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Benefit sheet reflects "In-Network" benefits payable to participating doctors / hospitals.

 
 IHC-Med =800 Physicians
Select-Med =1,900 Physicians
IHC-Care =2,800 Physicians

 

 

Benefits Base-Level   Mid-Level   High-level
           
Office Visit Copay You Pay a $15 Copay AFTER DEDUCTIBLE HAS BEEN MET   $15 Copay with no need to meet deductible first   $15 Copay with no need to meet deductible first
           
Calendar Yr. Ded. Deductible you choose with your quote   Deductible you choose with your quote   Deductible you choose with your quote
           
Out of Pocket Max.          
Single 3000 3000 3000
Family  6000 6000 6000
           
Lifetime Max.  Unlimited   Unlimited   Unlimited
           
Pre-Existing Waiting Period
There is a 12 month waiting period for prior medical conditions at the point of effective date here IF you do not have current coverage being replaced by us		 12 Month for prior medical conditions. Waived if you are replacing & or given credit if covered under 12 months   12 Month for prior medical conditions. Waived if you are replacing & or given credit if covered under 12 months   12 Month for prior medical conditions. Waived if you are replacing & or given credit if covered under 12 months
 
           
Prescription Coverage's   Base-Level     Mid-Level     High-level
Generic Must meet a $100 deductible first then you pay:   Must meet a $200 deductible first then you pay:   $5 generic
Name Brand $5 generic $5 generic  
Non-Preferred 25% of NB 25% of NB 25% of (NB) Name Brand
  50% of NF 50% of NF  
      50% pf (NF)
      Nonpreferred Brand Name
           
Hospitalization   Base-Level     Mid-Level     High-level
Room & Board You pay 20% after Ded. The insurance carrier pays the difference.   You pay 20% after Ded. The insurance carrier pays the difference.   You pay 20% after Ded. The insurance carrier pays the difference.
Inpatient Physician
Surgeon & Anesthesiologist
           
Maternity   Base-Level     Mid-Level     High-level
Outpatient Care $5,000 Deductible. 100% coverage thereafter   $5,000 Deductible. 100% coverage thereafter   $5,000 Deductible. 100% coverage thereafter
Physician Delivery Fee
Hospital Room & Board 
           
Out-Patient Care    Base-Level     Mid-Level     High-level
 Immunizations Covered 100%   Covered  100%   Covered 100%
Doctor Office Coverage's:           
Preventative Care-By Primary Doctor You Pay a $15 Copay AFTER DEDUCTIBLE HAS BEEN MET   $15 copay - No Ded.   $15 copay - No Ded.
Annual Physical 100% coverage 100% coverage
Immunizations  No Limit Maximum No Limit Maximum
           
Office Visits - Primary Care Covered 100%   AFTER DEDUCTIBLE HAS BEEN MET   $15 copay - No Ded.   $15 copay - No Ded.
Office Visits - After Hours $15 copay - No Ded. $15 copay - No Ded.
Office Visits Specialist $15 copay - No Ded. $15 copay - No Ded.
Minor Lab/X-ray w/ mammography 100% No Deductible 100% No Deductible
           
Major Lab/X-ray w/ CT scan, MRI/MRA  You pay 20% after Ded.   You pay 20% after Ded.   You pay 20% after Ded.
           
Physiotherapy -  No max   No max   No max
Physiotherapy -  No max No max No max
Providers Office - Deductible met than $15 copay - No Ded. $15 copay - No Ded.
Outpatient Facility You pay 20% after Ded. You pay 20% after Ded. You pay 20% after Ded.
           
Out Patient Surgery  You pay 20% after Ded.   You pay 20% after Ded.   You pay 20% after Ded.
           
Outpatient Hospital Services You pay 20% after Ded.   You pay 20% after Ded.   You pay 20% after Ded.
Chemotherapy, Radiation therapy
Kidney Dialysis
           
Eye Exams - Optometrist  100% Covered   100% Covered   100% Covered
           
Emergency Care   Base-Level     Mid-Level     High-level