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(2025) Platinum MI01 HMO
Plan Summary
Plan Type HMO
Metal Level Platinum
Office Visit for Primary Doctor
Find Doctors 		$15 Copay
Office Visit for Specialist $30 Copay
Office Visit for Other Practitioner (Nurse, Physician Assistant) $15 Copay
Annual Deductible None
Separate Prescription Drugs Deductible $0 per person | $0 per group
Coinsurance 10%
Retail Prescription Drugs Generic Drugs: $7 Copay;
Preferred Brand Drugs: $16 Copay;
Non-Preferred Brand Drugs: $25 Copay;
Specialty Drugs: 10% Coinsurance;
Annual Out-of-Pocket Limit Individual: $4,500
Lifetime Maximum Unlimited
Health Savings Account (HSA) Eligible No
Out-of-Network Coverage Emergency Care Only 
Out-of-Country Coverage Yes. Emergency and urgent care only 
Office Visit
Primary Care Physician Required Yes
Specialist Referrals Required Yes
Preventive Care Coverage
Periodic Health Exam No Charge
Periodic OB-GYN Exam No Charge
Well Baby Care No Charge
Emergency and Urgent Care
Emergency Room $150 Copay
Emergency Ambulance Services $150 Copay
Urgent Care Facility $15 Copay
Prescription Drug Coverage
Retail Prescription Drugs Generic Drugs: $7 Copay;
Preferred Brand Drugs: $16 Copay;
Non-Preferred Brand Drugs: $25 Copay;
Specialty Drugs: 10% Coinsurance;
Separate Prescription Drugs Deductible $0 per person | $0 per group
Mail Order Prescription Drugs N/A
Mail Order Supply N/A
Outpatient Coverage
Outpatient Surgery Outpatient Surgery Physician/Surgical Services:
10% Coinsurance
Outpatient Facility Fee:
10% Coinsurance
Outpatient Lab/X-Ray Outpatient Lab:
$15 Copay
X-rays:
$30 Copay
Imaging (CT and PET scans, MRIs) 10% Coinsurance
Outpatient Mental Health $15 Copay
Outpatient Substance Abuse $15 Copay
Outpatient Rehabilitation Services (PT, OT, ST) $15 Copay
Inpatient Coverage
Hospitalization Inpatient Hospital Services:
10% Coinsurance
Inpatient Physician and Surgical Services:
10% Coinsurance
Skilled Nursing Facility 10% Coinsurance, limited to 100 Days per Benefit Period
Inpatient Mental Health 10% Coinsurance
Inpatient Substance Abuse 10% Coinsurance
Home Healthcare 10% Coinsurance, limited to 100 Visit(s) per Year
Maternity Coverage
Pre & Postnatal Office Visit No Charge
Labor & Delivery Hospital Stay 10% Coinsurance
Pediatric Services
Dental Checkup for Children No Charge, limited to 1 Visit(s) per 6 Months
Vision Screening for Children No Charge, limited to 1 Visit(s) per Year
Eye Glasses for Children No Charge, limited to 1 Item(s) per Year
Major Dental Coverage (Pediatric) $300 Copay
Additional Coverage
Chiropractic Coverage Not Covered
Durable Medical Equipment 10% Coinsurance
Hospice No Charge, limited to 5 Days per Admission
Major Dental Coverage (Adult) Not Covered
Vision Coverage (Adult) Not Covered
Out-of-Network Coverage
Out-of-Network Authorization Required N/A
Out-of-Network Annual Deductible N/A
Out-of-Network Annual Coinsurance N/A
Out-of-Network Annual Out-of-Pocket Limit N/A
Additional Information
A.M. Best Rating N/A as of 06/12/2025
Electronic Signature for Application Available Yes
Details and documents about this plan
View Plan Brochure Exclusions and Limitations

Important notices and disclaimers

  • The information shown here is a summary of benefits for informational purposes only. Review the official plan documents (such as evidence of coverage, plan brochure, or insurance policy) for a detailed description of coverage benefits, limitations, and exclusions. Only the terms and conditions of coverage benefits listed in the policy are binding.
  • The benefits listed may be contingent on your use of physicians, hospitals, and services within the specific insurance company's provider network.
  • The Copayment, Deductible, and Coinsurance amounts are your share of the costs for covered benefits. These amounts are subject to change.
  • Each insurance carrier may have unique Notices, Disclaimers, and Fees. Please check below for information regarding the plans and carriers you selected.
  • The quotes or rates shown above are estimates only. Your premium is subject to change based on the optional benefits you selected, if any, and other relevant factors, such as changes in rates that take effect before your coverage start date. The insurance company always determines your actual premium. Insurance companies reserve the right to change the terms of a policy upon proper notification.
  • The Summary of Benefits & Coverage can be found at healthcare.gov. A paper copy of this Summary of Benefits & Coverage is available upon request by calling our toll free number. Click here to view the Uniform Glossary of Coverage and Medical Terms.