Bright Health

Silver 6700

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Summary Of Benefits

Plan Overview

Combined Medical and Drug Deductible	Individual: $6,700 Family: $13,400 Per Person: $6,700
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: 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.

Prescription Drug Information

Preferred Brand Drugs	CoPay: $90.00 CoInsurance: Not Applicable Covered: Covered
Non Preferred Brand Drugs	CoPay: $150.00 CoInsurance: Not Applicable Covered: Covered
Generic Drugs	CoPay: No Charge CoInsurance: Not Applicable Covered: Covered
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
Inpatient Services	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered

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
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% Coinsurance after deductible Covered: Covered Benefit Explanation: See policy document for plan limits.
Major Dental Care - Child	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered Benefit Explanation: See policy document for plan limits.

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