Plan Brochure
2022 Plan Comparison
2022 Drug Formulary
$0 Rx List (including contraceptives)
Provider Directory
- Overview
- Bright Health Bronze $0 Primary Care
- Bright Health Bronze $0 Medical Deductible
- Bright Health Bronze 7000 HSA
- Bright Health Bronze 8550
Bright Health Bronze Overview
Bright Health Bronze Plans have lower premiums and higher deductibles. These are best for healthy individuals who want to minimize their monthly premiums and are comfortable with the risk of a higher deductible in the event of a high-cost incident.
Advanced Premium Tax Credits (APTC) can be used to lower monthly premium payments if you quality.
Bright Health Bronze plans have been rated #2 and #4 by price and #1 in value and network in Cook County.
Bright Health has a total of 4 Bronze plans.
- Bronze 8550 – $8,550 individual deductible and 0% coinsurance.
- Bronze 7000 HSA – $7,000 individual deductible and 0% coinsurance.
- Bronze $0 Medical Deductible – $0 / $4,950 Rx individual deductible and 50% coinsurance
- Bronze $0 Primary Care – $7,200 individual deductible and 50% coinsurance
Bright Health Bronze $0 Primary Care
Download Summary of Benefits and Coverage here
Plan Guide here
Find a doctor here
| Important Questions | Answers | Why this Matters: |
| What is the overall deductible ? | $7,200 Individual or $14,400 Family |
See the Common Medical Events chart below for your costs for services this plan covers. Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. |
| Are there services covered before you meet your deductible? | Yes. Primary Care, Urgent Care and Generic Drugs are covered without a deductible. | This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ . |
| Are there other deductibles for specific services? |
No | You don’t have to meet deductibles for specific services |
| What is the out-of-pocket limit for this plan? |
$8,550 Individual or $17,100 Family |
The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. |
| What is not included in the out-of-pocket limit? |
Premiums, balance-billed charges, and health care this plan doesn’t cover. | Even though you pay these expenses, they don’t count toward the out-of-pocket limit. |
| Will you pay less if you use a network provider? | Yes. See https://brighthealthplan.com/provider-finder/ifp or call 1-855-827-4448 for a list of network providers. |
This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. |
| Do you need a referral to see a specialist? |
Yes | This plan will pay some or all of the costs to see a specialist for covered services but only if you have a referral before you see the specialist. |
Common Medical Event
Services You May Need
Your cost if you use
a Participating
Provider (You will pay the least)
Your cost if you use
a Non-Participating
Provider (You will pay the most)
Limitations & Exceptions, & Other Important Information
If you visit a health care provider’s office or clinic
Primary care visit to treat an injury or illness
No charge
Not covered
None
Specialist visit
50%
Not covered
None
Preventive care/screening/immunization
No charge
Not covered
You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.
If you have a test
Diagnostic test (x-ray, blood work)
50%
Not covered
Pre-authorization is required for Imaging (CT/PET/MRI).
Imaging (CT / PET scans, MRIs)
50%
Not covered
Pre-authorization is required for Imaging (CT/PET/MRI).
If you need drugs to treat
your illness or condition.
More information about
prescription drug coverage
is available at
www.brighthealthplan.com
your illness or condition.
More information about
prescription drug coverage
is available at
www.brighthealthplan.com
Generic drugs (Tier 2)
$25
Not covered
Tier 1 drugs are Preventive medications that are of $0 cost to you. Copays shown reflect the cost per retail prescription for a 30-day supply. Mail Order copays are 2.5 times the Retail cost for a 90-day supply
Preferred brand drugs (Tier 3)
50%
Not covered
Non-preferred brand drugs
(Tier 4)
(Tier 4)
50%
Not covered
Specialty drugs (Tier5)
50%
Not covered
If you have outpatient
surgery
surgery
Facility fee (e.g., ambulatory surgery center)
50%
Not covered
Services require pre-authorization.
Physician/surgeon fees
50%
Not covered
If you need immediate
medical attention
medical attention
Emergency room care
50%
50%
None
Emergency medical transportation
50%
50%
None
Urgent care
$50
$50
None
If you have a hospital
stay
stay
Facility fee (e.g., hospital room)
50%
Not covered
Services require pre-authorization.
Physician/surgeon fee
50%
Not covered
If you have mental
health, behavioral
health, or substance
abuse needs
health, behavioral
health, or substance
abuse needs
Outpatient services
50%
Not covered
None
Inpatient services
50%
Not covered
Services require pre-authorization.
