Imperial Courage Plan (HMO)
H2793 - 008 - 0
(2.5 / 5)
Imperial Courage Plan (HMO) is a Medicare Advantage (Part C) Plan by Imperial Insurance Companies Inc.
This page features plan details for 2023 Imperial Courage Plan (HMO) H2793 – 008 – 0 available in AZ, NV, TX.
IMPORTANT: This page features the 2023 version of this plan. See the 2024 version using the link below:
No 2024 version found. You can use the location links below to find 2024 plans in your area.
Locations
Imperial Courage Plan (HMO) is offered in the following locations.
Plan Overview
Imperial Courage Plan (HMO) offers the following coverage and cost-sharing.
| Insurer: | Imperial Insurance Companies Inc |
| Health Plan Deductible: | $0.00 |
| MOOP: | $2,999 In-network |
| Drugs Covered: | No |
Ready to sign up for Imperial Courage Plan (HMO) ?
Medicare Part B Give Back Benefit
The Part B Premium Reduction (Medicare Part B Give Back Benefit) lowers the cost of some Medicare Advantage plans.
Imperial Courage Plan (HMO) qualifies for a monthly Medicare Give Back Benefit of $75.00.
| Premium Reduction: | $75.00 |
Premium Breakdown
Imperial Courage Plan (HMO) has a monthly premium of $0.00. This amount includes your Part C premium but does not include your Part B premium.| Part B | Part C | Part B Give Back | Total |
|---|---|---|---|
| $164.90 | $0.00 | $75.00 | $89.90 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
Additional Benefits
Imperial Courage Plan (HMO) also provides the following benefits.
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
| In-Network: No |
Dental (comprehensive)
| Diagnostic services: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Endodontics: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Extractions: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Non-routine services: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Periodontics: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Prosthodontics, other oral/maxillofacial surgery, other services: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Restorative services: | $0 copay (limits may apply) (authorization not required) (referral not required) |
Dental (preventive)
| Cleaning: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Dental x-ray(s): | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Fluoride treatment: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Oral exam: | $0 copay (limits may apply) (authorization not required) (referral not required) |
Diagnostic procedures/lab services/imaging
| Diagnostic radiology services (e.g., MRI): | $0 copay (authorization required) (referral required) |
| Diagnostic tests and procedures: | $0 copay (authorization required) (referral required) |
| Lab services: | $0 copay (authorization required) (referral required) |
| Outpatient x-rays: | $0 copay (authorization required) (referral required) |
Doctor visits
| Primary: | $0 copay |
| Specialist: | $0 copay (authorization required) (referral required) |
Emergency care/Urgent care
| Emergency: | $100 copay per visit (always covered) |
| Urgent care: | $0 copay |
Foot care (podiatry services)
| Foot exams and treatment: | $0 copay (authorization required) (referral required) |
| Routine foot care: | $0 copay (limits may apply) (authorization required) (referral required) |
Ground ambulance
| $125 copay |
Health plan deductible
| $0.00 |
Health plan deductibles (other)
| In-Network: No |
Hearing
| Fitting/evaluation: | 20% coinsurance (limits may apply) (authorization required) (referral required) |
| Hearing aids: | 20% coinsurance (limits may apply) (authorization required) (referral required) |
| Hearing exam: | 20% coinsurance (authorization required) (referral required) |
Hospital coverage (inpatient)
| $125 per day for days 1 through 5 $0 per day for days 6 through 90 (authorization required) (referral required) |
Hospital coverage (outpatient)
| $0 copay (authorization required) (referral required) |
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
| $2,999 In-network |
Medical equipment/supplies
| Diabetes supplies: | $0 copay (authorization required) |
| Durable medical equipment (e.g., wheelchairs, oxygen): | 20% coinsurance per item (authorization required) |
| Prosthetics (e.g., braces, artificial limbs): | 20% coinsurance per item (authorization required) |
Medicare Part B drugs
| Chemotherapy: | 20% coinsurance (authorization required) |
| Other Part B drugs: | 20% coinsurance (authorization required) |
Mental health services
| Inpatient hospital – psychiatric: | $200 per day for days 1 through 7 $0 per day for days 8 through 90 (authorization required) (referral required) |
| Outpatient group therapy visit: | 20% coinsurance (authorization required) (referral required) |
| Outpatient group therapy visit with a psychiatrist: | $0 copay (authorization required) (referral required) |
| Outpatient individual therapy visit: | 20% coinsurance (authorization required) (referral required) |
| Outpatient individual therapy visit with a psychiatrist: | $0 copay (authorization required) (referral required) |
Optional supplemental benefits
| No |
Preventive care
| $0 copay (authorization not required) (referral not required) |
Rehabilitation services
| Occupational therapy visit: | $15 copay (authorization required) (referral required) |
| Physical therapy and speech and language therapy visit: | $15 copay (authorization required) (referral required) |
Skilled Nursing Facility
| $0 per day for days 1 through 20 $164.50 per day for days 21 through 100 (authorization required) (referral required) |
Transportation
| $0 copay (no limits) (authorization required) (referral required) |
Vision
| Contact lenses: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Eyeglass frames: | Not covered (no limits) |
| Eyeglass lenses: | Not covered (no limits) |
| Eyeglasses (frames and lenses): | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Other: | Not covered (no limits) |
| Routine eye exam: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Upgrades: | Not covered |
Wellness programs (e.g., fitness, nursing hotline)
| Covered (authorization not required) (referral not required) |
Ready to sign up for Imperial Courage Plan (HMO) ?