Imperial Preferred Silver – HMO
Network type: HMO
Coverage tier: Silver
Primary care visit: $20 copay
Specialist visit: 40% coinsurance after deductible
Urgent care visit: 40% coinsurance after deductible
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $4,500 per person $4,500 per person |
| Out-of-pocket max | $8,850 per person $17,700 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $20 copay |
| Specialist visit | 40% coinsurance after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | 40% coinsurance after deductible |
| Emergency room | 40% coinsurance after deductible |
| Ambulance | 40% coinsurance after deductible |
| Hospital stay (facility) | 40% coinsurance after deductible |
| Hospital stay (physician) | 40% coinsurance after deductible |
| Outpatient procedure (facility) | 40% coinsurance after deductible |
| Outpatient procedure (physician) | 40% coinsurance after deductible |
| Physical rehabilitation | $40 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 40% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $5 copay |
| Brand | 40% coinsurance after deductible |
| Non-preferred Brand | 40% coinsurance after deductible |
| Specialty | 40% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 40% coinsurance after deductible |
| Imaging (CT/PET/MRI) | 40% coinsurance after deductible |
| Blood work | 40% coinsurance after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $20 copay |
| Psychiatric hospital stay | 40% coinsurance after deductible |
