Imperial Preferred Gold – HMO

Description

Health Care Plan Details

Network type	HMO
Deductible	$1,350 per person $1,350 per person
Out-of-pocket max	$9,250 per person $18,500 per family
Metal tier	Gold

Visit Copay

Primary care visit	$20 copay
Specialist visit	20% coinsurance after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	20% coinsurance after deductible
Emergency room	20% coinsurance after deductible
Ambulance	20% coinsurance after deductible
Hospital stay (facility)	20% coinsurance after deductible
Hospital stay (physician)	20% coinsurance after deductible
Outpatient procedure (facility)	20% coinsurance after deductible
Outpatient procedure (physician)	20% coinsurance after deductible
Physical rehabilitation	$20 copay

Maternitowny and Pregnancy

Well baby care	20% coinsurance after deductible
Labor, delivery, hospital stay	20% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$3 copay
Brand	20% coinsurance after deductible
Non-preferred Brand	35% coinsurance after deductible
Specialty	50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	20% coinsurance after deductible
Imaging (CT/PET/MRI)	20% coinsurance after deductible
Blood work	20% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	$20 copay
Psychiatric hospital stay	20% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://documents.imperialhealthplan.com/2024/Marketplace/Plans/Texas/Imperial%20Preferred%20Gold_34826TX0030003-01_CY2024.pdf
Drug and medication plan formulary	https://client.formularynavigator.com/Search.aspx?siteCode=5828466201
Search doctor list	https://documents.imperialhealthplan.com/2024/Marketplace/Provider%20Directory/Texas/TEXAS%20Provider%20Directory%202024%20Exchange.pdf