar fo
r se
rvic
es r
ecei
ved
out
-of-
netw
ork
14
$1,
000,
000
max
imum
15
For
serv
ices
incu
rred
with
in 6
0-d
ays
of t
he in
jury
. A
fter
the
60-
day
s
the
ded
uctib
le w
ill b
e ap
plie
d t
o an
y co
vere
d c
harg
es.
Sum
mar
y of
ben
efits
MyP
rio
rity
HS
A
Ann
ual d
educ
tible
–
sing
lein
-net
wor
k1
– fa
mily
$2
,000
$4,0
00
$4,0
00
$8,0
00$5
,000
$1
0,00
0
Ann
ual d
educ
tible
–
sing
leou
t-of
-net
wor
k1
– fa
mily
$4,0
00
$8,0
00
$8,0
00
$16,
000
$10,
000
$20,
000
Ann
ual i
n-ne
twor
k
– si
ngle
ou
t-of
-poc
ket
max
imum
2 –
fam
ily$2
,000
$4
,000
$4,0
00
$8,0
00$5
,000
$1
0,00
0
Ann
ual o
ut-o
f-ne
twor
k
– si
ngle
ou
t-of
-poc
ket
max
imum
2 –
fam
ily$9
,000
$1
8,00
0$1
3,00
0$2
6,00
0$1
5,00
0 $3
0,00
0
Ann
ual b
enefi
t m
axim
um
(for
in a
nd o
ut-o
f-ne
twor
k se
rvic
es
com
bin
ed)
$2 m
illio
n
Ben
efit
In-n
etw
ork
Out
-of-
netw
ork
Pre
vent
ive
care
3
• $
0; 1
00%
cov
ered
• N
ot c
over
ed
Aft
er t
he d
educ
tible
is m
et t
he p
lan
pay
s
In-n
etw
ork
Out
-of-
netw
ork
Doc
tor'
s of
fice
visi
ts•
100
%•
50%
Urg
ent
care
•
100
%•
50%
Em
erge
ncy
room
• 1
00%
• 1
00%
Am
bul
ance
•
100
%•
100
%
Out
pat
ient
lab
/X-r
ay•
100
%•
50%
Out
pat
ient
sur
gery
Hos
pita
lizat
ion
Out
pat
ient
sp
eech
the
rap
y4
Out
pat
ient
occ
upat
iona
l the
rap
y4
Out
pat
ient
phy
sica
l the
rap
y/
spin
al m
anip
ulat
ion4
Car
dia
c re
hab
4
Ski
lled
nur
sing
; Sub
acut
e;
Inp
atie
nt r
ehab
; Hos
pic
e5
Hom
e he
alth
car
e6
Sub
stan
ce a
bus
e
Die
ticia
n se
rvic
es7
DM
E; P
&O
8
Pre
scrip
tion
dru
g co
vera
ge•
100
%•
Inc
lude
s or
al c
ontr
acep
tives
• N
ot c
over
ed
Med
ical
sp
ecia
lty d
rugs
9•
100
%•
50%
Tran
spla
nts10
• 1
00%
• 5
0%
Op
tiona
l Cov
erag
e
Acc
iden
t rid
erP
riorit
y H
ealth
will
pay
the
firs
t $1
,000
for
all c
over
ed e
xpen
ses
incu
rred
with
in 6
0 d
ays
of a
n in
jury
. Aft
er t
he $
1,00
0 or
60
day
s (w
hich
ever
com
es fi
rst)
cove
red
cha
rges
will
ap
ply
tow
ard
s th
e d
educ
tible
.
Wai
ting
per
iod
Pre
-exi
stin
g co
nditi
on e
xclu
sion
Ben
efits
will
be
excl
uded
for
each
Illn
ess
or In
jury
or
cond
ition
not
dis
clos
ed o
n th
e ap
plic
atio
n, fo
r w
hich
, dur
ing
the
six
mon
th p
erio
d pr
ior
to th
e ef
fect
ive
date
, med
ical
adv
ice,
dia
gnos
is, c
are
or
trea
tmen
t rec
omm
ende
d by
or
rece
ived
from
a H
ealth
Pro
fess
iona
l. F
or p
urpo
ses
of th
is li
mita
tion,
“t
reat
men
t” in
clud
es th
e us
e of
pre
scrip
tion
drug
s.
This
Pre
-Exi
stin
g C
ondi
tion
excl
usio
n w
ill a
pply
unt
il th
e en
d of
the
twel
ve m
onth
per
iod
begi
nnin
g on
the
effe
ctiv
e da
te u
nder
the
polic
y. T
he P
re-E
xist
ing
Con
ditio
n ex
clus
ion
does
not
app
ly to
a
new
born
who
bec
omes
a C
over
ed D
epen
dent
und
er th
is P
olic
y w
ithin
31
days
aft
er th
e bi
rth.
Sur
gerie
s su
bjec
t to
the
90 d
ay w
aitin
g pe
riod
incl
ude:
Ton
sille
ctom
y, A
deno
idec
tom
y, H
emor
rhoi
dect
omy,
Hys
tere
ctom
y an
d
Bun
ione
ctom
y, S
urgi
cal t
reat
men
t of t
he fo
llow
ing
cond
ition
s ar
e al
so s
ubje
ct to
the
90 d
ay w
aitin
g pe
riod:
Cys
toce
le, E
nter
ocel
e,
Rec
toce
le, U
reth
roce
le, U
terin
e P
rola
pse,
Ingu
inal
Her
nia
(oth
er th
an s
tran
gula
ted
or in
carc
erat
ed),
Car
pal T
unne
l Syn
drom
e an
d
Varic
ose
Vein
s.
