Gold Gym Access 1742 (Emergency Room & Inpatient Hospitalization Copay, $0 Outpatient Labs, $0 MRI, Open Access) – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: $40 copay
Specialist visit: $80 copay
Urgent care visit: $80 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $1,500 per person $1,500 per person |
| Out-of-pocket max | $7,750 per person $15,500 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $40 copay |
| Specialist visit | $80 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $80 copay |
| Emergency room | $250 copay |
| Ambulance | $250 copay |
| Hospital stay (facility) | $700 copay per Stay |
| Hospital stay (physician) | No charge |
| Outpatient procedure (facility) | 30% coinsurance after deductible |
| Outpatient procedure (physician) | 30% coinsurance after deductible |
| Physical rehabilitation | 30% coinsurance after deductible |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | $700 copay |
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 | $50 copay |
| Imaging (CT/PET/MRI) | No charge |
| Blood work | No charge |
Mental and Psychiatric Health Care
| Mental Health outpatient services | 30% coinsurance after deductible |
| Psychiatric hospital stay | $700 copay per Stay |
Health Plan Provider Information
| Health Plan Benefits | https://hf.org/2024_sbc_1742.pdf |
| Drug and medication plan formulary | https://hf.org/MP_formulary_2024 |
| Search doctor list | https://hf.org/MP_directory_2024 |
