HMO Preferred Plan
Benefits Summary

Care In-network cost when you select a preferred primary care doctor in our Prime Network In-network cost when you select a non-preferred primary care doctor in our Prime Network
Primary care doctor office visit $0 $10
Specialist office visit $0 $10
Lab/X-ray $0 $10
Routine physical exam $0 $0
Well-child care $0 $0
Physical therapy $0 $10
Outpatient mental health $0 $10
Urgent care $50 $50
Ambulatory surgery $50 $50
Ambulance $0 $0
Inpatient hospital care $100 $100
Anesthesia Included in hospital copay Included in hospital copay
Emergency room $150
(waived if admitted)
$150
(waived if admitted)

Refer to HIP policy form 155-23-LGTIERCERT (04/16).



Other basics about how to use your plan