Benefit Explanation: In Network (Tier 1) cost share applies to the first 3 visits. In Network (Tier 2) cost share applies to additional visits.
Specialist
CoPay: $80.00
CoInsurance: Not Applicable
Covered: Covered
Prescription Drug Information
Preferred Brand Drugs
CoPay: $150.00
CoInsurance: Not Applicable
Covered: Covered
Non Preferred Brand Drugs
CoPay: $250.00
CoInsurance: Not Applicable
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: 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
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
Limit Quantity: 2
Limit Unit : Visit(s) per Year
Benefit Explanation: Benefits are available up to the end of the month in which the dependent child turns 19.
1-817-813-4562, TTY 711
