Gold Gym Access 1736 (Primary Care & Urgent Care Copay, 0% Coinsurance, Open Access)

36194FL0120011
Gold
HMO

Gold Gym Access 1736 (Primary Care & Urgent Care Copay, 0% Coinsurance, Open Access) is a Gold HMO plan by Health First Commercial Plans, Inc..

IMPORTANT: You are viewing the 2024 version of Gold Gym Access 1736 (Primary Care & Urgent Care Copay, 0% Coinsurance, Open Access) 36194FL0120011. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.

Locations

Gold Gym Access 1736 (Primary Care & Urgent Care Copay, 0% Coinsurance, Open Access) is offered in the following counties.

Plan Overview

This is a plan overview for 2024 version of Gold Gym Access 1736 (Primary Care & Urgent Care Copay, 0% Coinsurance, Open Access) 36194FL0120011.
Insurer: Health First Commercial Plans, Inc.
Network Type: HMO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 36194FL0120011

Cost-Sharing Overview

Gold Gym Access 1736 (Primary Care & Urgent Care Copay, 0% Coinsurance, Open Access) offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Gold Gym Access 1736 (Primary Care & Urgent Care Copay, 0% Coinsurance, Open Access)?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

Gold Gym Access 1736 (Primary Care & Urgent Care Copay, 0% Coinsurance, Open Access) offers the following features and referral requirements.

Wellness Program: No
Disease Program: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy
Notice Pregnancy: No
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what Gold Gym Access 1736 (Primary Care & Urgent Care Copay, 0% Coinsurance, Open Access) covers when you are out of the service area or out of the country.

Out of Country Coverage: No
Out of Country Coverage Description:
Out of Service Area Coverage: No
Out of Service Area Coverage Description:
National Network: No

