Ind HMO Gold 2

57173NM0300012
Gold
HMO

Ind HMO Gold 2 is a Gold HMO plan by Presbyterian Health Plan, Inc..

Locations

Ind HMO Gold 2 is offered in the following counties.

No data was found

Plan Overview

This is a plan overview for 2022 version of Ind HMO Gold 2 57173NM0300012.
Insurer: Presbyterian Health Plan, Inc.
Network Type: HMO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 57173NM0300012

Cost-Sharing Overview

Ind HMO Gold 2 offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Ind HMO Gold 2?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

Ind HMO Gold 2 offers the following features and referral requirements.

Wellness Program: Yes
Disease Program: Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol
Notice Pregnancy: No
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what Ind HMO Gold 2 covers when you are out of the service area or out of the country.

Out of Country Coverage: Yes
Out of Country Coverage Description: Emergency and non-Emergency when Prior Authorization is obtained
Out of Service Area Coverage: Yes
Out of Service Area Coverage Description: Emergency and non-Emergency when Prior Authorization is obtained
National Network: Yes

Additional Benefits and Cost-Sharing

Ind HMO Gold 2 includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Accidental Dental
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Chiropractic Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No20 Visit(s) per Year Coverage is limited to 20 visits/calendar year for acupuncture and chiropractor.Substantially Equal
Reconstructive Surgery
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Reconstructive Surgery from which an improvement in physiological function can reasonably be expected will be Covered if performed for the correction of functional disorders.
Infertility Treatment
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Coverage limited to diagnosis and medically indicated treatments for physical conditions causing infertilityNot EHB
Outpatient Rehabilitation Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Hearing Aids
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No1 Item(s) per 3 Years Hearing Aids and the evaluation for the fitting of Hearing Aids are not Covered except for school-aged children under 18 years old (or under 21 years of age if still attending high school).
Acupuncture
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No20 Visit(s) per Year Coverage is limited to 20 visits/calendar year for acupuncture and chiropractor.Substantially Equal
Rehabilitative Speech Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Emergency Transportation/Ambulance
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Routine Foot Care
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Abortion for Which Public Funding is Prohibited
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Dialysis
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Well Baby Visits and Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Routine Dental Services (Adult)
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Eye Glasses for Children
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No1 Item(s) per Year Not EHB
Urgent Care Centers or Facilities
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Dental Check-Up for Children
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Other Law/Regulation
Weight Loss Programs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Not EHB
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Prior authorization may be required.
Major Dental Care – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Non-Preferred Brand Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Outpatient Surgery Physician/Surgical Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Prior authorization may be required.
X-rays and Diagnostic Imaging
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Durable Medical Equipment
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Only Durable Medical Equipment considered standard and/or basic as defined by nationally recognized guidelines are Covered.
Inpatient Physician and Surgical Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Generic Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No There are two levels of Generics. Generic Preferred and Generic Non-preferred.
Radiation
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Chemotherapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Specialty Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Emergency Room Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Basic Dental Care – Child
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Other Law/Regulation
Substance Abuse Disorder Inpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Prior authorization may be required.
Primary Care Visit to Treat an Injury or Illness
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Preventive Care/Screening/Immunization
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Specialist Visit
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Orthodontia – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Habilitation Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Diabetes Education
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Benefits are available when received from a Practitioner/Provider who is approved to provide diabetes education.
Treatment for Temporomandibular Joint Disorders
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Cosmetic Surgery
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Private-Duty Nursing
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Basic Dental Care – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Routine Eye Exam for Children
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No1 Exam(s) per Year Not EHB
Allergy Testing
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Preferred Brand Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Prenatal and Postnatal Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Long-Term/Custodial Nursing Home Care
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Transplant
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Prior authorization may be required.
Major Dental Care – Child
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Other Law/Regulation
Mental/Behavioral Health Outpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Skilled Nursing Facility
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Prior authorization may be required.Additional EHB Benefit
Imaging (CT/PET Scans, MRIs)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Home Health Care Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No100 Days per Year Prior authorization is required.Substantially Equal
Laboratory Outpatient and Professional Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Substance Abuse Disorder Outpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Nutritional Counseling
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Nutritional support Covered only when prescribed by an In-Network Practitioner/Provider and administered by enteral tube feedings.
Prosthetic Devices
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No1 Item(s) per Year Not EHB
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Additional EHB Benefit
Hospice Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Benefits for Inpatient and in-home Hospice services are Covered if you are terminally ill.
Bariatric Surgery
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No1 Procedure(s) per Year Bariatric surgery is Covered for patients with a Body Mass Index (BMI) of 35 kg/m2 or greater who are at high risk for increased morbidity due to specific obesity related comorbid medical conditions.Substantially Equal
Orthodontia – Child
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Other Law/Regulation
Mental/Behavioral Health Inpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Prior authorization may be required.
Delivery and All Inpatient Services for Maternity Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Prior authorization may be required.
Infusion Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Not EHB
Routine Eye Exam (Adult)
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No

Free Preventive Services

There is no copayment or coinsurance for any of the following Ind HMO Gold 2 preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Ready to sign up for Ind HMO Gold 2?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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