US Health and Life

HSA Eligible Bronze

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $7,000.00 Family: $14,000 Per Person: $7,000
Combined Medical and Drug Out of Pocket Maximum	Individual: $7,000.00 Family: $14,000 Per Person: $7,000

Office Visit

Primary Doctor	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered
Specialist	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered
Generic Drugs	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered
Specialty Drugs	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: No Charge 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: No Charge after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered
Urgent Care Facility	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered

Vision

Routine Eye Exams For Children

CoPay: Not Applicable
CoInsurance: No Charge after deductible
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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