Gym Access IND Bronze HMO HSA 5065 – HMO

Description

Health Care Plan Details

Network type	HMO
Deductible	$6,300 per person $6,300 per person
Out-of-pocket max	$7,500 per person $15,000 per family
Metal tier	Expanded Bronze

Visit Copay

Primary care visit	30% coinsurance after deductible
Specialist visit	30% coinsurance after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	30% coinsurance after deductible
Emergency room	30% coinsurance after deductible
Ambulance	30% coinsurance after deductible
Hospital stay (facility)	30% coinsurance after deductible
Hospital stay (physician)	30% coinsurance after deductible
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	30% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$10 copay after deductible
Brand	$30 copay after deductible
Non-preferred Brand	$55 copay after deductible
Specialty	50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	30% coinsurance after deductible
Imaging (CT/PET/MRI)	30% coinsurance after deductible
Blood work	30% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	30% coinsurance after deductible
Psychiatric hospital stay	30% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	http://www.fhcp.com/documents/ISBC/2024/56503FL2240001-01.pdf
Drug and medication plan formulary	https://fm.formularynavigator.com/FBO/126/2024_QHP_Formulary.pdf
Search doctor list	http://www.fhcp.com/find-providers/physician