Not
cov
ered
• C
erta
in s
urge
ries
— b
aria
tric
sur
gery
, ble
phar
opla
sty
of u
pper
eye
lids,
bre
ast r
educ
tion,
pann
icul
ecto
my,
sur
gica
l tre
atm
ent o
f mal
e gy
neco
mas
tia a
nd p
roce
dure
s to
cor
rect
obs
truc
tive
slee
p ap
nea
• F
amily
pla
nnin
g/in
fert
ility
ser
vice
s —
vas
ecto
my,
tuba
l lig
atio
n, d
iaph
ragm
, inf
ertil
ity c
ouns
elin
g
and
trea
tmen
t of u
nder
lyin
g ca
use
of in
fert
ility
• T
MJ,
por
t win
e st
ains
, ort
hogn
athi
c su
rger
y
*For
com
ple
te p
lan
det
ails
go
to p
rio
rity
hea
lth
.co
m
1
The
fam
ily d
educ
tible
may
be
met
by
1 or
mor
e in
div
idua
ls in
the
fam
ily
2
Incl
udes
ded
uctib
le a
nd c
oins
uran
ce
3
With
in P
riorit
y H
ealth
Pre
vent
ive
Hea
lth C
are
Gui
del
ines
4
30 v
isits
com
bin
ed fo
r in
and
out
-of-
netw
ork
serv
ices
max
imum
per
mem
ber
eac
h ye
ar
5
60-d
ay c
omb
ined
for
in a
nd o
ut-o
f-ne
twor
k se
rvic
es a
nnua
l max
per
mem
ber
6
60-v
isits
max
per
mem
ber
eac
h ye
ar
7
6 vi
sits
per
mem
ber
eac
h ye
ar
8 $2
,000
max
per
mem
ber
eac
h ye
ar fo
r in
-net
wor
k se
rvic
es; $
2,00
0 m
ax p
er m
emb
er e
ach
year
for
out-
of-n
etw
ork
serv
ices
9 $2
5,00
0 m
axim
um p
er m
emb
er e
ach
year
for
serv
ices
rec
eive
d o
ut-o
f-ne
twor
k
10
At
des
igna
ted
tra
nsp
lant
faci
lity
priorityhealth.com Formoreinformationcall855-MyPriority(855-697-7467)
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premiums if you choose
higher deductibles.
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priorityhealth.com Formoreinformationcall855-MyPriority(855-697-7467)
6 insurance terms you should know Before, the trivial details of insurance didn’t matter. Now you need to know. We make it easy …
1. Copay: Theamountyoupayforspecificmedicalservicesandprescriptionscoveredbytheplan.
2. Coinsurance: ThecostoftreatmentsharedbetweenyouandPriorityHealth.Thisisusually
calculatedasapercentageofthetotalcost.Oftencoinsuranceappliesonlyafteryoumeetyourdeductible.
3. Coverage: WithMyPriority,you’recovered.Your“coverage”iswhatwe’llpayfor.
4. Deductible: TheamountyoupayperplanyearbeforePriorityHealthstartspaying.
5. In-network: MyPriorityhasdoctors,hospitals,pharmaciesandothercareprovidersthatcharge
PriorityHealthmembersaspecialdiscountedrate.You’llsave,too,ifyouuseournetwork.
6. Urgent care: Ifyoucan’tseeyourregulardoctor,urgentcarecentersandwalk-incentersareusually
yourbestchoice.(You’llpay$30foreachvisituptofourvisits.)
Ded
uctib
les
– S
ingl
e(in
-net
wor
k)
– Fa
mily
$1,0
00
$2,0
00$2
,500
$5
,000
$3,5
00
$7,0
00$5
,000
$1
0,00
0$7
,500
$1
5,00
0$1
0,00
0 $2
0,00
0$1
,000
$2
,000
$2,5
00
$5,0
00$1
,000
$2
,000
$3,0
00$6
,000
Co
insu
ranc
e –
in-n
etw
ork
–
out-o
f-net
wor
k80
%
60%
80
%
60%
80
%
60%
80
%60
%
80%
60%
80
%60
%
70%
50
%
70%
50
%
70%
50
%
70%
50
%
Mal
e
0-25
dep
end
ents
$10
7.00
$
84.0
0 $
75.0
0 $
65.0
0 $
49.0
0 $
43.0
0 $
100.
00
$78
.00
$93
.00
$67
.00
0-18
110
.00
86.
00
77.
00
67.
00
50.
00
44.
00
103
.00
80.
00
96.
00
69.
00
19-2
4 1
16.0
0 9
1.00
8
1.00
7
0.00
5
3.00
4
6.00
1
09.0
0 8
4.00
1
01.0
0 7
2.00
25-2
9 1
31.0
0 1
03.0
0 9
2.00
7
9.00
5
9.00
5
2.00
1
23.0
0 9
5.00
1
08.0
0 7
7.00
30-3
4 1
49.0
0 1
18.0
0 1
05.0
0 9
1.00
6
8.00
5
9.00
1
40.0
0 1
08.0
0 1
17.0
0 8
4.00
35-3
9 1
77.0
0 1
39.0
0 1
24.0
0 1
07.0
0 8
0.00
7
0.00
1
66.0
0 1
28.0
0 1
38.0
0 9
9.00
40-4
4 2
04.0
0 1
61.0
0 1
43.0
0 1
24.0
0 9
3.00
8
1.00
1
92.0
0 1
48.0
0 1
60.0
0 1
15.0
0
45-4
9 2
52.0
0 1
98.0
0 1
76.0
0 1
52.0
0 1
14.0
0 1
00.0
0 2
36.0
0 1
82.0
0 1
97.0
0 1
41.0
0
50-5
4 3
19.0
0 2
51.0
0 2
24.0
0 1
93.0
0 1
45.0
0 1
27.0
0 2
99.0
0 2
31.0
0 2
50.0
0 1
79.0
0
55-5
9 3
94.0
0 3
10.0
0 2
76.0
0 2
39.0
0 1
79.0
0 1
57.0
0 3
70.0
0 2
85.0
0 3
09.0
0 2
21.0
0
60-6
4 4
82.0
0 3
79.0
0 3
38.0
0 2
92.0
0 2
19.0
0 1
91.0
0 4
52.0
0 3
49.0
0 3
78.0
0 2
71.0
0
Acc
iden
t ri
der
$4.
