Gym Access IND Gold HMO 4500 - 56503FL2090002 Health Insurance Plan

Florida Health Care Plan, Inc. health insurance plan with the Plan ID 56503FL2090002. The plan is called Gym Access IND Gold HMO 4500.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 81.97% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 18.03% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.

Health Insurance Plan ID 56503FL2090002
Health Insurance Plan Year 2023
State Florida
Health Insurance Issuer Florida Health Care Plan, Inc.
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 56503FL2090002-00
Provider Network(s) ['FLN001']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Wed, 27 Mar 2024 12:10 GMT).

Providers Florida All US States
All N/A N/A
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A
Available Variants of the Health Plan

Standard Off Exchange Plan - 56503FL2090002-00

Standard On Exchange Plan - 56503FL2090002-01

Open to Indians below 300% FPL - 56503FL2090002-02

Open to Indians above 300% FPL - 56503FL2090002-03

Last Plan Update Date Fri, 18 Nov 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Gym Access IND Gold HMO 4500 Health Insurance Plan, 56503FL2090002-00

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
NO
Accidental Dental
YES

$35.00

100.00%
Acupuncture
NO
Allergy Testing
YES

No Charge

100.00%
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Bone Marrow Transplant

Exclusions: Prior authorization is required.

Prior authorization is required. Cost sharing is a per day limit.

YES

$250.00

100.00%
Chemotherapy

Exclusions: Prior authorization is required.

Prior authorization is required.

YES

50.00%

100.00%
Chiropractic Care

Limit: 26.0 Visit(s) per Benefit Period

YES

$35.00

100.00%
Congenital Anomaly, including Cleft Lip/Palate

Exclusions: Prior authorization is required.

Prior authorization is required.

YES

$35.00

100.00%
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care

Exclusions: Pre-certification/pre-authorization of coverage required for non-emergency admissions.

Pre-certification/pre-authorization of coverage required for non-emergency admissions. Cost sharing is a per day limit, refer to Summary of Benefits and Coverage (SBC) for day limitation.

YES

$250.00

100.00%
Dental Anesthesia

Exclusions: Prior authorization is required.

Prior authorization is required.

YES

10.00%

100.00%
Dental Check-Up for Children
NO
Diabetes Care Management

Limit: 50.0 Item(s) per Month

Exclusions: In order for services to be covered, diabetes outpatient self-management training and educational services must be provided under the direct supervision of an FHCP certified Diabetes Educator or board-certified Physician spcializing in endocrinology. Additionally, nutrition counseling must be provided by a licensed FHCP contracted dietitian.

Includes all medically appropriate and necessary insulin, equipment and supplies, when used to treat diabetes, if the Member's Primary Care Physician, or a Contracting Specialist who specializes in the treatment of diabetes, certifies that such services are necessary.

YES

$10.00

100.00%
Diabetes Education
YES

No Charge

100.00%
Dialysis
YES

10.00%

100.00%
Durable Medical Equipment

Prior authorization is required.

YES

10.00%

100.00%
Emergency Room Services
YES

10.00% Coinsurance after deductible

10.00% Coinsurance after deductible
Emergency Transportation/Ambulance
YES

10.00% Coinsurance after deductible

10.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

YES

$25.00

100.00%
Gender Affirming Care

Exclusions: Includes sexual re-assignment procedures. Cosmetic procedures and/or complications from such procedure(s) are not covered and are excluded under the plan. Hormone therapy and psychological/behavioral health therapies are covered under their respective benefits.

Prior authorization is required. Cost sharing is a per day limit.

YES

$250.00

100.00%
Generic Drugs

Limit: 31.0 Days per Benefit Period

Exclusions: Available at FHCP and Select In-Network Walgreen's Pharmacies Only.

Available at FHCP and Select In-Network Walgreen's Pharmacies Only. Up to 93 day Mail Order available through FHCP Only. Refer to the schedule of benefits for cost sharing at Walgreen's pharmacy.

YES

$10.00

100.00%
Habilitation Services

Limit: 35.0 Visit(s) per Benefit Period

Includes Physical Therapy, Speech Therapy and Occupational Therapy.

