Gold Plans

Lowest Out-of-Pocket Costs

When you want to offer your employees the very best health care coverage, no or low copays with no deductible, our HMO Gold Plans are for you.
 
These plans take away your employees’ worries of medical expenses and let them focus on the job they are doing for you.
 
Plus, with FirstCare’s extensive network, you are sure to meet everyone’s individual needs.

Call us today to learn more about enrollment timeframes and to find a plan that fits your needs. 1-855-572-7238.

 

Glance through the chart below for a comparison, or open up the linked PDFs for more details.

 Print
2017
Plan Benefits
HMO
Gold
Coinsurance
Select Network
HMO
Gold
Copay
Select Network
HMO
Gold
Coinsurance
Select Plus Network
HMO
Gold
Copay
Select Plus Network
Medical Deductible (if any)
Single/Family
$1,200/$2,400 $0/$0 $1,200/$2,400 $0/$0
Medication Deductible (if any) 
Single/Family
$0/$0 $0/$0 $0/$0 $0/$0
Preventive Care Copay No Charge No Charge No Charge No Charge
Adult Primary Care Visit Copay $30 $30 $30 $30
Pediatric Primary Care Visit Copay
(Ages 0-19)
No Charge No Charge No Charge No Charge
Specialty Care Visit Copay $50 $50 $50 $50
Inpatient Copay 20%1 $700 per day, not to exceed $3,500 per stay 20%1 $700 per day, not to exceed $3,500 per stay
Outpatient Copay 20%1 $600 20%1 $600
Emergency Room Copay $5001 $500 $5001 $500
Urgent Care Copay $50 $50 $50 $50
Routine Lab/X-Ray Copay No Charge No Charge No Charge No Charge
Imaging (MRI, CT, Scans) Copay $250 per test1 $250 per test $250 per test1 $250 per test
Medication Copays:
Tier I
Tier II
Tier III
Tier IV
Tier V

$0
$10
$50
$100
30%
$0
$20
$50
$100
30%

$0
$10
$50
$100
30%

$0
$20
$50
$100
30%
Maximum Out-Of-Pocket
Single/Family
$4,600/$9,200 $7,150/$14,300 $4,600/$9,200 $7,150/$14,300
Plan ID 26539TX0130001-00 26539TX0130002-00 26539TX0130008-00 26539TX0130009-00
Summary of Benefits & Coverage
(SBC)
Plan Documents
1After Medical Deductible







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HMO: 1-800-884-4901
PPO: 1-800-240-3270
Administrative Services: 1-888-249-7366

Resources

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Need care advice? Should you see a doctor? Get the info you need today! FirstCare members can talk to a nurse 24/7 by calling 1.855.828.1013 to get answers 24 hours a day, 7 days a week! TTY users can call 7-1-1 or  1.800.955.8771. Voice communication is available at 1.800.955.8770.

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