IHC Gold HMO Regional Preferred $20/$50 – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: $20 copay
Specialist visit: $50 copay
Urgent care visit: $75 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | See brochure See brochure |
| Out-of-pocket max | N/A per person N/A per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $20 copay |
| Specialist visit | $50 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $75 copay |
| Emergency room | $100 copay |
| Ambulance | 50% after deductible |
| Hospital stay (facility) | 40% after deductible |
| Hospital stay (physician) | 40% after deductible |
| Outpatient procedure (facility) | 40% after deductible |
| Outpatient procedure (physician) | 40% after deductible |
| Physical rehabilitation | $50 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 40% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $10 copay |
| Brand | 50% coinsurance |
| Non-preferred Brand | 50% coinsurance |
| Specialty | 50% coinsurance |
Lab Tests and Diagnostic Procedures
| X-rays | $50 copay |
| Imaging (CT/PET/MRI) | $100 copay |
| Blood work | No charge |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $50 copay |
| Psychiatric hospital stay | 40% after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/mexfodq1J6mbzs3RHaFkbgSW.pdf |
