Gym Access IND Silver HMO BC 0941
| Plan Type: | HMO |
| Plan Tier: | Silver |
| Medical Deductible - Individual: | $5600 |
| Medical Deductible - Family: | $3000 |
| Drug Deductible - Individual: | $5600 |
| Drug Deductible - Family: | $3000 |
| Out of Pocket Max - Individual: | $7150 |
| Out of Pocket Max - Family: | $7150 |
| Primary Care Visit: | $50 |
| Specialist Visit: | $100 |
| Emergency Room: | $400 Copay after deductible |
| Hospital - Physician: | No Charge |
| Hospital - Facility: | $600 Copay per Stay after deductible |
| Link to Full SBC: | http://www.fhcp.com/documents/ISBC/2020/56503FL2550002-01.pdf |
| Plan Brochure: | http://www.fhcp.com/documents/ISOB/2020/56503FL2550002-01.pdf |
Other Coverage:
| Child Dental: | No |
| Adult Dental | No |
Prescription Drug Pricing:
| Generic Drugs: | $10 |
| Non-Preferred Brand Drugs: | $55 Copay after deductible |
| Preferred Brand Drugs: | $30 Copay after deductible |
| Specialty Drugs: | 50% Coinsurance after deductible |
| Link to Full Policy Formulary: | http://fm.formularynavigator.com/FBO/126/2020_QHP_Formulary_Member_Doc.pdf |
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