First Priority Health My Priority Blue Flex Hmo 6900s

In-Network Deductible
(Note: Unless excepted in the plan's benefit description, you must pay all the costs up to the deductible amount before the plan begins to pay for covered services you use. There may be additional details about the deductible that are not shown below. Please refer to the SBC for additional details.) $100 Extra Deductible for Drugs Doctor Visits Doctor Visit - Preventive Care Coinsurance: No Charge Doctor Visit - Primary Care Coinsurance: 10.00% Coinsurance after deductible Doctor Visit - Specialist Coinsurance: 10.00% Coinsurance after deductible Doctor Visit - Well Baby Visits and Care Coinsurance: 10.00% Coinsurance after deductible Other Practitioner Office Visit (Nurse, Physician Assistant) Coinsurance: 10.00% Coinsurance after deductible Hospital Inpatient Hospital Facility Coinsurance: 10.00% Coinsurance after deductible Inpatient Hospital Physician/Surgeon Coinsurance: 10.00% Coinsurance after deductible Outpatient Hospital Facility Coinsurance: 10.00% Coinsurance after deductible Outpatient Hospital Physician/Surgeon Coinsurance: 10.00% Coinsurance after deductible Inpatient Maternity Services Coinsurance: 10.00% Coinsurance after deductible Emergency Emergency Room Services Coinsurance: 10.00% Coinsurance after deductible Emergency Medical Transportation Coinsurance: 10.00% Coinsurance after deductible Urgent Care Centers or Facilities Coinsurance: 10.00% Coinsurance after deductible Drugs Plan's Drug Formulary View Plan's Drug Formulary Generic Drug on Formulary in a Local Pharmacy Coinsurance: 10.00% Coinsurance after deductible Preferred Brand Drug on Formulary in a Local Pharmacy Coinsurance: 10.00% Coinsurance after deductible Non-Preferred Brand Drug on Formulary in a Local Pharmacy Coinsurance: 10.00% Coinsurance after deductible Specialty Drug on Formulary in a Local Pharmacy Coinsurance: 10.00% Coinsurance after deductible Tests & Imaging Diagnostic Tests (Blood work) Coinsurance: 10.00% Coinsurance after deductible X-Rays Coinsurance: 10.00% Coinsurance after deductible Imaging (CT/PET Scans, MRI, etc) Coinsurance: 10.00% Coinsurance after deductible Mental/Behavioral Health Mental/Behavioral Health Inpatient Services Coinsurance: 10.00% Coinsurance after deductible Mental/Behavioral Health Outpatient Services Coinsurance: 10.00% Coinsurance after deductible Substance Use Disorder Inpatient Coinsurance: 10.00% Coinsurance after deductible Substance Use Disorder Outpatient Coinsurance: 10.00% Coinsurance after deductible Vision/Hearing Aids Routine Eye Exam for Child Coinsurance: No Charge Eye Glasses for Child Coinsurance: No Charge after deductible Routine Eye Exam - Adult Not Covered Hearing Aids Not Covered Child Dental Coverage Dental Check-Up for Children Coinsurance: No Charge Basic Dental Care – Child Coinsurance: 10.00% Coinsurance after deductible Major Dental Care – Child Coinsurance: 10.00% Coinsurance after deductible Orthodontia – Child Coinsurance: 10.00% Coinsurance after deductible Adult Dental Coverage Basic Dental Care – Adult Not Covered Major Dental Care – Adult Not Covered Orthodontia – Adult Not Covered Accidental Dental Coinsurance: 10.00% Coinsurance after deductible Home and Nursing Care Home Health Care Services Coinsurance: 10.00% Coinsurance after deductible Skilled Nursing Care - Facility Coinsurance: 10.00% Coinsurance after deductible Rehabilitative and habilitative services Habilitation Services Coinsurance: 10.00% Coinsurance after deductible Outpatient Rehabilitation Services Coinsurance: 10.00% Coinsurance after deductible Rehabilitative Occupational and Rehabilitative Physical Therapy Coinsurance: 10.00% Coinsurance after deductible Rehabilitative Speech Therapy Coinsurance: 10.00% Coinsurance after deductible Other Services Is HSA Eligible? No Allergy Testing Coinsurance: 10.00% Coinsurance after deductible Chemotherapy Coinsurance: 10.00% Coinsurance after deductible Chiropractic Coinsurance: 10.00% Coinsurance after deductible Diabetes Education Coinsurance: No Charge Dialysis Coinsurance: 10.00% Coinsurance after deductible Durable Medical Equipment Coinsurance: 10.00% Coinsurance after deductible Hospice Service Coinsurance: 10.00% Coinsurance after deductible Infusion Therapy Coinsurance: 10.00% Coinsurance after deductible Nutritional Counseling Coinsurance: No Charge Prosthetic Devices Coinsurance: 10.00% Coinsurance after deductible Radiation Coinsurance: 10.00% Coinsurance after deductible Reconstructive Surgery Coinsurance: 10.00% Coinsurance after deductible Routine Foot Care Not Covered Treatment for Temporomandibular Joint Disorders Coinsurance: 10.00% Coinsurance after deductible Transplant Coinsurance: 10.00% Coinsurance after deductible Weight Loss Programs Not Covered Wellness Programs Asthma Program Available Heart Disease Program Available Depression Program Available Diabetes Program Available High Blood Pressure & Cholesterol Program Available Low Back Pain Program Available Pain Management Program Available Pregnancy Program Available Weight Loss Programs Available Out-of-Network - See Summary of Benefits and Coverage View Summary of Benefits and Coverage

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Source: https://pa.checkbookhealth.org/hie/PA/2019/health-plans/83731PA0090001-06-my-Priority-Blue-Flex-HMO-Extra-Savings-Silver-100-94-percent-AV-Level-Silver-Plan