YES

$35.00

100.00%
Hearing Aids
NO
Home Health Care Services

Limit: 20.0 Days per Benefit Period

Exclusions: Prior authorization is required.

Prior authorization is required.

YES

10.00%

100.00%
Hospice Services
YES

10.00%

100.00%
Imaging (CT/PET Scans, MRIs)

Prior authorization is required. Tests in hospitals, or facilities owned and operated by hospitals, may have higher cost share.

YES

10.00% Coinsurance after deductible

100.00%
Infertility Treatment
NO
Infusion Therapy

Exclusions: Prior authorization is required.

Prior authorization is required.

YES

50.00%

100.00%
Inpatient Hospital Services (e.g., Hospital Stay)

Exclusions: Pre-certification/pre-authorization of coverage required for non-emergency admissions. Cost sharing is a per day limit.

Pre-certification/pre-authorization of coverage required for non-emergency admissions. Cost sharing is a per day limit.

YES

$250.00 Copay per Day

100.00%
Inpatient Physician and Surgical Services
YES

No Charge

100.00%
Laboratory Outpatient and Professional Services

Tests in hospitals, or facilities owned and operated by hospitals, may have higher cost share.

YES

$25.00

100.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
NO
Mental/Behavioral Health Inpatient Services

Exclusions: Pre-certification/pre-authorization of coverage required for non-emergency admissions. Cost sharing is a per day limit.

Pre-certification/pre-authorization of coverage required for non-emergency admissions. Cost sharing is a per day limit.

YES

$250.00 Copay per Day

100.00%
Mental/Behavioral Health Outpatient Services
YES

$35.00

100.00%
Non-Preferred Brand Drugs

Limit: 31.0 Days per Benefit Period

Exclusions: Available at FHCP and Select In-Network Walgreen's Pharmacies Only.

Available at FHCP and Select In-Network Walgreen's Pharmacies Only. Up to 93 day Mail Order available through FHCP Only. Refer to the schedule of benefits for cost sharing at Walgreen's pharmacy.

YES

$55.00

100.00%
Nutritional Counseling

Diabetes education coverage includes nutritional counseling; covered as preventive care

YES

No Charge

100.00%
Nutrition/Formulas

Exclusions: Prior authorization is required.

Prior authorization is required.

YES

10.00%

100.00%
Off Label Prescription Drugs

Limit: 31.0 Days per Benefit Period

Exclusions: Available at FHCP Pharmacy Only.

Available at FHCP Pharmacy Only.

YES

$55.00

100.00%
Orthodontia - Adult
NO
Orthodontia - Child
NO
Osteoporosis
YES

$35.00

100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)

Exclusions: Additional cost share may apply for Allergy Shots, Injections and Infusions.

Additional cost share may apply for Allergy Shots, Injections and Infusions.

YES

$25.00

100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)

Exclusions: Prior authorization is required.

Prior authorization is required.

YES

10.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 35.0 Visit(s) per Benefit Period

Includes Physical Therapy, Speech Therapy and Occupational Therapy.

YES

$35.00

100.00%
Outpatient Surgery Physician/Surgical Services

Exclusions: Prior authorization is required.

Prior authorization is required.

YES

10.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs

Limit: 31.0 Days per Benefit Period

Exclusions: Available at FHCP and Select In-Network Walgreen's Pharmacies Only.

Available at FHCP and Select In-Network Walgreen's Pharmacies Only. Up to 93 day Mail Order available through FHCP Only. Refer to the schedule of benefits for cost sharing at Walgreen's pharmacy.

YES

$30.00

100.00%
Prenatal and Postnatal Care
YES

$35.00

100.00%
Preventive Care/Screening/Immunization
YES

No Charge

100.00%
Primary Care Visit to Treat an Injury or Illness

Exclusions: Additional cost share may apply for Allergy Shots, Injections and Infusions.

Additional cost share may apply for Allergy Shots, Injections and Infusions.

YES

$25.00

100.00%
Private-Duty Nursing
NO
Prosthetic Devices

Exclusions: Prior authorization is required.

Prior authorization is required.

YES

10.00%

100.00%
Radiation

Exclusions: Prior authorization is required.

