2019 Gym Access IND Bronze HMO BC 3841 Plan Details

Insurance Type	ACA (Obamacare)
Plan Name	Gym Access IND Bronze HMO BC 3841
Plan ID	qhp-56503FL2530002
Plan Year	2019
Insurance Provider	Florida Healthcare Plan
Metal Level	Expanded Bronze
Plan Type	HMO
Deductible	$6,400
Out-of-Pocket Maximum	$7,900
Personal Score
Plan Highlights

Costs for Medical Care
Primary Care Visit to Treat an Injury or Illness	$35 Copay
Specialist Visit	$65 Copay
Laboratory Outpatient and Professional Services	50.00% Coinsurance after deductible
X-rays and Diagnostic Imaging	50.00% Coinsurance after deductible
Deductible - Family	$12800
Out-of-Pocket Maximum - Family	$15800

Prescription drug coverage
Generic Drugs	$18 Copay
Preferred Brand Drugs	$65 Copay
Non-Preferred Brand Drugs	50% Coinsurance after deductible
Specialty Drugs	50% Coinsurance after deductible

Access to doctors and hospitals
Provider directory URL	Coming Soon

Hospital services
Emergency Room Services	50% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)	$100 Copay
Inpatient Physician and Surgical Services	No Charge after Deductible

Maternity
Prenatal and Postnatal Care	Not Applicable

Mental Health
Mental/Behavioral Health Outpatient Services	Not Applicable
Mental/Behavioral Health Inpatient Services	Not Applicable

Vision Coverage
Routine Eye Exam for Children	Not Applicable
Eye Glasses for Children	Not Applicable

Exclusions and Limitations
More Included Benefits	Hospice Services Reconstructive Surgery Diabetes Care Management Off Label Prescription Drugs Dental Anesthesia Congenital Anomaly, including Cleft Lip/Palate Bone Marrow Transplant Nutrition/Formulas Osteoporosis Gym Access Other Practitioner Office Visit (Nurse, Physician Assistant) Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Outpatient Surgery Physician/Surgical Services Urgent Care Centers or Facilities Home Health Care Services Inpatient Physician and Surgical Services Skilled Nursing Facility Outpatient Rehabilitation Services Habilitation Services Chiropractic Care Durable Medical Equipment Imaging (CT/PET Scans, MRIs) Preventive Care/Screening/Immunization Rehabilitative Speech Therapy Rehabilitative Occupational and Rehabilitative Physical Therapy Well Baby Visits and Care Transplant Accidental Dental Dialysis Allergy Testing Chemotherapy Radiation Diabetes Education Prosthetic Devices Infusion Therapy Treatment for Temporomandibular Joint Disorders Nutritional Counseling
More Excluded Benefits	Infertility Treatment Long-Term/Custodial Nursing Home Care Private-Duty Nursing Bariatric Surgery Cosmetic Surgery Hearing Aids Routine Foot Care Acupuncture Weight Loss Programs Dental Check-Up for Children Abortion for Which Public Funding is Prohibited

Exclusions and Limitations

More Included Benefits

Hospice Services
Reconstructive Surgery
Diabetes Care Management
Off Label Prescription Drugs
Dental Anesthesia
Congenital Anomaly, including Cleft Lip/Palate
Bone Marrow Transplant
Nutrition/Formulas
Osteoporosis
Gym Access
Other Practitioner Office Visit (Nurse, Physician Assistant)
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Outpatient Surgery Physician/Surgical Services
Urgent Care Centers or Facilities
Home Health Care Services
Inpatient Physician and Surgical Services
Skilled Nursing Facility
Outpatient Rehabilitation Services
Habilitation Services
Chiropractic Care
Durable Medical Equipment
Imaging (CT/PET Scans, MRIs)
Preventive Care/Screening/Immunization
Rehabilitative Speech Therapy
Rehabilitative Occupational and Rehabilitative Physical Therapy
Well Baby Visits and Care
Transplant
Accidental Dental
Dialysis
Allergy Testing
Chemotherapy
Radiation
Diabetes Education
Prosthetic Devices
Infusion Therapy
Treatment for Temporomandibular Joint Disorders
Nutritional Counseling

More Excluded Benefits

Infertility Treatment
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Bariatric Surgery
Cosmetic Surgery
Hearing Aids
Routine Foot Care
Acupuncture
Weight Loss Programs
Dental Check-Up for Children
Abortion for Which Public Funding is Prohibited

+ See All Coverage Details

Premium

Plan Name

Deductible

from $298

Molina Marketplace Bronze

$6,400.00

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from $303

Health First Bronze HMO 100 HSA 1794

$6,450.00

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from $306

Florida Hospital Bronze HMO 100 HSA 1795

$6,450.00

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from $306

Health First GYM ACCESS Bronze HMO 100 HSA 1658

$6,450.00

Select

from $309

Florida Hospital GYM ACCESS Bronze HMO 100 HSA 1660

$6,450.00

Select

Last Name

Location/Distance

Please select the correct zip

Cohen, Sheldon

Zip Code	33186 (edit)
Applicant	2/19/1984 Male (edit)
Coverage Start	2/20/2019 (edit)

Gym Access IND Bronze HMO BC 3841

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Benefits & Coverage

Costs for Medical Care

Prescription drug coverage

Access to doctors and hospitals

Hospital services

Maternity

Mental Health

Vision Coverage

Exclusions and Limitations

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