Gold $0 Deductible + Adult Dental & Vision

12379FL0010201
Gold
EPO

Gold $0 Deductible + Adult Dental & Vision is a Gold EPO plan by Bright HealthCare.

Locations

Gold $0 Deductible + Adult Dental & Vision is offered in the following counties.

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Plan Overview

This is a plan overview for 2022 version of Gold $0 Deductible + Adult Dental & Vision 12379FL0010201.
Insurer: Bright HealthCare
Network Type: EPO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 12379FL0010201

Cost-Sharing Overview

Gold $0 Deductible + Adult Dental & Vision offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Gold $0 Deductible + Adult Dental & Vision?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

Gold $0 Deductible + Adult Dental & Vision offers the following features and referral requirements.

Wellness Program: Yes
Disease Program: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pregnancy
Notice Pregnancy: No
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what Gold $0 Deductible + Adult Dental & Vision covers when you are out of the service area or out of the country.

Out of Country Coverage: Yes
Out of Country Coverage Description: Emergency Only
Out of Service Area Coverage: Yes
Out of Service Area Coverage Description: Emergency Only
National Network: No

Additional Benefits and Cost-Sharing

Gold $0 Deductible + Adult Dental & Vision includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
$20.00 / N/A / No charge applies to the first 2 visits, copay applies to additional visits.
Specialist Visit
Covered
$40.00 / N/A /
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
N/A / 20% Coinsurance after deductible /
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
$200.00 / N/A /
Outpatient Surgery Physician/Surgical Services
Covered
$50.00 / N/A /
Hospice Services
Covered
N/A / 20% Coinsurance after deductible /
Routine Dental Services (Adult)
Covered
No Charge / N/A /
Infertility Treatment
Not Covered
/ /
Long-Term/Custodial Nursing Home Care
Not Covered
/ /
Private-Duty Nursing
Not Covered
/ /
Routine Eye Exam (Adult)
Covered
$10.00 / N/A / 1 Exam(s) per Year Includes $130 materials allowance per year and a discount on charges above the allowance. Contact lenses have a $25 copay.
Urgent Care Centers or Facilities
Covered
$50.00 / N/A /
Home Health Care Services
Covered
N/A / 20% Coinsurance after deductible / 20 Days per Year
Emergency Room Services
Covered
$500.00 / N/A /
Emergency Transportation/Ambulance
Covered
N/A / 20% Coinsurance after deductible /
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
N/A / 20% Coinsurance after deductible /
Inpatient Physician and Surgical Services
Covered
N/A / 20% Coinsurance after deductible /
Bariatric Surgery
Not Covered
/ /
Cosmetic Surgery
Not Covered
/ /
Skilled Nursing Facility
Covered
N/A / 20% Coinsurance after deductible / 60 Days per Year
Prenatal and Postnatal Care
Covered
No Charge / N/A /
Delivery and All Inpatient Services for Maternity Care
Covered
N/A / 20% Coinsurance after deductible /
Mental/Behavioral Health Outpatient Services
Covered
No Charge / N/A /
Mental/Behavioral Health Inpatient Services
Covered
N/A / 20% Coinsurance after deductible /
Substance Abuse Disorder Outpatient Services
Covered
No Charge / N/A /
Substance Abuse Disorder Inpatient Services
Covered
N/A / 20% Coinsurance after deductible /
Generic Drugs
Covered
$15.00 / N/A / 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.
Preferred Brand Drugs
Covered
$50.00 / N/A /
Non-Preferred Brand Drugs
Covered
$125.00 / N/A /
Specialty Drugs
Covered
N/A / 20% Coinsurance after deductible /
Outpatient Rehabilitation Services
Covered
N/A / 20% Coinsurance after deductible / 35 Days per Year Combined limit for Occupational Therapy, Physical Therapy, Speech Therapy, and Chiropractic Manipulations.
Habilitation Services
Covered
N/A / 20% Coinsurance after deductible /
Chiropractic Care
Covered
$40.00 / N/A / 35 Days per Year Combined limit for Occupational Therapy, Physical Therapy, Speech Therapy, and Chiropractic Manipulations.
Durable Medical Equipment
Covered
N/A / 20% Coinsurance after deductible /
Hearing Aids
Not Covered
/ /
Imaging (CT/PET Scans, MRIs)
Covered
N/A / 20% Coinsurance after deductible /
Preventive Care/Screening/Immunization
Covered
No Charge / N/A /
Routine Foot Care
Not Covered
/ /
Acupuncture
Not Covered
/ /
Weight Loss Programs
Not Covered
/ /
Routine Eye Exam for Children
Covered
No Charge / N/A / 1 Exam(s) per Year Benefits are available up to the end of the month in which the dependent child turns 19.
Eye Glasses for Children
Covered
No Charge / N/A / 1 Item(s) per Year Benefits are available up to the end of the month in which the dependent child turns 19.
Dental Check-Up for Children
Covered
No Charge / N/A / Benefits are available up to the end of the month in which the dependent child turns 19.
Rehabilitative Speech Therapy
Covered
N/A / 20% Coinsurance after deductible / 35 Days per Year Combined limit for Occupational Therapy, Physical Therapy, Speech Therapy, and Chiropractic Manipulations.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
N/A / 20% Coinsurance after deductible / 35 Days per Year Combined limit for Occupational Therapy, Physical Therapy, Speech Therapy, and Chiropractic Manipulations.
Well Baby Visits and Care
Covered
No Charge / N/A /
Laboratory Outpatient and Professional Services
Covered
$50.00 / N/A /
X-rays and Diagnostic Imaging
Covered
$100.00 / N/A /
Basic Dental Care – Child
Covered
$50.00 / N/A / Benefits are available up to the end of the month in which the dependent child turns 19.
Orthodontia – Child
Covered
$2,800.00 / N/A / Benefits are available up to the end of the month in which the dependent child turns 19.
Major Dental Care – Child
Covered
$690.00 / N/A / Benefits are available up to the end of the month in which the dependent child turns 19.
Basic Dental Care – Adult
Covered
$50.00 / N/A / $25 Deductible per Individual; $75 Deductible per Family
Orthodontia – Adult
Not Covered
/ /
Major Dental Care – Adult
Covered
$690.00 / N/A /
Abortion for Which Public Funding is Prohibited
Not Covered
/ /
Transplant
Covered
N/A / 20% Coinsurance after deductible /
Accidental Dental
Covered
N/A / 20% Coinsurance after deductible /
Dialysis
Covered
N/A / 20% Coinsurance after deductible /
Allergy Testing
Covered
N/A / 20% Coinsurance after deductible /
Chemotherapy
Covered
N/A / 20% Coinsurance after deductible /
Radiation
Covered
N/A / 20% Coinsurance after deductible /
Diabetes Education
Covered
No Charge / N/A /
Prosthetic Devices
Covered
N/A / 20% Coinsurance after deductible /
Infusion Therapy
Covered
N/A / 20% Coinsurance after deductible /
Treatment for Temporomandibular Joint Disorders
Covered
N/A / 20% Coinsurance after deductible /
Nutritional Counseling
Covered
No Charge / N/A / Diabetes coverage includes ‘nutrition counseling’; home health services include ‘nutritional guidance.’
Reconstructive Surgery
Covered
N/A / 20% Coinsurance after deductible /

Free Preventive Services

There is no copayment or coinsurance for any of the following Gold $0 Deductible + Adult Dental & Vision preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for Gold $0 Deductible + Adult Dental & Vision including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for Gold $0 Deductible + Adult Dental & Vision?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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