BridgeSpan Health

BridgeSpan Standard Gold Plan

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Medical Deductible	Individual: $1,500.00 Family: $3000 Per Person: $1500
Prescription Drug Deductible	Individual: $0.00 Family: $0 Per Person: $0
Combined Medical and Drug Out of Pocket Maximum	Individual: $7,000.00 Family: $14000 Per Person: $7000

Office Visit

Primary Doctor	CoPay: $20.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: $5 copay for the first three in-network primary care provider, other practitioner, outpatient mental/behavioral health, or outpatient substance abuse disorder visits combined per year prior to the deductible being met.
Specialist	CoPay: $40.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $30.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Insulin limit of $35 for a 30 day supply and $105 for a 90-day supply
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 50.00% Covered: Covered Benefit Explanation: Insulin limit of $35 for a 30 day supply and $105 for a 90-day supply
Generic Drugs	CoPay: $10.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Insulin limit of $35 for a 30 day supply and $105 for a 90-day supply
Specialty Drugs	CoPay: Not Applicable CoInsurance: 50.00% Covered: Covered Limit Quantity: 30 Limit Unit : Days per Month Benefit Explanation: $500 cap per prescription for the Standard Gold Plan. Insulin: Insulin limit of $35 for a 30 day supply and $105 for a 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: $60.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Out of service area coverage is available.

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 : Exam(s) per Year

Major Dental Care

Routine Dental Checkups for Children	Covered: Not Covered
Routine Dental Checkups for Adults	Covered: Not Covered