Silver Gym Access 1688 (Open Access, Fitness Center Included) – HMO

Description

Health Care Plan Details

Network type	HMO
Deductible	$3,850 per person $3,850 per person
Out-of-pocket max	$8,700 per person $17,400 per family
Metal tier	Silver

Visit Copay

Primary care visit	20% coinsurance after deductible
Specialist visit	20% coinsurance after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	20% coinsurance after deductible
Emergency room	20% coinsurance after deductible
Ambulance	20% coinsurance after deductible
Hospital stay (facility)	20% coinsurance after deductible
Hospital stay (physician)	20% coinsurance after deductible
Outpatient procedure (facility)	20% coinsurance after deductible
Outpatient procedure (physician)	20% coinsurance after deductible
Physical rehabilitation	20% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	20% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$15 copay
Brand	$30 copay after deductible
Non-preferred Brand	$50 copay after deductible
Specialty	30% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	20% coinsurance after deductible
Imaging (CT/PET/MRI)	20% coinsurance after deductible
Blood work	20% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	20% coinsurance after deductible
Psychiatric hospital stay	20% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://hf.org/2024_sbc_1688.pdf
Drug and medication plan formulary	https://hf.org/MP_formulary_2024
Search doctor list	https://hf.org/MP_directory_2024