00
$8.
00
$10
.00
$12
.00
$14
.00
$16
.00
$4.
00
$8.
00
$4.0
0$6
.00
Fem
ale
0-25
dep
end
ents
$10
7.00
$
84.0
0 $
75.0
0 $
65.0
0 $
49.0
0 $
43.0
0 $
100.
00
$78
.00
$93
.00
$67
.00
0-18
110
.00
86.
00
77.
00
67.
00
50.
00
44.
00
103
.00
80.
00
96.
00
69.
00
19-2
4 1
16.0
0 9
1.00
8
1.00
7
0.00
5
3.00
4
6.00
1
09.0
0 8
4.00
1
01.0
0 7
2.00
25-2
9 1
43.0
0 1
12.0
0 1
00.0
0 8
6.00
6
5.00
5
7.00
1
34.0
0 1
03.0
0 1
18.0
0 8
4.00
30-3
4 1
72.0
0 1
35.0
0 1
20.0
0 1
04.0
0 7
8.00
6
8.00
1
61.0
0 1
24.0
0 1
35.0
0 9
6.00
35-3
9 2
27.0
0 1
78.0
0 1
59.0
0 1
37.0
0 1
03.0
0 9
0.00
2
12.0
0 1
64.0
0 1
78.0
0 1
27.0
0
40-4
4 2
69.0
0 2
12.0
0 1
88.0
0 1
63.0
0 1
22.0
0 1
07.0
0 2
52.0
0 1
95.0
0 2
11.0
0 1
51.0
0
45-4
9 3
14.0
0 2
47.0
0 2
20.0
0 1
90.0
0 1
43.0
0 1
25.0
0 2
95.0
0 2
28.0
0 2
46.0
0 1
76.0
0
50-5
4 3
61.0
0 2
84.0
0 2
53.0
0 2
18.0
0 1
64.0
0 1
43.0
0 3
38.0
0 2
61.0
0 2
83.0
0 2
03.0
0
55-5
9 4
22.0
0 3
32.0
0 2
95.0
0 2
55.0
0 1
92.0
0 1
68.0
0 3
95.0
0 3
05.0
0 3
30.0
0 2
37.0
0
60-6
4 4
96.0
0 3
91.0
0 3
48.0
0 3
01.0
0 2
26.0
0 1
97.0
0 4
65.0
0 3
59.0
0 3
89.0
0 2
79.0
0
Acc
iden
t ri
der
$6.
00
$10
.00
$12
.00
$16
.00
$18
.00
$20
.00
$6.
00
$10
.00
$4.0
0$8
.00
70%
Med
ical
60%
Bra
nd/G
ener
icD
rug
70%
Med
ical
50%
Gen
eric
Dru
gs O
nly
Pre
ferr
ed p
rem
ium
s
MyP
rio
rity
PP
O
* W
hen
you
age
into
the
next
age
bra
cket
, you
r pr
emiu
ms
will
be a
djus
ted
at y
our
annu
al r
enew
al.
* If
you
mov
e to
a c
ount
y th
at is
in a
diff
eren
t pre
miu
m ta
ble,
you
r pr
emiu
ms
will
be a
djus
ted
on th
e ne
xt b
illing
cyc
le a
fter
you
have
not
ified
us
of y
our
addr
ess
chan
ge.
80%
Med
ical
60%
Bra
nd/G
ener
ic D
rug
Co
unti
es: K
alam
azoo
, Len
awee
, Liv
ings
ton,
Mac
omb
, Mon
roe,
Oak
land
, St.
Cla
ir, W
asht
enaw
, Way
ne
Ded
uctib
les
– S
ingl
e(in
-net
wor
k)
– Fa
mily
$1,0
00
$2,0
00$2
,500
$5
,000
$3,5
00
$7,0
00$5
,000
$1
0,00
0$7
,500
$1
5,00
0$1
0,00
0 $2
0,00
0$1
,000
$2
,000
$2,5
00
$5,0
00$1
,000
$2
,000
$3,0
00$6
,000
Co
insu
ranc
e –
in-n
etw
ork
–
out-o
f-net
wor
k80
%
60%
80
%
60%
80
%
60%
80
%60
%
80%
60%
80
%60
%
70%
50
%
70%
50
%
70%
50
%
70%
50
%
Mal
e
0-25
dep
end
ents
$10
2.00
$
81.0
0 $
72.0
0 $
62.0
0 $
46.0
0 $
41.0
0 $
96.0
0 $
74.0
0 $
89.0
0 $
64.0
0
0-18
105
.00
83.
00
73.
00
63.
00
48.
00
42.
00
98.
00
76.
00
91.
00
65.