If you are pregnant
Office visits
No charge
Not covered
Delivery stays exceeding 48 hours for vaginal delivery or 96 hours for a cesarean delivery require preauthorization.
Childbirth/delivery professional services
50%
Not covered
Delivery stays exceeding 48 hours for vaginal delivery or 96 hours for a cesarean delivery require preauthorization.
Childbirth/delivery facility services
50%
Not covered
Delivery stays exceeding 48 hours for vaginal delivery or 96 hours for a cesarean delivery require preauthorization.
If you need help
recovering or have other special health needs
recovering or have other special health needs
Home health care
50%
Not covered
Services require pre-authorization
Rehabilitation services
50%
Not covered
Habilitation services
50%
Not covered
Skilled nursing care
50%
Not covered
Durable medical equipment
50%
Not covered
Services require pre-authorization.
Hospice service
50%
Not covered
Services require pre-authorization.
If your child needs
dental or eye care
dental or eye care
Children’s eye exam
No Charge
Not covered
Limited to 1 eye exam per calendar year through the end of the month in which the dependent child turns19.
Children’s glasses
No Charge
Not covered
Limited to 1 pair of glasses including standard frames and standard lenses, or a one-year supply of contact lenses through the end of the month in which the dependent child turns 19.
Children’s dental check-up
Not Covered
Not Covered
Includes diagnostic and preventive services for dependent children through the end of the month in which the dependent child turns 19. Refer to the policy for covered services and limitations.
Excluded Services & Other Covered Services:
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
- Acupuncture
- Cosmetic Surgery
- Dental care (Adults)
- Long-term care
- Non-emergency care when traveling outside the U.S.
- Routine eye care (Adults)
- Weight loss programs
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
- Abortion care
- Bariatric surgery
- Chiropractic care
- Hearing aids
- Infertility treatment
- Private-duty nursing
- Routine foot care (for diabetes)
Bright Health Bronze $0 Medical Deductible
Download Summary of Benefits and Coverage here
Plan Guide here
Find a doctor here
| Important Questions | Answers | Why this Matters: |
| What is the overall deductible ? | $0 Individual or $0 Family |
See the Common Medical Events chart below for your costs for services this plan covers. Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. |
| Are there services covered before you meet your deductible? | Yes. Primary Care, Specialty Care, Lab and Xray services, some Prescription Drugs, Urgent Care, Outpatient Mental Health, Inpatient and Outpatient Hospital care, and Pediatric Dental and Vision are covered before the deductible. | This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ . |
| Are there other deductibles for specific services? |
Yes, Prescription Drugs. $4,950 Individual or $9,900 Family |
You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services. |
| What is the out-of-pocket limit for this plan? |
$8,550 Individual or $17,100 Family |
The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. |
| What is not included in the out-of-pocket limit? |
Premiums, balance-billed charges, and health care this plan doesn’t cover. | Even though you pay these expenses, they don’t count toward the out-of-pocket limit. |
| Will you pay less if you use a network provider? | Yes. See https://brighthealthplan.com/provider-finder/ifp or call 1-855-827-4448 for a list of network providers. |
This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. |
| Do you need a referral to see a specialist? |
Yes | This plan will pay some or all of the costs to see a specialist for covered services but only if you have a referral before you see the specialist. |
Common Medical Event
Services You May Need
Your cost if you use
a Participating
Provider (You will pay the least)
Your cost if you use
a Non-Participating
Provider (You will pay the most)
Limitations & Exceptions, & Other Important Information
If you visit a health care provider’s office or clinic
Primary care visit to treat an injury or illness
$50
Not covered
None
Specialist visit
$100
Not covered
None
Preventive care/screening/immunization
No charge
Not covered
You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.
If you have a test
Diagnostic test (x-ray, blood work)
Labs $50 per visit X-ray $100 per visit
Not covered
Pre-authorization is required for Imaging (CT/PET/MRI).
Imaging (CT / PET scans, MRIs)
$300
Not covered
Pre-authorization is required for Imaging (CT/PET/MRI).
If you need drugs to treat
your illness or condition.
More information about
prescription drug coverage
is available at
www.brighthealthplan.com
your illness or condition.
More information about
prescription drug coverage
is available at
www.brighthealthplan.com
Generic drugs (Tier 2)
$30
Not covered
Tier 1 drugs are Preventive medications that are of $0 cost to you. Copays shown reflect the cost per retail prescription for a 30-day supply. Mail Order copays are 2.5 times the Retail cost for a 90-day supply
Preferred brand drugs (Tier 3)
$200
Not covered
Non-preferred brand drugs
(Tier 4)
(Tier 4)
50%
Not covered
Specialty drugs (Tier5)
50%
Not covered
If you have outpatient
surgery
surgery
Facility fee (e.g., ambulatory surgery center)
$1,000
Not covered
Services require pre-authorization.