Prior authorization is required.

YES

10.00%

100.00%
Reconstructive Surgery

Exclusions: Prior authorization is required.

Only for Breast reconstruction following a Mastectomy. Prior authorization is required. Cost sharing is a per day limit.

YES

$250.00

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 35.0 Visit(s) per Benefit Period

Combined limit for all outpatient therapy. Includes Physical Therapy, Speech Therapy and Occupational Therapy.

YES

$35.00

100.00%
Rehabilitative Speech Therapy

Limit: 35.0 Visit(s) per Benefit Period

Combined limit for all outpatient therapy. Includes Physical Therapy, Speech Therapy and Occupational Therapy.

YES

$35.00

100.00%
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children

Limit: 1.0 Visit(s) per Year

YES

$10.00

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 60.0 Days per Benefit Period

Exclusions: Prior authorization is required.

Prior authorization is required.

YES

$50.00 Copay per Day

100.00%
Specialist Visit

Exclusions: Additional cost share may apply for Allergy Shots, Injections and Infusions.

Additional cost share may apply for Allergy Shots, Injections and Infusions.

YES

$35.00

100.00%
Specialty Drugs

Limit: 31.0 Days per Benefit Period

Exclusions: Available at FHCP Pharmacy Only. Mail Order not available

Available at FHCP Pharmacy Only. Mail Order not available

YES

50.00%

100.00%
Substance Abuse Disorder Inpatient Services

Exclusions: Pre-certification/pre-authorization of coverage required for non-emergency admissions. Cost sharing is a per day limit.

Pre-certification/pre-authorization of coverage required for non-emergency admissions. Cost sharing is a per day limit.

YES

$250.00 Copay per Day

100.00%
Substance Abuse Disorder Outpatient Services
YES

$35.00

100.00%
Transplant

Exclusions: Prior authorization is required. Cost sharing is a per day limit.

Prior authorization is required. Inpatient per day limitation applies.

YES

$250.00

100.00%
Treatment for Temporomandibular Joint Disorders

Exclusions: Prior authorization is required.

Prior authorization is required. One splint in a six month period unless a more frequent replacement is determined to be medically necessary.

YES

$35.00

100.00%
Urgent Care Centers or Facilities
YES

$75.00

$75.00
Weight Loss Programs
YES

No Charge

100.00%
Well Baby Visits and Care
YES

No Charge

100.00%
X-rays and Diagnostic Imaging

Tests in hospitals, or facilities owned and operated by hospitals, may have higher cost share.

YES

10.00% Coinsurance after deductible

100.00%

Gym Access IND Gold HMO 4500 Health Insurance Plan Variant 56503FL2090002-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.819686628
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2023
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Standard Gold Off Exchange Plan
Dental Only Plan No
Design Type Not Applicable
Disease Management Programs Offered Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pregnancy, Weight Loss Programs
EHB Percent of Total Premium 1
First Tier Utilization 100%
Formulary ID FLF011
Formulary URL URL
HIOS Product ID 56503FL209
Import Date 11/18/2022 1:01
Limited Cost Sharing Plan Variation - Estimated Advanced Payment $0.00
Inpatient Copayment Maximum Days 3
HSA Eligible No
New/Existing Plan Existing
Notice Required for Pregnancy No
Is a Referral Required for Specialist? Yes
Issuer ID 56503
Issuer Marketplace Marketing Name Florida Health Care Plans
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Gold
Multiple In Network Tiers No
National Network No
Network ID FLN001
Out of Country Coverage Yes
Out of Country Coverage Description Emergency and Urgent Care Only
Out of Service Area Coverage Yes
Out of Service Area Coverage Description Emergency and Urgent Care only, unless pre-authorized by Issuer.
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 56503FL2090002-00
Plan Marketing Name Gym Access IND Gold HMO 4500
Plan Type HMO
Plan Variant Marketing Name Gym Access IND Gold HMO 4500
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $900
SBC Scenario, Having a Baby, Deductible $300
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $1,200
SBC Scenario, Having Diabetes, Deductible $0
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $20
SBC Scenario, Treatment of a Simple Fracture, Copayment $300
SBC Scenario, Treatment of a Simple Fracture, Deductible $1,800
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID FLS001
Source Name HIOS
Specialist Requiring a Referral The member's PCP will refer to all specialists, except those listed as "Direct Access" specialists.
Plan ID 56503FL2090002
State Code FL
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group per group not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person per person not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual Not Applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group per group not applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 10.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $5100 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $2550 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $2,550
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group per group not applicable
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person per person not applicable
Combined Medical and Drug EHB Deductible, Out of Network, Individual Not Applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $10000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $5000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $5,000
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group per group not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person per person not applicable
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual Not Applicable
Unique Plan Design No
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered Yes