Additional Benefits and Cost-Sharing

Gold Gym Access 1736 (Primary Care & Urgent Care Copay, 0% Coinsurance, Open Access) includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
$25.00 Not ApplicableNot Applicable 100.00% Virtual Health provided as a means to receive this benefit.
Specialist Visit
Covered
$45.00 Not ApplicableNot Applicable 100.00% Virtual Health provided as a means to receive this benefit.
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$25.00 Not ApplicableNot Applicable 100.00% Specialist Visit cost-share will apply if visit is in a specialist’s office.
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00%
Hospice Services
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00% Covered hospice services do not include bereavement counseling, pastoral counseling, financial or legal counseling or custodial care.
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Not Covered
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Not Covered
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$40.00 Not Applicable$40.00 Not Applicable Virtual Health provided as a means to receive this benefit. Virtual Urgent Care copay $20.
Home Health Care Services
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00%60.0 Visit(s) per Year One date of service is equal to one visit.
Emergency Room Services
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 0.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 0.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00% Coverage for inpatient rehabilitation services are limited to 21 days per calendar year.
Inpatient Physician and Surgical Services
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00%
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00%60.0 Days per Year
Prenatal and Postnatal Care
Covered
$0.00 Not ApplicableNot Applicable 100.00% Visits 16+ and visits with a perinatologist are subject to the Specialist Visit cost-share. Birthing classes are covered at $0 copay.
Delivery and All Inpatient Services for Maternity Care
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00%
Mental/Behavioral Health Outpatient Services
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00%
Mental/Behavioral Health Inpatient Services
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00%
Substance Abuse Disorder Outpatient Services
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00%
Substance Abuse Disorder Inpatient Services
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00%
Generic Drugs
Covered
$15.00 Not ApplicableNot Applicable 100.00% Preferred Generic Drugs: $2 copay for 30 days’ supply.
Preferred Brand Drugs
Covered
$30.00 Copay after deductible Not ApplicableNot Applicable 100.00%
Non-Preferred Brand Drugs
Covered
$50.00 Copay after deductible Not ApplicableNot Applicable 100.00%
Specialty Drugs
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00% Coverage is limited to 30-day supply from preferred specialty pharmacy.
Outpatient Rehabilitation Services
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00%35.0 Visit(s) per Year Combined limit for all outpatient rehabilitative physical, occupational and speech therapy. Limit applies per condition.
Habilitation Services
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00%35.0 Visit(s) per Year Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings. Combined limit for all outpatient habilitative physical, occupational and speech therapy. Limit applies per condition.
Chiropractic Care
Covered
$45.00 Not ApplicableNot Applicable 100.00%26.0 Visit(s) per Year
Durable Medical Equipment
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00% Items that are primarily for convenience or comfort and items available over-the-counter are excluded. The replacement of equipment is also excluded, unless it is non-functional and not practically repairable.
Hearing Aids
Not Covered
Imaging (CT/PET Scans, MRIs)
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00% Cost-share applies per visit, per type
Preventive Care/Screening/Immunization
Covered
$0.00 Not ApplicableNot Applicable 100.00% Limited to services recommended with an “A” or “B” rating by the U.S. Preventive Services Task Force (USPSTF), immunizations recommended for routine use by the Centers for Disease Control and Prevention (CDC), and services listed in guidelines of the Health Resources and Services Administration (HRSA) for women and children.
Routine Foot Care
Covered
$45.00 Not ApplicableNot Applicable 100.00% Routine foot care, including any service or supply in connection with foot care, is only covered when medically necessary.
Acupuncture
Not Covered
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
$0.00 Not ApplicableNot Applicable 100.00%1.0 Exam(s) per Year Covered up through the end of the birth month in which the covered person reaches age nineteen (19).
Eye Glasses for Children
Covered
$0.00 Not ApplicableNot Applicable 100.00%1.0 Item(s) per Year Covered up through the end of the birth month in which the covered person reaches age nineteen (19).
Dental Check-Up for Children
Covered
$0.00 Not ApplicableNot Applicable 100.00%1.0 Visit(s) per 6 Months 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.
Rehabilitative Speech Therapy
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00%35.0 Visit(s) per Year Combined limit for all outpatient rehabilitative physical, occupational and speech therapy. Limit applies per condition.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00%35.0 Visit(s) per Year Combined limit for all outpatient rehabilitative physical, occupational and speech therapy. Limit applies per condition.
Well Baby Visits and Care
Covered
$0.00 Not ApplicableNot Applicable 100.00%
Laboratory Outpatient and Professional Services
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00%
X-rays and Diagnostic Imaging
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00% Cost-share applies per visit, per type
Basic Dental Care – Child
Covered
$0.00 Not ApplicableNot Applicable 100.00% Covered up through the end of the birth month in which the covered person reaches age nineteen (19).
Orthodontia – Child
Covered
$0.00 Not ApplicableNot Applicable 100.00% Covered up through the end of the birth month in which the covered person reaches age nineteen (19).
Major Dental Care – Child
Covered
$0.00 Not ApplicableNot Applicable 100.00% Covered up through the end of the birth month in which the covered person reaches age nineteen (19).
Basic Dental Care – Adult
Not Covered
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Not Covered
Abortion for Which Public Funding is Prohibited
Not Covered
Transplant
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00% Includes bone marrow transplant
Accidental Dental
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00% Coverage is limited to care and stabilization treatment rendered within 62 calendar days of an accidental dental injury.
Dialysis
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00%
Allergy Testing
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00%
Chemotherapy
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00%
Radiation
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00%
Diabetes Education
Covered
$0.00 Not ApplicableNot Applicable 100.00% In order to be covered, diabetes outpatient self-management training and educational services must be provided under the direct supervision of a certified diabetes educator or board certified physician specializing in endocrinology.
Prosthetic Devices
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00% Covered prosthetic devices (except cardiac pacemakers and prosthetic devices incident to a mastectomy) are limited to the first such permanent prosthesis, including the first temporary prosthesis if necessary, prescribed for each condition. Coverage is provided for necessary replacement of a prosthetic device owned by the enrollee when due to irreparable damage, wear, a change in the enrollee’s condition, or when necessitated due to growth of a child.
Infusion Therapy
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00% Includes chemotherapy, infusions, therapeutic injections, allergy immunotherapy, and other medications ordered and administered by a provider.
Treatment for Temporomandibular Joint Disorders
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00%1.0 Item(s) per 6 Months One splint in a six (6) month period is covered, unless a more frequent replacement is determined to be medically necessary. Splints are subject to the Durable Medical Equipment cost-share. Medically necessary outpatient surgical procedures are subject to the Outpatient Facility Fee and Outpatient Surgery Physician/Surgical Services cost-share.
Nutritional Counseling
Covered
$0.00 Not ApplicableNot Applicable 100.00%
Reconstructive Surgery
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00% Any cosmetic reconstructive surgery is exclused. Surgery performed outpatient is subject to the Outpatient Facility Fee and Outpatient Surgery Physician/Surgical Services cost-share.
Gender Affirming Care
Not Covered
Anesthesia Services for Dental Care
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00% Includes general anesthesia and hospitalization services in connection with dental treatment provided in a hospital or ambulatory surgical center.
Enteral/Parenteral and Oral Nutrition Therapy
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00%
Osteoporosis Treatment
Covered
$45.00 Not ApplicableNot Applicable 100.00% Treatment provided at a primary care physician’s office will be subject to the Primary Care Visit cost-share.
Cardiac and Pulmonary Rehabilitation
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00%36.0 Days per Lifetime
Preferred Generic Drugs
Covered
$2.00 Not ApplicableNot Applicable 100.00%
Genetic Testing Lab Services
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00% BRCA Analysis to determine a woman’s genetic risk for breast and ovarian cancer is covered as a preventive benefit when medical necessity criteria are met and authorized in advance by the health plan.
Hyperbaric Oxygen Therapy
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00%
Outpatient Observation
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00%
Partial Hospitalization
Covered
Not Applicable 0.00% Coinsurance after deductibleNot Applicable 100.00% A structured program of active treatment for psychiatric care that is more intense than the care performed in a physician?s or therapist?s office.
Fitness Center Membership
Covered
$0.00 Not ApplicableNot Applicable 100.00%
Mental Health Office Visit
Covered
$45.00 Not ApplicableNot Applicable 100.00% Virtual Health provided as a means to receive this benefit.
Substance Abuse Office Visit
Covered
$45.00 Not ApplicableNot Applicable 100.00% Virtual Health provided as a means to receive this benefit.

Free Preventive Services

There is no copayment or coinsurance for any of the following Gold Gym Access 1736 (Primary Care & Urgent Care Copay, 0% Coinsurance, Open Access) preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for Gold Gym Access 1736 (Primary Care & Urgent Care Copay, 0% Coinsurance, Open Access) including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for Gold Gym Access 1736 (Primary Care & Urgent Care Copay, 0% Coinsurance, Open Access)?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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