Bright Health

Silver 4000 ($35 Primary Care + $15 Generic)

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $4,000 Family: $8,000 Per Person: $4,000
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,700 Family: $17,400 Per Person: $8,700

Office Visit

Primary Doctor	CoPay: $35.00 CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered
Generic Drugs	CoPay: $15.00 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.
Specialty Drugs	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Services require pre-authorization.
Inpatient Services	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Services require pre-authorization.

Emergency and Urgent Care

Emergency Room	CoPay: Not Applicable CoInsurance: 40.00% 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: 40.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Delivery stays exceeding 48 hours for vaginal delivery or 96 hours for cesarean delivery require pre-authorization.
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 up to 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 Benefit Explanation: Benefits are available up to the end of the month in which the dependent child turns 19.
Basic Dental Care - Adult	Benefit Explanation: Benefits are available up to the end of the month in which the dependent child turns 19.
Basic Dental Care - Child	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Benefits are available up to the end of the month in which the dependent child turns 19.
Major Dental Care - Child	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Benefits are available up to the end of the month in which the dependent child turns 19.

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