Copay & Coinsurance of Gym Access IND Gold HMO 4500 Health Insurance Plan, 56503FL2090002

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about Gym Access IND Gold HMO 4500, 56503FL2090002 Health Insurance Plan, 56503FL2090002

  • Does Gym Access IND Gold HMO 4500 Health Insurance Plan, 56503FL2090002 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (56503FL2090002) Health Insurance Plan, Variant (56503FL2090002-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pregnancy, Weight Loss Programs

    Does (56503FL2090002) Health Insurance Plan, Variant (56503FL2090002-00) have Out Of Country Coverage?

    Yes. Details: Emergency and Urgent Care Only

    Does (56503FL2090002) Health Insurance Plan, Variant (56503FL2090002-00) have Out of Service Area Coverage?

    Yes. Details: Emergency and Urgent Care only, unless pre-authorized by Issuer.

    Does (56503FL2090002) Health Insurance Plan, Variant (56503FL2090002-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pregnancy, Weight Loss Programs

    Does Gym Access IND Gold HMO 4500 Health Insurance Plan, Variant (56503FL2090002-00) offer Disease Management Programs for Asthma?

    Yes, the Gym Access IND Gold HMO 4500 Health Insurance Plan Variant 56503FL2090002-00 offers Disease Management Program for Asthma.

    Does Gym Access IND Gold HMO 4500 Health Insurance Plan, Variant (56503FL2090002-00) offer Disease Management Programs for Heart disease?

    Yes, the Gym Access IND Gold HMO 4500 Health Insurance Plan Variant 56503FL2090002-00 offers Disease Management Program for Heart disease.

    Does Gym Access IND Gold HMO 4500 Health Insurance Plan, Variant (56503FL2090002-00) offer Disease Management Programs for Depression?

    Yes, the Gym Access IND Gold HMO 4500 Health Insurance Plan Variant 56503FL2090002-00 offers Disease Management Program for Depression.

    Does Gym Access IND Gold HMO 4500 Health Insurance Plan, Variant (56503FL2090002-00) offer Disease Management Programs for Diabetes?

    Yes, the Gym Access IND Gold HMO 4500 Health Insurance Plan Variant 56503FL2090002-00 offers Disease Management Program for Diabetes.

    Does Gym Access IND Gold HMO 4500 Health Insurance Plan, Variant (56503FL2090002-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Gym Access IND Gold HMO 4500 Health Insurance Plan Variant 56503FL2090002-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Gym Access IND Gold HMO 4500 Health Insurance Plan, Variant (56503FL2090002-00) offer Disease Management Programs for Low back pain?

    Yes, the Gym Access IND Gold HMO 4500 Health Insurance Plan Variant 56503FL2090002-00 offers Disease Management Program for Low back pain.

    Does Gym Access IND Gold HMO 4500 Health Insurance Plan, Variant (56503FL2090002-00) offer Disease Management Programs for Pregnancy?

    Yes, the Gym Access IND Gold HMO 4500 Health Insurance Plan Variant 56503FL2090002-00 offers Disease Management Program for Pregnancy.

    Does Gym Access IND Gold HMO 4500 Health Insurance Plan, Variant (56503FL2090002-00) offer Disease Management Programs for Weight loss programs?

    Yes, the Gym Access IND Gold HMO 4500 Health Insurance Plan Variant 56503FL2090002-00 offers Disease Management Program for Weight loss programs.

 

Disclaimer: This is based on the import(Date: Wed, 27 Mar 2024 12:10 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API