Gym Access IND Silver HMO OA 1009 – 87% – HMO
87% cost sharing reduction [Popular Plan]
Network type: HMO
Coverage tier: Silver
Primary care visit: $10 copay
Specialist visit: $30 copay
Urgent care visit: $50 copay
Description
This plan has 87% cost sharing reduction [Popular Plan]
Health Care Plan Details
| Network type | HMO |
| Deductible | $0 per person $0 per person |
| Out-of-pocket max | $3,150 per person $6,300 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $10 copay |
| Specialist visit | $30 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $50 copay |
| Emergency room | $150 copay |
| Ambulance | $150 copay |
| Hospital stay (facility) | $500 copay per Day |
| Hospital stay (physician) | No charge |
| Outpatient procedure (facility) | $350 copay |
| Outpatient procedure (physician) | $30 copay |
| Physical rehabilitation | $10 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | $500 copay |
Pharmacy, Drugs, and Medication
| Generic | $18 copay |
| Brand | $65 copay |
| Non-preferred Brand | 50% coinsurance after deductible |
| Specialty | 50% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | $30 copay |
| Imaging (CT/PET/MRI) | $100 copay |
| Blood work | No charge |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $10 copay |
| Psychiatric hospital stay | $500 copay per Day |
Health Plan Provider Information
| Health Plan Benefits | http://www.fhcp.com/documents/ISBC/2024/56503FL2940001-05.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 |