00
19-2
4 1
11.0
0 8
7.00
7
8.00
6
7.00
5
0.00
4
4.00
1
04.0
0 8
0.00
9
6.00
6
9.00
25-2
9 1
25.0
0 9
8.00
8
7.00
7
6.00
5
7.00
5
0.00
1
17.0
0 9
0.00
1
03.0
0 7
4.00
30-3
4 1
43.0
0 1
12.0
0 1
00.0
0 8
6.00
6
5.00
5
7.00
1
34.0
0 1
03.0
0 1
12.0
0 8
0.00
35-3
9 1
69.0
0 1
33.0
0 1
18.0
0 1
02.0
0 7
7.00
6
7.00
1
58.0
0 1
22.0
0 1
32.0
0 9
5.00
40-4
4 1
95.0
0 1
53.0
0 1
37.0
0 1
18.0
0 8
9.00
7
7.00
1
83.0
0 1
41.0
0 1
53.0
0 1
09.0
0
45-4
9 2
40.0
0 1
89.0
0 1
68.0
0 1
46.0
0 1
09.0
0 9
5.00
2
25.0
0 1
74.0
0 1
88.0
0 1
35.0
0
50-5
4 3
05.0
0 2
40.0
0 2
13.0
0 1
85.0
0 1
39.0
0 1
21.0
0 2
86.0
0 2
21.0
0 2
39.0
0 1
71.0
0
55-5
9 3
76.0
0 2
96.0
0 2
64.0
0 2
28.0
0 1
71.0
0 1
49.0
0 3
53.0
0 2
72.0
0 2
95.0
0 2
11.0
0
60-6
4 4
60.0
0 3
62.0
0 3
22.0
0 2
79.0
0 2
09.0
0 1
83.0
0 4
31.0
0 3
33.0
0 3
60.0
0 2
58.0
0
Acc
iden
t ri
der
$4.
00
$8.
00
$10
.00
$12
.00
$14
.00
$16
.00
$4.
00
$8.
00
$4.
00
$6.
00
Fem
ale
0-25
dep
end
ents
$10
2.00
$
81.0
0 $
72.0
0 $
62.0
0 $
46.0
0 $
41.0
0 $
96.0
0 $
74.0
0 $
89.0
0 $
64.0
0
0-18
105
.00
83.
00
73.
00
63.
00
48.
00
42.
00
98.
00
76.
00
91.
00
65.
00
19-2
4 1
11.0
0 8
7.00
7
8.00
6
7.00
5
0.00
4
4.00
1
04.0
0 8
0.00
9
6.00
6
9.00
25-2
9 1
36.0
0 1
07.0
0 9
5.00
8
2.00
6
2.00
5
4.00
1
28.0
0 9
9.00
1
12.0
0 8
0.00
30-3
4 1
64.0
0 1
29.0
0 1
15.0
0 9
9.00
7
5.00
6
5.00
1
54.0
0 1
19.0
0 1
29.0
0 9
2.00
35-3
9 2
16.0
0 1
70.0
0 1
52.0
0 1
31.0
0 9
8.00
8
6.00
2
03.0
0 1
57.0
0 1
69.0
0 1
21.0
0
40-4
4 2
57.0
0 2
02.0
0 1
80.0
0 1
55.0
0 1
17.0
0 1
02.0
0 2
41.0
0 1
86.0
0 2
01.0
0 1
44.0
0
45-4
9 3
00.0
0 2
36.0
0 2
10.0
0 1
82.0
0 1
36.0
0 1
19.0
0 2
81.0
0 2
17.0
0 2
35.0
0 1
68.0
0
50-5
4 3
44.0
0 2
71.0
0 2
41.0
0 2
09.0
0 1
57.0
0 1
37.0
0 3
23.0
0 2
49.0
0 2
70.0
0 1
93.0
0
55-5
9 4
03.0
0 3
17.0
0 2
82.0
0 2
44.0
0 1
83.0
0 1
60.0
0 3
78.0
0 2
92.0
0 3
15.0
0 2
26.0
0
60-6
4 4
74.0
0 3
73.0
0 3
32.0
0 2
87.0
0 2
15.0
0 1
88.0
0 4
44.0
0 3
43.0
0 3
71.0
0 2
66.0
0
Acc
iden
t ri
der
$6.
00
$10
.00
$12
.00
$14
.00
$16
.00
$18
.00
$4.
00
$8.
00
$4.
00
$8.
00
Pre
ferr
ed p
rem
ium
s
MyP
rio
rity
PP
O
* W
hen
you
age
into
the
next
age
bra
cket
, you
r pr
emiu
ms
will
be a
djus
ted
at y
our
annu
al r
enew
al.
* If
you
mov
e to
a c
ount
y th
at is
in a
diff
eren
t pre
miu
m ta
ble,
you
r pr
emiu
ms
will
be a
djus
ted
on th
e ne
xt b
illing
cyc
le a
fter
you
have
not
ified
us
of y
our
addr
ess
chan
ge.
* W
hen
you
age
into
the
next
age
bra
cket
, you
r pr
emiu
ms
will
be a
djus
ted
at y
our
annu
al r
enew
al.
* If
you
mov
e to
a c
ount
y th
at is
in a
diff
eren
t pre
miu
m ta
ble,
you
r pr
emiu
ms
will
be a
djus
ted
on th
e ne
xt b
illing
cyc
le a
fter
you
have
not
ified
us
of y
our
addr
ess
chan
ge.
Co
unti
es: J
acks
on, H
illsd
ale
70%
Med
ical
60%
Bra
nd/G
ener
icD
rug
70%
Med
ical
50%
Gen
eric
Dru
gs O
nly
80%
Med
ical
60%
Bra
nd/G
ener
ic D
rug
Co
unti
es: A
llega
n, A
rena
c, B
arry
, Bay
, Ber
rien,
Bra
nch,
Cal
houn
, Cas
s, C
lare
, Clin
ton,
E
aton
, Gen
esee
, Gla
dw
in, G
ratio
t, H
uron
, Ing
ham
, Ion
ia, I
sab
ella
, Ken
t, L
ake,
Lap
eer,
Mas
on, M
ecos
ta, M
idla
nd, M
ontc
alm
, Mus
kego
n, N
eway
go, O
cean
a, O
ttaw
a, S
agin
aw, S
t.
