Gym Access IND Bronze HMO OA 1211 – HMO
Network type: HMO
Coverage tier: Expanded Bronze
Primary care visit: $50 copay
Specialist visit: $85 copay
Urgent care visit: $85 copay
Description
Health Care Plan Details
Network type | HMO |
Deductible | $0 per person $0 per person |
Out-of-pocket max | $9,450 per person $18,900 per family |
Metal tier | Expanded Bronze |
Visit Copay
Primary care visit | $50 copay |
Specialist visit | $85 copay |
Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
Urgent care | $85 copay |
Emergency room | $1,000 copay |
Ambulance | 50% coinsurance |
Hospital stay (facility) | $3000 copay per Stay |
Hospital stay (physician) | No charge |
Outpatient procedure (facility) | $1,000 copay |
Outpatient procedure (physician) | $85 copay |
Physical rehabilitation | $85 copay |
Maternitowny and Pregnancy
Well baby care | No charge |
Labor, delivery, hospital stay | $3,000 copay |
Pharmacy, Drugs, and Medication
Generic | $35 copay |
Brand | $200 copay |
Non-preferred Brand | 50% coinsurance after deductible |
Specialty | 50% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
X-rays | $100 copay |
Imaging (CT/PET/MRI) | $850 copay |
Blood work | $50 copay |
Mental and Psychiatric Health Care
Mental Health outpatient services | $85 copay |
Psychiatric hospital stay | $3000 copay per Stay |
Health Plan Provider Information
Health Plan Benefits | http://www.fhcp.com/documents/ISBC/2024/56503FL2930001-01.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 |