Imperial Preferred Silver – HMO

Description

Health Care Plan Details

Network type	HMO
Deductible	$3,750 per person $3,750 per person
Out-of-pocket max	$8,850 per person $17,700 per family
Metal tier	Silver

Visit Copay

Primary care visit	$25 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	$50 copay

Maternitowny and Pregnancy

Well baby care	40% coinsurance after deductible
Labor, delivery, hospital stay	40% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$10 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	$25 copay
Psychiatric hospital stay	40% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://documents.imperialhealthplan.com/2024/Marketplace/Provider%20Directory/Arizona/Imperial%20Preferred%20Silver_85533AZ0020001-01_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/