Imperial Preferred Gold – HMO

Description

Health Care Plan Details

Network type	HMO
Deductible	$1,000 per person $1,000 per person
Out-of-pocket max	$8,000 per person $16,000 per family
Metal tier	Gold

Visit Copay

Primary care visit	$20 copay
Specialist visit	$40 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	35% coinsurance after deductible
Emergency room	35% coinsurance after deductible
Ambulance	35% coinsurance after deductible
Hospital stay (facility)	35% coinsurance after deductible
Hospital stay (physician)	35% coinsurance after deductible
Outpatient procedure (facility)	35% coinsurance after deductible
Outpatient procedure (physician)	35% coinsurance after deductible
Physical rehabilitation	$40 copay

Maternitowny and Pregnancy

Well baby care	35% coinsurance after deductible
Labor, delivery, hospital stay	35% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$5 copay
Brand	$60 copay
Non-preferred Brand	50% coinsurance after deductible
Specialty	50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	35% coinsurance after deductible
Imaging (CT/PET/MRI)	35% coinsurance after deductible
Blood work	35% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	$20 copay
Psychiatric hospital stay	35% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://documents.imperialhealthplan.com/2024/Marketplace/Provider%20Directory/Arizona/Imperial%20Preferred%20Gold_85533AZ0020002-01_CY2024.pdf.pdf
Drug and medication plan formulary	https://exchange.imperialhealthplan.com/arizona/drug-formulary/
Search doctor list	https://exchange.imperialhealthplan.com/arizona/provider-directory/