US Health and Life

Balanced Bronze 1

Plan Overview

Combined Medical and Drug Deductible
  • Individual: $8,000.00
  • Family: $16,000
  • Per Person: $8,000
Combined Medical and Drug Out of Pocket Maximum
  • Individual: $8,700.00
  • Family: $17,400
  • Per Person: $8,700

Office Visit

Primary Doctor
  • CoPay: $50.00
  • CoInsurance: Not Applicable
  • Covered: Covered
Specialist
  • CoPay: $100.00
  • CoInsurance: Not Applicable
  • Covered: Covered

Prescription Drug Information

Preferred Brand Drugs
  • CoPay: Not Applicable
  • CoInsurance: 50.00% Coinsurance after deductible
  • Covered: Covered
Non Preferred Brand Drugs
  • CoPay: Not Applicable
  • CoInsurance: 50.00% Coinsurance after deductible
  • Covered: Covered
Generic Drugs
  • CoPay: $20.00
  • CoInsurance: Not Applicable
  • Covered: Covered
Specialty Drugs
  • CoPay: Not Applicable
  • CoInsurance: 50.00% Coinsurance after deductible
  • Covered: Covered

Inpatient Coverage

Hospital Services
  • CoPay: Not Applicable
  • CoInsurance: 50.00% Coinsurance after deductible
  • Covered: Covered
  • Benefit Explanation: Maximum 60 days per Benefit Period for Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis). Limit is combined both In and Out of Network.
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: Not Applicable
  • CoInsurance: 50.00% Coinsurance after deductible
  • 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: $50.00
  • CoInsurance: Not Applicable
  • Covered: Covered

Vision

Routine Eye Exams For Children
  • CoPay: $50.00
  • CoInsurance: Not Applicable
  • Covered: Covered

Major Dental Care

Routine Dental Checkups for Children
  • CoPay: Not Applicable
  • CoInsurance: Not Applicable
  • Covered: Not Covered
Routine Dental Checkups for Adults
  • Covered: Not Covered
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