Bright Health

Bronze 5300 HSA

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $5,300 Family: $10,600 Per Person: $5,300
Combined Medical and Drug Out of Pocket Maximum	Individual: $7,050 Family: $14,100 Per Person: $7,050

Office Visit

Primary Doctor	CoPay: $50 Copay after deductible CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: $100 Copay after deductible CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered Benefit Explanation: The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-day supply.
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered Benefit Explanation: The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-day supply.
Generic Drugs	CoPay: $20.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: No charge applies for certain generic drugs. For a list of generics available for no charge, open a new browser window and copy/paste this link into your browser: https://cdn1.brighthealthplan.com/docs/formulary/2022_IFP_0_DrugList.pdf. Cost share may apply for other generic drugs. The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-day supply.
Specialty Drugs	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered Benefit Explanation: The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-day supply.

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered
Urgent Care Facility	CoPay: $50.00 CoInsurance: 50% Coinsurance after deductible Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: No Charge CoInsurance: Not Applicable Covered: Covered Benefit Explanation: No charge applies to preventive prenatal and postnatal care.

Vision

Routine Eye Exams For Children

CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per Year
Benefit Explanation: Benefits are available through the end of the month in which the dependent child turns 19.

Major Dental Care

Routine Dental Checkups for Children	CoPay: No Charge CoInsurance: Not Applicable Covered: Covered Limit Quantity: 2 Limit Unit : Exam(s) per Year Benefit Explanation: Benefits are available through the end of the month in which the dependent child turns 19.
Routine Dental Checkups for Adults	Covered: Not Covered
Basic Dental Care - Adult	Covered: Not Covered
Basic Dental Care - Child	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Limitations apply. Refer to policy for full description of exclusions and limitations.
Major Dental Care - Adult	Covered: Not Covered
Major Dental Care - Child	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Limitations apply. Refer to policy for full description of exclusions and limitations.

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