Jose
ph,
San
ilac,
Shi
awas
ee, T
usco
la, V
an B
uren
Ded
uctib
les
– S
ingl
e(in
-net
wor
k)
– Fa
mily
$1,0
00
$2,0
00$2
,500
$5
,000
$3,5
00
$7,0
00$5
,000
$1
0,00
0$7
,500
$1
5,00
0$1
0,00
0 $2
0,00
0$1
,000
$2
,000
$2,5
00
$5,0
00$1
,000
$2
,000
$3,0
00$6
,000
Co
insu
ranc
e –
in-n
etw
ork
–
out-o
f-net
wor
k80
%
60%
80
%
60%
80
%
60%
80
%60
%
80%
60%
80
%60
%
70%
50
%
70%
50
%
70%
50
%
70%
50
%
Mal
e
0-25
dep
end
ents
$98
.00
$77
.00
$69
.00
$59
.00
$44
.00
$39
.00
$92
.00
$71
.00
$85
.00
$61
.00
0-18
100
.00
79.
00
70.
00
61.
00
46.
00
40.
00
94.
00
73.
00
87.
00
63.
00
19-2
4 1
06.0
0 8
3.00
7
4.00
6
4.00
4
8.00
4
2.00
9
9.00
7
7.00
9
2.00
6
6.00
25-2
9 1
20.0
0 9
4.00
8
4.00
7
2.00
5
4.00
4
7.00
1
12.0
0 8
7.00
9
9.00
7
1.00
30-3
4 1
37.0
0 1
07.0
0 9
6.00
8
3.00
6
2.00
5
4.00
1
28.0
0 9
9.00
1
07.0
0 7
7.00
35-3
9 1
61.0
0 1
27.0
0 1
13.0
0 9
8.00
7
3.00
6
4.00
1
51.0
0 1
17.0
0 1
26.0
0 9
1.00
40-4
4 1
87.0
0 1
47.0
0 1
31.0
0 1
13.0
0 8
5.00
7
4.00
1
75.0
0 1
35.0
0 1
46.0
0 1
05.0
0
45-4
9 2
30.0
0 1
81.0
0 1
61.0
0 1
39.0
0 1
05.0
0 9
1.00
2
16.0
0 1
67.0
0 1
80.0
0 1
29.0
0
50-5
4 2
92.0
0 2
30.0
0 2
04.0
0 1
77.0
0 1
33.0
0 1
16.0
0 2
73.0
0 2
11.0
0 2
28.0
0 1
64.0
0
55-5
9 3
60.0
0 2
84.0
0 2
52.0
0 2
18.0
0 1
64.0
0 1
43.0
0 3
38.0
0 2
61.0
0 2
82.0
0 2
02.0
0
60-6
4 4
40.0
0 3
47.0
0 3
08.0
0 2
67.0
0 2
00.0
0 1
75.0
0 4
13.0
0 3
19.0
0 3
45.0
0 2
47.0
0
Acc
iden
t ri
der
$4.
00
$8.
00
$10
.00
$10
.00
$12
.00
$14
.00
$4.
00
$6.
00
$4.
00 $
6.00
Fem
ale
0-25
dep
end
ents
$98
.00
$77
.00
$69
.00
$59
.00
$44
.00
$39
.00
$92
.00
$71
.00
$85
.00
$61
.00
0-18
100
.00
79.
00
70.
00
61.
00
46.
00
40.
00
94.
00
73.
00
87.
00
63.
00
19-2
4 1
06.0
0 8
3.00
7
4.00
6
4.00
4
8.00
4
2.00
9
9.00
7
7.00
9
2.00
6
6.00
25-2
9 1
30.0
0 1
03.0
0 9
1.00
7
9.00
5
9.00
5
2.00
1
22.0
0 9
4.00
1
07.0
0 7
7.00
30-3
4 1
57.0
0 1
24.0
0 1
10.0
0 9
5.00
7
1.00
6
2.00
1
47.0
0 1
14.0
0 1
23.0
0 8
8.00
35-3
9 2
07.0
0 1
63.0
0 1
45.0
0 1
25.0
0 9
4.00
8
2.00
1
94.0
0 1
50.0
0 1
62.0
0 1
16.0
0
40-4
4 2
46.0
0 1
93.0
0 1
72.0
0 1
49.0
0 1
12.0
0 9
8.00
2
30.0
0 1
78.0
0 1
92.0
0 1
38.0
0
45-4
9 2
87.0
0 2
26.0
0 2
01.0
0 1
74.0
0 1
30.0
0 1
14.0
0 2
69.0
0 2
08.0
0 2
25.0
0 1
61.0
0
50-5
4 3
30.0
0 2
59.0
0 2
31.0
0 2
00.0
0 1
50.0
0 1
31.0
0 3
09.0
0 2
39.0
0 2
58.0
0 1
85.0
0
55-5
9 3
85.0
0 3
03.0
0 2
70.0
0 2
33.0
0 1
75.0
0 1
53.0
0 3
61.0
0 2
79.0
0 3
02.0
0 2
16.0
0
60-6
4 4
54.0
0 3
57.0
0 3
18.0
0 2
75.0
0 2
06.0
0 1
80.0
0 4
25.0
0 3
28.0
0 3
55.0
0 2
55.0
0
Acc
iden
t ri
der
$4.
00
$10
.00
$12
.00
$14
.00
$16
.00
$18
.00
$4.
00
$8.
00
$4.
00 $
8.00
Pre
ferr
ed p
rem
ium
s
MyP
rio
rity
PP
OS
M
* W
hen
you
age
into
the
next
age
bra
cket
, you
r pr
emiu
ms
will
be a
djus
ted
at y
our
annu
al r
enew
al.
* If
you
mov
e to
a c
ount
y th
at is
in a
diff
eren
t pre
miu
m ta
ble,
you
r pr
emiu
ms
will
be a
djus
ted
on th
e ne
xt b
illing
cyc
le a
fter
you
have
not
ified
us
of y
our
addr
ess
chan
ge.
