Imperial Insurance Companies Inc

Imperial Standard Gold

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $1,500.00 Family: $3000 Per Person: $1500
Combined Medical and Drug Out of Pocket Maximum	Individual: $7,800.00 Family: $15600 Per Person: $7800

Office Visit

Primary Doctor	CoPay: $30.00 CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: $60.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $30.00 CoInsurance: Not Applicable Covered: Covered
Non Preferred Brand Drugs	CoPay: $60.00 CoInsurance: Not Applicable Covered: Covered
Generic Drugs	CoPay: $15.00 CoInsurance: Not Applicable Covered: Covered
Specialty Drugs	CoPay: $250.00 CoInsurance: Not Applicable Covered: Covered

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 25.00% Coinsurance after deductible Covered: Covered Benefit Explanation: All usual Hospital services and supplies, including semiprivate room, intensive care, and coronary care units; Preauthorization is required.
Inpatient Services	CoPay: Not Applicable CoInsurance: 25.00% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: Not Applicable CoInsurance: 25.00% Coinsurance after deductible Covered: Covered
Urgent Care Facility	CoPay: $45.00 CoInsurance: Not Applicable Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 25.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Will cover 48-hour hospital stay for uncomplicated vaginal delivery and 96-hour hospital stay for uncomplicated caesarean section.
Pre and Postnatal Office Visit	CoPay: $30.00 CoInsurance: Not Applicable Covered: Covered

Vision

Routine Eye Exams for Children

CoPay: Not Applicable
CoInsurance: 0.00%
Covered: Covered
Limit Quantity: 1
Limit Unit : Visit(s) per Year

Major Dental Care

Routine Dental Checkups for Children

CoPay: Not Applicable
CoInsurance: 0.00%
Covered: Covered
Limit Quantity: 1
Limit Unit : Visit(s) per 6 Months