Imperial Dynamic Plan (HMO)

Health Insurance Company: Imperial Health Plan of California, Inc.

Medicare Advantage Plan Details

Imperial Health Plan of California, Inc.
$0 /mo
monthly premium
Imperial Dynamic Plan (HMO)
Additional Coverage
Overall Star Rating (2024)
  • Rx
  • Dental
  • Vision
  • Hearing
out of 5 stars

General Plan Details

Medical Deductible
Out-of-Pocket Maximum
Rx Drug Coverage
Rx Deductible

Additional Benefits

Dental Coverage
Vision Coverage
Mental Health Coverage
Chiropractic Coverage
Optional Supplemental Benefits
Part B Give Back

Doctor & Hospital Coverage

Primary Doctor Office Visit
$0 copay
Specialist Office Visit
$0 copay
Periodic Exam Coverage
$0 copay

Emergency Room

$125 copay per visit (always covered)

Ambulance Coverage

$150 copay

Lab, X-Ray, Radiology Coverage

Outpatient diag procs/tests/lab services:
Medicare-covered diagnostic procedures/tests: $0 copay
Medicare-covered lab services: $0 copay
Outpatient diag/therapeutic rad services:
Medicare-covered diagnostic radiological services (e.g., CT, MRI, etc): $0 copay
Medicare-covered x-ray services: $0 copay

Outpatient Surgery Coverage

Outpatient hospital:
Medicare-covered outpatient hospital services: $100 copay per visit

Hospitalization Coverage

Inpatient hospital-acute:
$50 per day for days 1 through 5
$0 per day for days 6 through 90
Inpatient hospital psychiatric:
$50 per day for days 1 through 5
$0 per day for days 6 through 90

Rehabilitation Coverage

Occupational therapy services:
$0 copay
Physical therapy and speech and language therapy services:
$0 copay

Urgent Care Coverage

$0 copay

Skilled Nursing Facility (SNF)

$0 per day for days 1 through 20
$200 per day for days 21 through 100

Mental Health Coverage

Medicare-covered individual sessions: 20% coinsurance
Medicare-covered group sessions: 20% coinsurance

Dental, Vision, Hearing Benefits

Dental Services

Oral exams: $0 copay
Prophylaxis (cleaning): $0 copay
Dental x-rays: $0 copay

Vision Benefits

Eye exams:
Routine eye exams: $0 copay
Contact Lenses: $0 copay
Eyeglasses: $0 copay

Hearing Benefits

Hearing exams:
Routine hearing exams: $0 copay
Hearing aids:
Hearing aids (all types): $0 copay

Rx Drug Coverage - Standard Retail Cost

Tier 1: Preferred Generic

$0.00 copay (30-day supply)
$0.00 copay (90-day supply)

Tier 2: Generic

$3.00 copay (30-day supply)
$6.00 copay (90-day supply)

Tier 3: Preferred Brand

$30.00 copay (30-day supply)
$90.00 copay (90-day supply)

Tier 4: Non-Preferred Drug

$75.00 copay (30-day supply)
$200.00 copay (90-day supply)

Tier 5: Specialty Tier

33% coinsurance (30-day supply)

Plan Links

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Where This Plan is Available

Additional Plan Info

Plan ID:
Insurance Company Website:
Imperial Health Plan of California, Inc.

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