Benefit Explanation: In Network (Tier 1) cost share applies to the first visit. In Network (Tier 2) cost share applies to additional visits.
Specialist
CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: In Network (Tier 1) cost share applies to the first visit. In Network (Tier 2) cost share applies to additional visits.
Prescription Drug Information
Preferred Brand Drugs
CoPay: $200.00
CoInsurance: Not Applicable
Covered: Covered
Non Preferred Brand Drugs
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
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: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Inpatient Coverage
Hospital Services
CoPay: $3000.00 Copay per Day
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Copay applies per day, up to 2 days.
Inpatient Services
CoPay: $300.00
CoInsurance: Not Applicable
Covered: Covered
Emergency and Urgent Care
Emergency Room
CoPay: $1,000.00
CoInsurance: Not Applicable
Covered: Covered
Urgent Care Facility
CoPay: $50.00
CoInsurance: Not Applicable
Covered: Covered
Maternity
Labor and Delivery Hospital Stay
CoPay: $3,000.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Copay applies per day, up to 2 days.
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
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.
1-817-813-4562, TTY 711
