Health First Commercial Plans, Inc.

Health First GYM ACCESS Gold HMO 100 1736

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Medical Deductible	Individual: $2,650.00 Family: $5,300 Per Person: $2,650
Prescription Drug Deductible	Individual: $200.00 Family: $400 Per Person: $200
Combined Medical and Drug Out of Pocket Maximum	Individual: $6,800.00 Family: $13,600 Per Person: $6,800

Office Visit

Primary Doctor	CoPay: $25.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Virtual Health provided as a means to receive this benefit.
Specialist	CoPay: $45.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Virtual Health provided as a means to receive this benefit.

Prescription Drug Information

Preferred Brand Drugs	CoPay: $30.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered
Non Preferred Brand Drugs	CoPay: $50.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered
Generic Drugs	CoPay: $15.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Preferred Generic Drugs: $15 copay for 30 days' supply.
Specialty Drugs	CoPay: Not Applicable CoInsurance: 30.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Coverage is limited to 30-day supply from preferred specialty pharmacy.

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Coverage for inpatient rehabilitation services are limited to 21 days per calendar year.
Inpatient Services	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered
Urgent Care Facility	CoPay: $40.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Virtual Health provided as a means to receive this benefit.

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: $0.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Visits 16+ and visits with a perinatologist are subject to the Specialist Visit cost-share.

Vision

Routine Eye Exams For Children

CoPay: $0.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per Year
Benefit Explanation: Covered up through the end of the birth month in which the covered person reaches age nineteen (19).

Major Dental Care

Routine Dental Checkups for Children	CoPay: $0.00 CoInsurance: Not Applicable Covered: Covered Limit Quantity: 1 Limit Unit : Visit(s) per 6 Months Benefit Explanation: Covered up through the end of the birth month in which the covered person reaches age nineteen (19). Basic and major dental care and orthodontic services.
Routine Dental Checkups for Adults	Covered: Not Covered

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