Bright Health

Bronze 7200 + Adult Dental & Vision($0 Telehealth + $0 Primary Care + $0 Mental Health + $0 Prescription List)

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $7,200 Family: $14,400 Per Person: $7,200
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,700 Family: $17,400 Per Person: $8,700

Office Visit

Primary Doctor	CoPay: No Charge CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible 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: $35.00 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: Not Applicable 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

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	CoPay: No Charge CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Limited to $1,000 per person per Calendar Year
Basic Dental Care - Adult	CoPay: Not Applicable CoInsurance: 30.00% Coinsurance after deductible Covered: Covered Benefit Explanation: $25 Deductible per Individual; $75 Deductible per Family; Limited to $1,000 per person per Calendar Year
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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