| Benefits |
IHC Preferred |
IHC Basic |
IHC 50 |
IHC 30/50 |
IHC 30 |
IHC 15 |
| Benefits Summary PDF |
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| Primary Care Physician |
$30 copay |
$30 copay |
$50 copay |
$30 copay |
$30 copay |
$15 copay |
| Specialist Office Visits |
$30 copay |
$30 copay; plan pays a maximum of $700 per calendar year |
$50 copay |
$50 copay |
$30 copay |
$15 copay |
| Outpatient X-Ray and Lab Services |
100% covered |
100% covered |
$50 copay |
$50 copay |
$30 copay |
$15 copay |
| Well Baby/Child Care |
$30 copay |
$30 copay |
$50 copay |
$30 copay |
$30 copay |
$15 copay |
| Inpatient Hospital Services |
$500 copay/ confinement, then covered at 100% |
$500 copay/ confinement, then covered at 100%; maximum 90 days/ calendar year |
$500 copay/day;
maximum 5 days/ admission; $5,000 maximum copay/ calendar year |
$300copay/ day;
maximum 5 days/ admission; $3,000 maximum copay/ calendar year |
$300 copay/ day;
maximum 5 days/admission; $3,000 maximum copay/ calendar year |
$150 copay/ day.
maximum 5 days/admission; $1,500 maximum copay/ calendar year |
| Prenatal Care |
$50 copay for initial visit; subsequent visits are covered in full.
Inpatient: see Inpatient Hospital Care. |
See Inpatient Hospital Care; First three prenatal visits are covered as specialists office visits. Delivery and newborn are covered; Prenatal (with the exception of first three office visits and Postnatal not covered) |
$50 copay for the initial visit |
$30 copay for the initial visit |
$25 copay for the initial visit; subsequent visits are covered in full |
$25 copay for the initial visit; subsequent visits are covered in full |
| Emergency Room |
$100 copay per visit |
$100 copay per visit |
$100 copay per visit* |
$100 copay per visit* |
$100 copay per visit* |
$100 copay per visit* |
| Outpatient and Ambulatory Surgery |
$250 copay per surgery, then 100% |
$250 copay per surgery, then 100% |
Facility – $100 copay;
Practitioner – $50 copay |
Facility – $100 copay;
Practitioner – $50 copay |
Facility – $30 copay;
Practitioner – $30 copay |
Facility – $15 copay;
Practitioner – $15 copay |
| Biologically Based Mental Illness |
Outpatient: plan pays 70%; 30 visits/ calendar year
Inpatient: $500 copay/ confinement |
Outpatient: plan pays 70%; 30 visits/calendar year
Inpatient: $500 copay/ confinement; 90 days maximum/ calendar year |
Outpatient: $50 copay
Inpatient: $500 copay/ day; maximum 5 days/admission; $5,000 maximum copay/ year |
Outpatient: $50 copay
Inpatient: $300 copay/ day; maximum 5 days/ admission; $3,000 maximum copay/year |
Outpatient: $30 copay
Inpatient: $250 copay/ day; maximum 5 days/ admission; $3,000 maximum copay/ year |
Outpatient: $15 copay
Inpatient: $150 copay/ day; maximum 5 days/ admission; $1,500 maximum copay/ year |
| Non-Biologically Based Mental Illness |
Not covered |
Not covered |
Outpatient: $50 copay; maximum 20 visits/ calendar year combined with substance abuse
Inpatient: $500 copay/ day; maximum 5 days/admission; $5,000 maximum copay/ year combined with substance abuse |
Outpatient: $50 copay; maximum 20 visits/ calendar year combined with substance abuse
Inpatient: $300 copay/ day; maximum 5 days/ admission; $3,000 maximum copay/year combined with substance abuse |
Outpatient: $30 copay; maximum 20 visits/ calendar year combined with substance abuse
Inpatient: $300 copay/ day; maximum 5 days/ admission; $3,000 maximum copay/ year combined with substance abuse |
Outpatient: $15 copay; maximum 20 visits/ calendar year combined with substance abuse
Inpatient: $150 copay/ day; maximum 5 days/ admission; $1,500 maximum copay/ year combined with substance abuse |
| Substance Abuse |
Outpatient: plan pays 70%; 30 visits/ calendar year combined with alcohol abuse
Inpatient: $500 copay/ confinement then pays 70%; 30 days maximum/ calendar year combined with alcohol abuse |
Outpatient: plan pays 70%; 30 visits/ calendar year combined with alcohol abuse
Inpatient: $500 copay/ confinement then pays 70%; 30 days maximum/ calendar year combined with alcohol abuse |
Outpatient: $50 copay; 20 visits/ calendar year combined with non-biologically based mental illness
Inpatient: $500 copay/ day; maximum 5 days/ admission; $5,000 maximum copay/ year combined with non-biologically based mental illness |
Outpatient: $50 copay; 20 visits/ calendar year combined with non-biologically based mental illness
Inpatient: $300 copay/ day; maximum 5 days/ admission; $3,000 maximum copay/ year combined with non-biologically based mental illness |
Outpatient: $30 copay; 20 visits/ calendar year combined with non-biologically based mental illness
Inpatient: $300 copay/ day; maximum 5 days/ admission; $3,000 maximum copay/ year combined with non-biologically based mental illness |
Outpatient: $15 copay; 20 visits/ calendar year combined with non-biologically based mental illness
Inpatient: $150 copay/ day; maximum 5 days/ admission; $1,500 maximum copay/ year combined with non-biologically based mental illness |
| Alcohol Abuse |
Outpatient: plan pays 70%; 30 visits/ calendar year combined with substance abuse
Inpatient: $500 copay/ confinement then pays 70%; 30 days maximum/ calendar year combined with substance abuse |
Outpatient: plan pays 70%; 30 visits/ calendar year combined with substance abuse
Inpatient: $500 copay/ confinement then pays 70%; 30 days maximum/ calendar year combined with substance abuse |
See biologically based mental illness |
See biologically based mental illness |
See biologically based mental illness |
See biologically based mental illness |
| Pre-Admission Testing |
100% covered |
100% covered |
$50 copay |
$50 copay |
$30 copay |
$15 copay |
| Prescription Drug |
Plan pays 50% up to $1,500 per person per year |
Not covered |
50% coinsurance |
50% coinsurance |
50% coinsurance |
50% coinsurance |
| Lifetime Maximum |
Unlimited |
Unlimited |
Unlimited |
Unlimited |
Unlimited |
Unlimited |