70%
Med
ical
60%
Bra
nd/G
ener
icD
rug
70%
Med
ical
50%
Gen
eric
Dru
gs O
nly
80%
Med
ical
60%
Bra
nd/G
ener
ic D
rug
Ded
uctib
les
– S
ingl
e(in
-net
wor
k)
– Fa
mily
$1,0
00
$2,0
00$2
,500
$5
,000
$3,5
00
$7,0
00$5
,000
$1
0,00
0$7
,500
$1
5,00
0$1
0,00
0 $2
0,00
0$1
,000
$2
,000
$2,5
00
$5,0
00$1
,000
$2
,000
$3,0
00$6
,000
Co
insu
ranc
e –
in-n
etw
ork
–
out-o
f-net
wor
k80
%
60%
80
%
60%
80
%
60%
80
%60
%
80%
60%
80
%60
%
70%
50
%
70%
50
%
70%
50
%
70%
50
%
Mal
e
0-25
dep
end
ents
$93
.00
$73
.00
$65
.00
$56
.00
$42
.00
$37
.00
$87
.00
$67
.00
$81
.00
$58
.00
0-18
95.
00
75.
00
66.
00
57.
00
43.
00
38.
00
89.
00
69.
00
83.
00
59.
00
19-2
4 1
00.0
0 7
9.00
7
0.00
6
1.00
4
6.00
4
0.00
9
4.00
7
3.00
8
7.00
6
2.00
25-2
9 1
13.0
0 8
9.00
7
9.00
6
8.00
5
1.00
4
5.00
1
06.0
0 8
2.00
9
3.00
6
7.00
30-3
4 1
29.0
0 1
02.0
0 9
0.00
7
8.00
5
9.00
5
1.00
1
21.0
0 9
3.00
1
01.0
0 7
2.00
35-3
9 1
53.0
0 1
20.0
0 1
07.0
0 9
2.00
6
9.00
6
1.00
1
43.0
0 1
10.0
0 1
19.0
0 8
6.00
40-4
4 1
76.0
0 1
39.0
0 1
24.0
0 1
07.0
0 8
0.00
7
0.00
1
65.0
0 1
28.0
0 1
38.0
0 9
9.00
45-4
9 2
17.0
0 1
71.0
0 1
52.0
0 1
32.0
0 9
9.00
8
6.00
2
04.0
0 1
57.0
0 1
70.0
0 1
22.0
0
50-5
4 2
76.0
0 2
17.0
0 1
93.0
0 1
67.0
0 1
25.0
0 1
10.0
0 2
59.0
0 2
00.0
0 2
16.0
0 1
55.0
0
55-5
9 3
40.0
0 2
68.0
0 2
38.0
0 2
06.0
0 1
55.0
0 1
35.0
0 3
19.0
0 2
46.0
0 2
67.0
0 1
91.0
0
60-6
4 4
16.0
0 3
28.0
0 2
92.0
0 2
52.0
0 1
89.0
0 1
65.0
0 3
90.0
0 3
01.0
0 3
26.0
0 2
34.0
0
Acc
iden
t ri
der
$4.
00
$8.
00
$8.
00
$10
.00
$12
.00
$14
.00
$4.
00
$6.
00
$4.
00
$6.
00
Fem
ale
0-25
dep
end
ents
$93
.00
$73
.00
$65
.00
$56
.00
$42
.00
$37
.00
$87
.00
$67
.00
$81
.00
$58
.00
0-18
95.
00
75.
00
66.
00
57.
00
43.
00
38.
00
89.
00
69.
00
83.
00
59.
00
19-2
4 1
00.0
0 7
9.00
7
0.00
6
1.00
4
6.00
4
0.00
9
4.00
7
3.00
8
7.00
6
2.00
25-2
9 1
23.0
0 9
7.00
8
6.00
7
5.00
5
6.00
4
9.00
1
15.0
0 8
9.00
1
02.0
0 7
3.00
30-3
4 1
48.0
0 1
17.0
0 1
04.0
0 9
0.00
6
7.00
5
9.00
1
39.0
0 1
07.0
0 1
16.0
0 8
3.00
35-3
9 1
96.0
0 1
54.0
0 1
37.0
0 1
19.0
0 8
9.00
7
8.00
1
84.0
0 1
42.0
0 1
53.0
0 1
10.0
0
40-4
4 2
32.0
0 1
83.0
0 1
63.0
0 1
41.0
0 1
06.0
0 9
2.00
2
18.0
0 1
68.0
0 1
82.0
0 1
30.0
0
45-4
9 2
71.0
0 2
14.0
0 1
90.0
0 1
64.0
0 1
23.0
0 1
08.0
0 2
54.0
0 1
96.0
0 2
13.0
0 1
52.0
0
50-5
4 3
12.0
0 2
45.0
0 2
18.0
0 1
89.0
0 1
42.0
0 1
24.0
0 2
92.0
0 2
26.0
0 2
44.0
0 1
75.0
0
55-5
9 3
64.0
0 2
87.0
0 2
55.0
0 2
21.0
0 1
66.0
0 1
45.0
0 3
42.0
0 2
64.0
0 2
85.0
0 2
05.0
0
60-6
4 4
29.0
0 3
38.0
0 3
00.0
0 2
60.0
0 1
95.0
0 1
70.0
0 4
02.0
0 3
10.0
0 3
36.0
0 2
41.0
0
Acc
iden
t ri
der
$4.
00
$8.
00
$10
.00
$14
.00
$16
.00
$18
.00
$4.
00
$8.
00
$4.
00
$8.
00
Pre
ferr
ed p
rem
ium
s
MyP
rio
rity
PP
OS
M
* W
hen
you
age
into
the
next
age
bra
cket
, you
r pr
emiu
ms
will
be a
djus
ted
at y
our
annu
al r
enew
al.
* If
you
mov
e to
a c
ount
y th
at is
in a
diff
eren
t pre
miu
m ta
ble,
you
r pr
emiu
ms
will
be a
djus
ted
on th
e ne
xt b
illing
cyc
le a
fter
you
have
not
ified
us
of y
our
addr
ess
chan
ge.