Physician/surgeon fees
$300
Not covered
If you need immediate
medical attention
medical attention
Emergency room care
$1,000
$1,000
None
Emergency medical transportation
50%
50%
None
Urgent care
$50
$50
None
If you have a hospital
stay
stay
Facility fee (e.g., hospital room)
$2,500 per day
Not covered
Copay applies to first 2 days of hospitalization. Services require pre-authorization.
Physician/surgeon fee
$300
Not covered
If you have mental
health, behavioral
health, or substance
abuse needs
health, behavioral
health, or substance
abuse needs
Outpatient services
$50
Not covered
None
Inpatient services
$2,500
Not covered
Copay applies to first 2 days of hospitalization. Services require pre-authorization.
If you are pregnant
Office visits
No charge
Not covered
Copay applies to first 2 days of hospitalization. Delivery stays exceeding 48 hours for vaginal delivery or 96 hours for a cesarean delivery require preauthorization.
Childbirth/delivery professional services
No charge
Not covered
Copay applies to first 2 days of hospitalization. Delivery stays exceeding 48 hours for vaginal delivery or 96 hours for a cesarean delivery require preauthorization.
Childbirth/delivery facility services
$2,500 per day
Not covered
Copay applies to first 2 days of hospitalization. Delivery stays exceeding 48 hours for vaginal delivery or 96 hours for a cesarean delivery require preauthorization.
If you need help
recovering or have other special health needs
recovering or have other special health needs
Home health care
50%
Not covered
Services require pre-authorization
Copay applies per day up to 2 days. Services require pre-authorization. .
Rehabilitation services
$100
Not covered
Habilitation services
$100
Not covered
Skilled nursing care
$2,500 per day
Not covered
Durable medical equipment
50%
Not covered
Services require pre-authorization.
Hospice service
50%
Not covered
Services require pre-authorization.
If your child needs
dental or eye care
dental or eye care
Children’s eye exam
No Charge
Not covered
Limited to 1 eye exam per calendar year through the end of the month in which the dependent child turns19.
Children’s glasses
No Charge
Not covered
Limited to 1 pair of glasses including standard frames and standard lenses, or a one-year supply of contact lenses through the end of the month in which the dependent child turns 19.
Children’s dental check-up
Not Covered
Not Covered
Includes diagnostic and preventive services for dependent children through the end of the month in which the dependent child turns 19. Refer to the policy for covered services and limitations.
Excluded Services & Other Covered Services:
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
- Acupuncture
- Cosmetic Surgery
- Dental care (Adults)
- Long-term care
- Non-emergency care when traveling outside the U.S.
- Routine eye care (Adults)
- Weight loss programs
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
- Abortion care
- Bariatric surgery
- Chiropractic care
- Hearing aids
- Infertility treatment
- Private-duty nursing
- Routine foot care (for diabetes)
Bright Health Bronze 7000 HSA
Download Summary of Benefits and Coverage here
Plan Guide here
Find a doctor here
| Important Questions | Answers | Why this Matters: |
| What is the overall deductible ? | $7,000 Individual or $14,000 Family |
See the Common Medical Events chart below for your costs for services this plan covers. Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. |
| Are there services covered before you meet your deductible? | No. You will have to meet the deductible before the plan pays for any services. |
This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ . |
| Are there other deductibles for specific services? |
No | You don’t have to meet deductibles for specific services. |
| What is the out-of-pocket limit for this plan? |
$7,000 Individual or $14,000 Family |
The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. |
| What is not included in the out-of-pocket limit? |
Premiums, balance-billed charges, and health care this plan doesn’t cover. | Even though you pay these expenses, they don’t count toward the out-of-pocket limit. |
| Will you pay less if you use a network provider? | Yes. See https://brighthealthplan.com/provider-finder/ifp or call 1-855-827-4448 for a list of network providers. |
This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. |
| Do you need a referral to see a specialist? |
Yes | This plan will pay some or all of the costs to see a specialist for covered services but only if you have a referral before you see the specialist. |
Common Medical Event
Services You May Need
Your cost if you use
a Participating
Provider (You will pay the least)
Your cost if you use
a Non-Participating
Provider (You will pay the most)
Limitations & Exceptions, & Other Important Information
If you visit a health care provider’s office or clinic
Primary care visit to treat an injury or illness
0%
Not covered
None
Specialist visit
0%
Not covered
None
Preventive care/screening/immunization
No charge
Not covered
You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.
