Gym Access IND Bronze Standardized HMO – HMO
Network type: HMO
Coverage tier: Expanded Bronze
Primary care visit: $40 copay
Specialist visit: $80 copay
Urgent care visit: $75 copay
Description
Health Care Plan Details
Network type | HMO |
Deductible | $7,150 per person $7,150 per person |
Out-of-pocket max | $9,100 per person $18,200 per family |
Metal tier | Expanded Bronze |
Visit Copay
Primary care visit | $40 copay |
Specialist visit | $80 copay |
Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
Urgent care | $75 copay |
Emergency room | 40% coinsurance after deductible |
Ambulance | 40% coinsurance after deductible |
Hospital stay (facility) | 40% coinsurance after deductible |
Hospital stay (physician) | 40% coinsurance after deductible |
Outpatient procedure (facility) | 40% coinsurance after deductible |
Outpatient procedure (physician) | 40% coinsurance after deductible |
Physical rehabilitation | 40% coinsurance after deductible |
Maternitowny and Pregnancy
Well baby care | No charge |
Labor, delivery, hospital stay | 40% 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) | 40% coinsurance after deductible |
Blood work | No charge after deductible |
Mental and Psychiatric Health Care
Mental Health outpatient services | $80 copay |
Psychiatric hospital stay | 40% coinsurance after deductible |
Health Plan Provider Information
Health Plan Benefits | http://www.fhcp.com/documents/ISBC/2024/56503FL2670001-01.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 |