Gym Access IND Gold HMO H.S.A 9010 – HMO

Description

Health Care Plan Details

Network type	HMO
Deductible	$1,750 per person $1,750 per person
Out-of-pocket max	$4,900 per person $9,800 per family
Metal tier	Gold

Visit Copay

Primary care visit	10% coinsurance after deductible
Specialist visit	10% coinsurance after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	10% coinsurance after deductible
Emergency room	10% coinsurance after deductible
Ambulance	10% coinsurance after deductible
Hospital stay (facility)	10% coinsurance after deductible
Hospital stay (physician)	10% coinsurance after deductible
Outpatient procedure (facility)	10% coinsurance after deductible
Outpatient procedure (physician)	10% coinsurance after deductible
Physical rehabilitation	10% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	10% 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	10% coinsurance after deductible
Imaging (CT/PET/MRI)	10% coinsurance after deductible
Blood work	10% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	10% coinsurance after deductible
Psychiatric hospital stay	10% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	http://www.fhcp.com/documents/ISBC/2024/56503FL2860001-01.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