If you have a test
Diagnostic test (x-ray, blood work)
0%
Not covered
Pre-authorization is required for Imaging (CT/PET/MRI).
Imaging (CT / PET scans, MRIs)
0%
Not covered
Pre-authorization is required for Imaging (CT/PET/MRI).
If you need drugs to treat
your illness or condition.
More information about
prescription drug coverage
is available at
www.brighthealthplan.com
your illness or condition.
More information about
prescription drug coverage
is available at
www.brighthealthplan.com
Generic drugs (Tier 2)
0%
Not covered
Tier 1 drugs are Preventive medications that are of $0 cost to you. Copays shown reflect the cost per retail prescription for a 30-day supply. Mail Order copays are 2.5 times the Retail cost for a 90-day supply
Preferred brand drugs (Tier 3)
0%
Not covered
Non-preferred brand drugs
(Tier 4)
(Tier 4)
0%
Not covered
Specialty drugs (Tier5)
0%
Not covered
If you have outpatient
surgery
surgery
Facility fee (e.g., ambulatory surgery center)
0%
Not covered
Services require pre-authorization.
Physician/surgeon fees
0%
Not covered
If you need immediate
medical attention
medical attention
Emergency room care
0%
0%
None
Emergency medical transportation
0%
0%
None
Urgent care
0%
0%
None
If you have a hospital
stay
stay
Facility fee (e.g., hospital room)
0%
Not covered
Services require pre-authorization.
Physician/surgeon fee
0%
Not covered
If you have mental
health, behavioral
health, or substance
abuse needs
health, behavioral
health, or substance
abuse needs
Outpatient services
0%
Not covered
None
Inpatient services
0%
Not covered
Preauthorization required
If you are pregnant
Office visits
0%
Not covered
Delivery stays exceeding 48 hours for vaginal delivery or 96 hours for a cesarean delivery require preauthorization.
Childbirth/delivery professional services
0%
Not covered
Delivery stays exceeding 48 hours for vaginal delivery or 96 hours for a cesarean delivery require preauthorization.
Childbirth/delivery facility services
0%
Not covered
Delivery stays exceeding 48 hours for vaginal delivery or 96 hours for a cesarean delivery require preauthorization.
If you need help
recovering or have other special health needs
recovering or have other special health needs
Home health care
0%
Not covered
Services require pre-authorization.
Rehabilitation services
0%
Not covered
Habilitation services
0%
Not covered
Skilled nursing care
0%
Not covered
Durable medical equipment
0%
Not covered
Services require pre-authorization.
Hospice service
0%
Not covered
Services require pre-authorization.
If your child needs
dental or eye care
dental or eye care
Children’s eye exam
No Charge
Not covered
Limited to 1 eye exam per calendar year through the end of the month in which the dependent child turns19.
Children’s glasses
No Charge
Not covered
Limited to 1 pair of glasses including standard frames and standard lenses, or a one-year supply of contact lenses through the end of the month in which the dependent child turns 19.
Children’s dental check-up
Not Covered
Not Covered
Includes diagnostic and preventive services for dependent children through the end of the month in which the dependent child turns 19. Refer to the policy for covered services and limitations.
Excluded Services & Other Covered Services:
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
- Acupuncture
- Cosmetic Surgery
- Dental care (Adults)
- Long-term care
- Non-emergency care when traveling outside the U.S.
- Routine eye care (Adults)
- Weight loss programs
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
- Abortion care
- Bariatric surgery
- Chiropractic care
- Hearing aids
- Infertility treatment
- Private-duty nursing
- Routine foot care (for diabetes)
Bright Health Bronze 8550
Download Summary of Benefits and Coverage here
Plan Guide here
Find a doctor here
| Important Questions | Answers | Why this Matters: |
| What is the overall deductible ? | $8,550 Individual or $17,100 Family |
See the Common Medical Events chart below for your costs for services this plan covers. Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. |
| Are there services covered before you meet your deductible? | Yes. Primary Care, Urgent Care and Generic Drugs are covered without a deductible. | This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/ . |
| Are there other deductibles for specific services? |
No | You don’t have to meet deductibles for specific services. |
| What is the out-of-pocket limit for this plan? |
$8,550 Individual or $17,100 Family |
The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. |
| What is not included in the out-of-pocket limit? |
Premiums, balance-billed charges, and health care this plan doesn’t cover. | Even though you pay these expenses, they don’t count toward the out-of-pocket limit. |
| Will you pay less if you use a network provider? | Yes. See https://brighthealthplan.com/provider-finder/ifp or call 1-855-827-4448 for a list of network providers. |
This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. |
| Do you need a referral to see a specialist? |
Yes | This plan will pay some or all of the costs to see a specialist for covered services but only if you have a referral before you see the specialist. |
Common Medical Event
Services You May Need
Your cost if you use
a Participating
Provider (You will pay the least)
Your cost if you use
a Non-Participating
Provider (You will pay the most)
Limitations & Exceptions, & Other Important Information
If you visit a health care provider’s office or clinic
Primary care visit to treat an injury or illness
$25 first 2 visits, then 0%
Not covered
$25 for the first 2 visits, then no charge after deductible
Specialist visit
0%
Not covered
None
Preventive care/screening/immunization
No charge
Not covered
You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.
