BridgeSpan Health

BridgeSpan Silver Essential 4000 With 4 Copay No Deductible Office Visits

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $4,000 Family: $8,000 Per Person: $4,000
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,700 Family: $17,400 Per Person: $8,700

Office Visit

Primary Doctor	CoPay: $45.00 Copay with deductible CoInsurance: 20.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Silver Essential plan the first 4 office visits per calendar year are not subject to the deductible for in-network providers
Specialist	CoPay: $45.00 Copay with deductible CoInsurance: 20.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Silver Essential plan the first 4 office visits per calendar year are not subject to the deductible for in-network providers

Prescription Drug Information

Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 30.00% Coinsurance after deductible Covered: Covered Benefit Explanation: insulin limit of $28 per 30 days $84 for 90 day supply
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered Benefit Explanation: insulin limit of $28 per 30 days $84 for 90 day supply
Generic Drugs	CoPay: $10.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: insulin limit of $28 per 30 days $84 for 90 day supply
Specialty Drugs	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered Benefit Explanation: First fill allowed at a retail pharmacy. Insulin limit of $28 per 30 days, $84 for 90 day-supply

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Out of service area coverage is available.
Urgent Care Facility	CoPay: $45.00 Copay with deductible CoInsurance: 20.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Silver Essential plan the first 4 office visits per calendar year are not subject to the deductible for in-network providers

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered

Vision

Routine Eye Exams For Children

CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Visit(s) per Benefit Period

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