Silver Gym Access 1664 (Primary Care & Specialist Copays, Open Access, Fitness Center Included) – HMO
Network type: HMO
Coverage tier: Silver
Primary care visit: $50 copay
Specialist visit: $100 copay
Urgent care visit: No charge after deductible
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $5,750 per person $5,750 per person |
| Out-of-pocket max | $9,100 per person $18,200 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $50 copay |
| Specialist visit | $100 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | No charge after deductible |
| Emergency room | No charge after deductible |
| Ambulance | No charge after deductible |
| Hospital stay (facility) | No charge after deductible |
| Hospital stay (physician) | No charge after deductible |
| Outpatient procedure (facility) | No charge after deductible |
| Outpatient procedure (physician) | No charge after deductible |
| Physical rehabilitation | No charge after deductible |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | No charge after deductible |
Pharmacy, Drugs, and Medication
| Generic | $15 copay |
| Brand | $30 copay after deductible |
| Non-preferred Brand | $50 copay after deductible |
| Specialty | 20% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | No charge after deductible |
| Imaging (CT/PET/MRI) | No charge after deductible |
| Blood work | No charge after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | No charge after deductible |
| Psychiatric hospital stay | No charge after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://hf.org/2024_sbc_1664.pdf |
| Drug and medication plan formulary | https://hf.org/MP_formulary_2024 |
| Search doctor list | https://hf.org/MP_directory_2024 |
