BridgeSpan Health

BridgeSpan Cascade Silver

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $2,000 Family: $4,000 Per Person: $2,000
Combined Medical and Drug Out of Pocket Maximum	Individual: $7,800 Family: $15,600 Per Person: $7,800

Office Visit

Primary Doctor	CoPay: $25.00 CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: $60.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $70.00 CoInsurance: Not Applicable Covered: Covered Limit Quantity: 30 Limit Unit : Days per Month Benefit Explanation: Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill.
Non Preferred Brand Drugs	CoPay: $250.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered Limit Quantity: 30 Limit Unit : Days per Month Benefit Explanation: Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill.
Generic Drugs	CoPay: $20.00 CoInsurance: Not Applicable Covered: Covered Limit Quantity: 30 Limit Unit : Days per Month Benefit Explanation: Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill. 53732WA0790024 both WAF010, WAF013 apply; 53732WA0790025 both WAF017, WAF014 apply; 53732WA0790026 both WAF018, WAF015 apply
Specialty Drugs	CoPay: $250.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered Limit Quantity: 30 Limit Unit : Days per Month Benefit Explanation: First fill allowed at a retail pharmacy. Additional fills must be provided at a specialty pharmacy. Coverage is limited to a 30-day supply for specialty and self-administrable cancer chemotherapy medications from a specialty pharmacy per fill or refill.

Inpatient Coverage

Hospital Services	CoPay: $800.00 Copay per Day after deductible CoInsurance: Not Applicable Covered: Covered
Inpatient Services	CoPay: $800.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: $800.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Out of service area coverage is available.
Urgent Care Facility	CoPay: $60.00 CoInsurance: Not Applicable Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: $800.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered
Pre and Postnatal Office Visit	CoPay: $800.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered

Vision

Routine Eye Exams For Children

CoPay: No Charge
CoInsurance: No Charge
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per Year

Major Dental Care

Routine Dental Checkups for Children	Covered: Not Covered
Basic Dental Care - Child	Covered: Not Covered
Major Dental Care - Child	Covered: Not Covered

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