Bright Health

Peak Gold $0 Ded + Adult Dental & Vision Rx Copay

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Summary Of Benefits

Plan Overview

Combined Medical and Drug Deductible	Individual: $0 Family: $0 Per Person: $0
Combined Medical and Drug Out of Pocket Maximum	Individual: $6,500 Family: $13,000 Per Person: $6,500

Office Visit

Primary Doctor	CoPay: No Charge CoInsurance: Not Applicable Covered: Covered Benefit Explanation: In Network (Tier 1) cost share applies to the first 2 visits. In Network (Tier 2) cost share applies to additional visits.
Specialist	CoPay: $40.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $50.00 CoInsurance: Not Applicable Covered: Covered
Non Preferred Brand Drugs	CoPay: $100.00 CoInsurance: Not Applicable Covered: Covered
Generic Drugs	CoPay: No Charge 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.
Specialty Drugs	CoPay: $540.00 CoInsurance: Not Applicable Covered: Covered

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 20.00% Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: 20.00% Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: $600.00 CoInsurance: Not Applicable Covered: Covered
Urgent Care Facility	CoPay: $75.00 CoInsurance: Not Applicable Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 20.00% 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

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
Routine Dental Checkups for Adults	CoPay: No Charge CoInsurance: Not Applicable Covered: Covered
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
Basic Dental Care - Child	CoPay: Not Applicable CoInsurance: 50.00% Covered: Covered Benefit Explanation: See policy document for plan limits.
Major Dental Care - Child	CoPay: Not Applicable CoInsurance: 50.00% Covered: Covered Benefit Explanation: See policy document for plan limits.

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