Bright Health

Bronze $0 Medical Deductible ($0 Telehealth + $0 Primary Care + $0 Specialist + $0 Mental Health + $0 Prescription List)

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Medical Deductible	Individual: $0 Family: $0 Per Person: $0
Prescription Drug Deductible	Individual: $4,950 Family: $9,900 Per Person: $4,950
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 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 Stay 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: Newborn benefits do not apply to the newborn child of an Eligible Dependent daughter unless placement with the Employee is confirmed through a court order or legal guardianship.
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 : Visit(s) per Year
Benefit Explanation: Benefits are available up to the end of the month in which the member turns 19.

Major Dental Care

Routine Dental Checkups for Children	CoPay: No Charge CoInsurance: Not Applicable Covered: Covered Limit Quantity: 2 Limit Unit : Visit(s) per Year Benefit Explanation: Benefits are available up to the end of the month in which the member turns 19.
Routine Dental Checkups for Adults	Covered: Not Covered
Basic Dental Care - Adult	Covered: Not Covered
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 member turns 19.
Major Dental Care - Adult	Covered: Not Covered
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 member turns 19.

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