Gym Access IND Bronze POS 1042 – POS
Network type: POS
Coverage tier: Expanded Bronze
Primary care visit: $40 copay
Specialist visit: $75 copay
Urgent care visit: $100 copay
Description
Health Care Plan Details
Network type | POS |
Deductible | $5,500 per person $5,500 per person |
Out-of-pocket max | $9,400 per person $18,800 per family |
Metal tier | Expanded Bronze |
Visit Copay
Primary care visit | $40 copay |
Specialist visit | $75 copay |
Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
Urgent care | $100 copay |
Emergency room | 50% coinsurance after deductible |
Ambulance | 50% coinsurance after deductible |
Hospital stay (facility) | 50% coinsurance after deductible |
Hospital stay (physician) | 50% coinsurance after deductible |
Outpatient procedure (facility) | 50% coinsurance after deductible |
Outpatient procedure (physician) | 50% coinsurance after deductible |
Physical rehabilitation | $40 copay |
Maternitowny and Pregnancy
Well baby care | No charge |
Labor, delivery, hospital stay | 50% coinsurance after deductible |
Pharmacy, Drugs, and Medication
Generic | $35 copay |
Brand | 35% coinsurance after deductible |
Non-preferred Brand | 40% coinsurance after deductible |
Specialty | 45% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
X-rays | No charge after deductible |
Imaging (CT/PET/MRI) | 50% coinsurance after deductible |
Blood work | No charge after deductible |
Mental and Psychiatric Health Care
Mental Health outpatient services | $75 copay |
Psychiatric hospital stay | 50% coinsurance after deductible |
Health Plan Provider Information
Health Plan Benefits | http://www.fhcp.com/documents/ISBC/2024/56503FL2790001-01.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 |