* W
hen
you
age
into
the
next
age
bra
cket
, you
r pr
emiu
ms
will
be a
djus
ted
at y
our
annu
al r
enew
al.
* If
you
mov
e to
a c
ount
y th
at is
in a
diff
eren
t pre
miu
m ta
ble,
you
r pr
emiu
ms
will
be a
djus
ted
on th
e ne
xt b
illing
cyc
le a
fter
you
have
not
ified
us
of y
our
addr
ess
chan
ge.
Co
unti
es: A
lcon
a, A
lger
, Alp
ena,
Ant
rim, B
arag
a, B
enzi
e, C
harle
voix
, Che
boy
gan,
Chi
pp
ewa,
C
raw
ford
, Del
ta, D
icki
nson
, Em
met
, Gog
ebic
, Gra
nd T
rave
rse,
Hou
ghto
n, Io
sco,
Iron
, Kal
kask
a,
Kew
eena
w, L
eela
nau,
Luc
e, M
acki
nac,
Man
iste
e, M
arq
uett
e, M
enom
inee
, Mis
sauk
ee, M
ontm
oren
cy,
Oge
maw
, Ont
onag
on, O
scod
a, O
tseg
o, P
resq
ue Is
le, R
osco
mm
on, S
choo
lcra
ft, W
exfo
rd
70%
Med
ical
60%
Bra
nd/G
ener
icD
rug
70%
Med
ical
50%
Gen
eric
Dru
gs O
nly
80%
Med
ical
60%
Bra
nd/G
ener
ic D
rug
Co
unti
es:
Jack
son,
Hill
sdal
e
Ded
uctib
le
In-n
etw
ork
$2,0
00 S
ingl
e $4
,000
Fam
ily$4
,000
Sin
gle
$8,0
00 F
amily
$5,0
00 S
ingl
e $1
0,00
0 Fa
mily
Mal
e
0-25
dep
end
ents
$79
.00
$61
.00
$56
.00
0-18
81.
00
62.
00
57.
00
19-2
4 8
6.00
6
6.00
6
0.00
25-2
9 9
7.00
7
4.00
6
8.00
30-3
4 1
10.0
0 8
5.00
7
8.00
35-3
9 1
31.0
0 1
00.0
0 9
2.00
40-4
4 1
51.0
0 1
16.0
0 1
06.0
0
45-4
9 1
86.0
0 1
43.0
0 1
31.0
0
50-5
4 2
36.0
0 1
81.0
0 1
66.0
0
55-5
9 2
91.0
0 2
23.0
0 2
05.0
0
60-6
4 3
56.0
0 2
73.0
0 2
51.0
0
Acc
iden
t ri
der
$4.
00
$2.
00
$2.
00
Fem
ale
0-25
dep
end
ents
$79
.00
$61
.00
$56
.00
0-18
81.
00
62.
00
57.
00
19-2
4 8
6.00
6
6.00
6
0.00
25-2
9 1
05.0
0 8
1.00
7
4.00
30-3
4 1
27.0
0 9
7.00
9
0.00
35-3
9 1
68.0
0 1
28.0
0 1
18.0
0
40-4
4 1
99.0
0 1
52.0
0 1
40.0
0
45-4
9 2
32.0
0 1
78.0
0 1
64.0
0
50-5
4 2
67.0
0 2
04.0
0 1
88.0
0
55-5
9 3
12.0
0 2
39.0
0 2
20.0
0
60-6
4 3
67.0
0 2
81.0
0 2
59.0
0
Acc
iden
t ri
der
$4.
00
$4.
00
$4.
00
Co
unti
es: K
alam
azoo
, Len
awee
, Liv
ings
ton,
Mac
omb
, Mon
roe,
Oak
land
, St.
Cla
ir,
Was
hten
aw, W
ayne
Ded
uctib
le
In-n
etw
ork
$2,0
00 S
ingl
e $4
,000
Fam
ily$4
,000
Sin
gle
$8,0
00 F
amily
$5,0
00 S
ingl
e $1
0,00
0 Fa
mily
Mal
e
0-25
dep
end
ents
$83
.00
$64
.00
$58
.00
0-18
85.
00
65.
00
60.
00
19-2
4 9
0.00
6
9.00
6
3.00
25-2
9 1
01.0
0 7
8.00
7
1.00
30-3
4 1
16.0
0 8
9.00
8
2.00
35-3
9 1
37.0
0 1
05.0
0 9
6.00
40-4
4 1
58.0
0 1
21.0
0 1
11.0
0
45-4
9 1
95.0
0 1
49.0
0 1
37.0
0
50-5
4 2
47.0
0 1
90.0
0 1
74.0
0
55-5
9 3
05.0
0 2
34.0
0 2
15.0
0
60-6
4 3
73.0
0 2
86.0
0 2
63.0
0
Acc
iden
t ri
der
$4.
00
$4.
00
$2.
00
Fem
ale
0-25
dep
end
ents
$83
.00
$64
.00
$58
.00
0-18
85.
00
65.
00
60.
00
19-2
4 9
0.00
6
9.00
6
3.00
25-2
9 1
10.0
0 8
5.00
7
8.00
30-3
4 1
33.0
0 1
02.0
0 9
4.00
35-3
9 1
75.0
0 1
35.0
0 1
24.0
0
40-4
4 2
08.0
0 1
60.0
0 1
47.0
0
45-4
9 2
43.0
0 1
87.0
0 1
71.0
0
50-5
4 2
79.0
0 2
14.0
0 1
97.0
0
55-5
9 3
27.0
0 2
50.0
0 2
30.0
0
60-6
4 3
84.0
0 2
95.0
0 2
71.0
0
Acc
iden
t ri
der
$4.
00
$4.
00
$4.
