2019 Health First GYM ACCESS Silver HMO 80 HSA 1728 Plan Details

Insurance Type	ACA (Obamacare)
Plan Name	Health First GYM ACCESS Silver HMO 80 HSA 1728
Plan ID	qhp-36194FL0120010
Plan Year	2019
Insurance Provider	Health First Commercial Plans, Inc.
Metal Level	Silver
Plan Type	HMO
Deductible	$2,500
Out-of-Pocket Maximum	$6,500
Personal Score
Plan Highlights

Costs for Medical Care
Primary Care Visit to Treat an Injury or Illness	20% Coinsurance after deductible
Specialist Visit	20% Coinsurance after deductible
Laboratory Outpatient and Professional Services	20.00% Coinsurance after deductible
X-rays and Diagnostic Imaging	20.00% Coinsurance after deductible
Deductible - Family	$5000
Out-of-Pocket Maximum - Family	$13000

Prescription drug coverage
Generic Drugs	10% Coinsurance after deductible
Preferred Brand Drugs	10% Coinsurance after deductible
Non-Preferred Brand Drugs	10% Coinsurance after deductible
Specialty Drugs	10% Coinsurance after deductible

Access to doctors and hospitals
Provider directory URL	Coming Soon

Hospital services
Emergency Room Services	20% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)	20% Coinsurance after deductible
Inpatient Physician and Surgical Services	20% Coinsurance after deductible

Maternity
Prenatal and Postnatal Care	Not Applicable

Mental Health
Mental/Behavioral Health Outpatient Services	20.00% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services	20.00% Coinsurance after deductible

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

Exclusions and Limitations
More Included Benefits	Skilled Nursing Facility Outpatient Rehabilitation Services Habilitation Services Chiropractic Care Durable Medical Equipment Imaging (CT/PET Scans, MRIs) Preventive Care/Screening/Immunization Routine Foot Care Urgent Care Centers or Facilities Other Practitioner Office Visit (Nurse, Physician Assistant) Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Outpatient Surgery Physician/Surgical Services Hospice Services Home Health Care Services Inpatient Physician and Surgical Services Dental Check-Up for Children 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 Reconstructive Surgery Anesthesia Services for Dental Care Enteral/Parenteral and Oral Nutrition Therapy Osteoporosis Treatment Cardiac and Pulmonary Rehabilitation Preferred Generic Drugs Genetic Testing Lab Services Hyperbaric Oxygen Therapy Outpatient Observation Partial Hospitalization Allergy Injections Fitness Center Membership
More Excluded Benefits	Hearing Aids Acupuncture Weight Loss Programs Infertility Treatment Long-Term/Custodial Nursing Home Care Private-Duty Nursing Bariatric Surgery Cosmetic Surgery Abortion for Which Public Funding is Prohibited

Exclusions and Limitations

More Included Benefits

Skilled Nursing Facility
Outpatient Rehabilitation Services
Habilitation Services
Chiropractic Care
Durable Medical Equipment
Imaging (CT/PET Scans, MRIs)
Preventive Care/Screening/Immunization
Routine Foot Care
Urgent Care Centers or Facilities
Other Practitioner Office Visit (Nurse, Physician Assistant)
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Outpatient Surgery Physician/Surgical Services
Hospice Services
Home Health Care Services
Inpatient Physician and Surgical Services
Dental Check-Up for Children
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
Reconstructive Surgery
Anesthesia Services for Dental Care
Enteral/Parenteral and Oral Nutrition Therapy
Osteoporosis Treatment
Cardiac and Pulmonary Rehabilitation
Preferred Generic Drugs
Genetic Testing Lab Services
Hyperbaric Oxygen Therapy
Outpatient Observation
Partial Hospitalization
Allergy Injections
Fitness Center Membership

More Excluded Benefits

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

+ See All Coverage Details

Premium

Plan Name

Deductible

from $399

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$2,500.00

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from $403

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$2,500.00

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from $404

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$2,500.00

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from $411

Gym Access IND Essential Plus Silver HMO 53

$2,500.00

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from $425

Health First Silver HMO 65 1806

$2,650.00

Select

Last Name

Location/Distance

Please select the correct zip

Cohen, Sheldon

Zip Code	33186 (edit)
Applicant	2/21/1984 Male (edit)
Coverage Start	2/23/2019 (edit)

Health First GYM ACCESS Silver HMO 80 HSA 1728

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Maternity

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Exclusions and Limitations

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