If you have a test
Diagnostic test (x-ray, blood work)
0%
Not covered
Pre-authorization is required for Imaging (CT/PET/MRI).
Imaging (CT / PET scans, MRIs)
0%
Not covered
Pre-authorization is required for Imaging (CT/PET/MRI).
If you need drugs to treat
your illness or condition.
More information about
prescription drug coverage
is available at
www.brighthealthplan.com
your illness or condition.
More information about
prescription drug coverage
is available at
www.brighthealthplan.com
Generic drugs (Tier 2)
$25
Not covered
Tier 1 drugs are Preventive medications that are of $0 cost to you. Copays shown reflect the cost per retail prescription for a 30-day supply. Mail Order copays are 2.5 times the Retail cost for a 90-day supply
Preferred brand drugs (Tier 3)
0%
Not covered
Non-preferred brand drugs
(Tier 4)
(Tier 4)
0%
Not covered
Specialty drugs (Tier5)
0%
Not covered
If you have outpatient
surgery
surgery
Facility fee (e.g., ambulatory surgery center)
0%
Not covered
Services require pre-authorization.
Physician/surgeon fees
0%
Not covered
If you need immediate
medical attention
medical attention
Emergency room care
0%
0%
None
Emergency medical transportation
0%
0%
None
Urgent care
0%
$50
None
If you have a hospital
stay
stay
Facility fee (e.g., hospital room)
0%
Not covered
Services require pre-authorization.
Physician/surgeon fee
0%
Not covered
If you have mental
health, behavioral
health, or substance
abuse needs
health, behavioral
health, or substance
abuse needs
Outpatient services
0%
Not covered
None
Inpatient services
0%
Not covered
Preauthorization required
If you are pregnant
Office visits
No charge
Not covered
Delivery stays exceeding 48 hours for vaginal delivery or 96 hours for a cesarean delivery require preauthorization.
Childbirth/delivery professional services
0%
Not covered
Delivery stays exceeding 48 hours for vaginal delivery or 96 hours for a cesarean delivery require preauthorization.
Childbirth/delivery facility
services
services
0%
Not covered
Delivery stays exceeding 48 hours for vaginal delivery or 96 hours for a cesarean delivery require preauthorization.
If you need help
recovering or have other special health needs
recovering or have other special health needs
Home health care
0%
Not covered
Services require pre-authorization.
Rehabilitation services
0%
Not covered
Habilitation services
0%
Not covered
Skilled nursing care
0%
Not covered
Durable medical equipment
0%
Not covered
Services require pre-authorization.
Hospice service
0%
Not covered
Services require pre-authorization.
If your child needs
dental or eye care
dental or eye care
Children’s eye exam
No Charge
Not covered
Limited to 1 eye exam per calendar year through the end of the month in which the dependent child turns19.
Children’s glasses
No Charge
Not covered
Limited to 1 pair of glasses including standard frames and standard lenses, or a one-year supply of contact lenses through the end of the month in which the dependent child turns 19.
Children’s dental check-up
Not Covered
Not Covered
Includes diagnostic and preventive services for dependent children through the end of the month in which the dependent child turns 19. Refer to the policy for covered services and limitations.
Excluded Services & Other Covered Services:
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
- Acupuncture
- Cosmetic Surgery
- Dental care (Adults)
- Long-term care
- Non-emergency care when traveling outside the U.S.
- Routine eye care (Adults)
- Weight loss programs
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
- Abortion care
- Bariatric surgery
- Chiropractic care
- Hearing aids
- Infertility treatment
- Private-duty nursing
- Routine foot care (for diabetes)