Imperial Insurance Company Traditional (HMO)

H2793 - 003 - 0
2.5 out of 5 stars (2.5 / 5)

Imperial Insurance Company Traditional (HMO) is a Medicare Advantage (Part C) Plan by Imperial Insurance Companies Inc.

This page features plan details for 2023 Imperial Insurance Company Traditional (HMO) H2793 – 003 – 0 available in AZ,TX,NV.

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 Insurance Company Traditional (HMO) is offered in the following locations.

Plan Overview

Imperial Insurance Company Traditional (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:Yes

Ready to sign up for Imperial Insurance Company Traditional (HMO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 TTY 711.

8am – 11pm EST. 7 days a week

Premium Breakdown

Imperial Insurance Company Traditional (HMO) has a monthly premium of $0.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.
Part B Part C Part D Part B Give Back Total
$164.90 $0.00 $0.00 $0.00 $164.90
Please Note:
  • Your Part B premium may differ based on factors including late enrollment, income, and disability status.
  • You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.

Drug Info

Imperial Insurance Company Traditional (HMO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible: $0.00
Initial Coverage Limit: $4,660.00
Catastrophic Coverage Limit: $7,400.00
Drug Benefit Type: Enhanced
Gap Coverage: Yes
Formulary Link: Formulary Link

Part D Premium Reduction

The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs. The table below shows how the LIS impacts the Part D premium of this plan.
Part D LIS 25% LIS 50% LIS 75% LIS Full
$0.00 $43.40 $34.80 $26.30 $17.70

Initial Coverage Phase

After you pay your $0.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $4,660.00. Once you reach that amount, you will enter the next coverage phase.

Gap Coverage Phase

After your total drug costs (including what this plan has paid and what you have paid) reach $4,660.00, you will pay no more than the amounts below for any drug tier until you reach $7,400.00.

Tier Cost
All other tiers (Generic)25%
All other tiers (Brand-name)25%

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,400.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.

Drug TypeCost Share
Generic drugs$4.15 copay or 5% (whichever costs more)
Brand-name drugs$10.35 copay or 5% (whichever costs more)

Additional Benefits

Imperial Insurance Company Traditional (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 Insurance Company Traditional (HMO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 TTY 711.

8am – 11pm EST. 7 days a week

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