00
Pre
ferr
ed p
rem
ium
s
MyP
rio
rity
HS
A
* W
hen
you
age
into
the
next
age
bra
cket
, you
r pr
emiu
ms
will
be a
djus
ted
at y
our
annu
al r
enew
al.
* If
you
mov
e to
a c
ount
y th
at is
in a
diff
eren
t pre
miu
m ta
ble,
you
r pr
emiu
ms
will
be a
djus
ted
on th
e ne
xt b
illing
cyc
le a
fter
you
have
not
ified
us
of y
our
addr
ess
chan
ge.
Co
unti
es: A
lcon
a, A
lger
, Alp
ena,
Ant
rim, B
arag
a, B
enzi
e, C
harle
voix
, Che
boy
gan,
C
hip
pew
a, C
raw
ford
, Del
ta, D
icki
nson
, Em
met
, Gog
ebic
, Gra
nd T
rave
rse,
Hou
ghto
n,
Iosc
o, Ir
on, K
alka
ska,
Kew
eena
w, L
eela
nau,
Luc
e, M
acki
nac,
Man
iste
e, M
arq
uett
e,
Men
omin
ee, M
issa
ukee
, Mon
tmor
ency
, Oge
maw
, Ont
onag
on, O
scod
a, O
tseg
o,
Pre
sque
Isle
, Ros
com
mon
, Sch
oolc
raft
, Wex
ford
Ded
uctib
le
In-n
etw
ork
$2,0
00 S
ingl
e $4
,000
Fam
ily$4
,000
Sin
gle
$8,0
00 F
amily
$5,0
00 S
ingl
e $1
0,00
0 Fa
mily
Mal
e
0-25
dep
end
ents
$72
.00
$55
.00
$50
.00
0-18
73.
00
56.
00
52.
00
19-2
4 7
8.00
5
9.00
5
5.00
25-2
9 8
7.00
6
7.00
6
2.00
30-3
4 1
00.0
0 7
7.00
7
0.00
35-3
9 1
18.0
0 9
1.00
8
3.00
40-4
4 1
37.0
0 1
05.0
0 9
6.00
45-4
9 1
68.0
0 1
29.0
0 1
19.0
0
50-5
4 2
13.0
0 1
64.0
0 1
50.0
0
55-5
9 2
64.0
0 2
02.0
0 1
86.0
0
60-6
4 3
22.0
0 2
47.0
0 2
27.0
0
Acc
iden
t ri
der
$4.
00
$2.
00
$2.
00
Fem
ale
0-25
dep
end
ents
$72
.00
$55
.00
$50
.00
0-18
73.
00
56.
00
52.
00
19-2
4 7
8.00
5
9.00
5
5.00
25-2
9 9
5.00
7
3.00
6
7.00
30-3
4 1
15.0
0 8
8.00
8
1.00
35-3
9 1
52.0
0 1
16.0
0 1
07.0
0
40-4
4 1
80.0
0 1
38.0
0 1
27.0
0
45-4
9 2
10.0
0 1
61.0
0 1
48.0
0
50-5
4 2
41.0
0 1
85.0
0 1
70.0
0
55-5
9 2
82.0
0 2
16.0
0 1
99.0
0
60-6
4 3
32.0
0 2
55.0
0 2
34.0
0
Acc
iden
t ri
der
$4.
00
$4.
00
$4.
00
Co
unti
es: A
llega
n, A
rena
c, B
arry
, Bay
, Ber
rien,
Bra
nch,
Cal
houn
, Cas
s, C
lare
, Clin
ton,
E
aton
, Gen
esee
, Gla
dw
in, G
ratio
t, H
uron
, Ing
ham
, Ion
ia, I
sab
ella
, Ken
t, L
ake,
Lap
eer,
Mas
on, M
ecos
ta, M
idla
nd, M
ontc
alm
, Mus
kego
n, N
eway
go, O
cean
a, O
ttaw
a, S
agin
aw,
St.
Jos
eph,
San
ilac,
Shi
awas
ee, T
usco
la, V
an B
uren
Ded
uctib
le
In-n
etw
ork
$2,0
00 S
ingl
e $4
,000
Fam
ily$4
,000
Sin
gle
$8,0
00 F
amily
$5,0
00 S
ingl
e $1
0,00
0 Fa
mily
Mal
e
0-25
dep
end
ents
$76
.00
$58
.00
$53
.00
0-18
78.
00
60.
00
55.
00
19-2
4 8
2.00
6
3.00
5
8.00
25-2
9 9
3.00
7
1.00
6
5.00
30-3
4 1
06.0
0 8
1.00
7
4.00
35-3
9 1
25.0
0 9
6.00
8
8.00
40-4
4 1
45.0
0 1
11.0
0 1
02.0
0
45-4
9 1
78.0
0 1
37.0
0 1
26.0
0
50-5
4 2
26.0
0 1
73.0
0 1
59.0
0
55-5
9 2
79.0
0 2
14.0
0 1
96.0
0
60-6
4 3
41.0
0 2
61.0
0 2
40.0
0
Acc
iden
t ri
der
$4.
00
$4.
00
$2.
00
Fem
ale
0-25
dep
end
ents
$76
.00
$58
.00
$53
.00
0-18
78.
00
60.
00
55.
00
19-2
4 8
2.00
6
3.00
5
8.00
25-2
9 1
01.0
0 7
7.00
7
1.00
30-3
4 1
22.0
0 9
3.00
8
6.00
35-3
9 1
60.0
0 1
23.0
0 1
13.0
0
40-4
4 1
90.0
0 1
46.0
0 1
34.0
0
45-4
9 2
22.0
0 1
70.0
0 1
57.0
0
50-5
4 2
55.0
0 1
96.0
0 1
80.0
0
55-5
9 2
98.0
0 2
29.0
0 2
10.0
0
60-6
4 3
51.0
0 2
69.0
0 2
47.0
0
Acc
iden
t ri
der
$4.
00
$4.
00
$4.
00
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ium
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