Silver 4000

12379FL0010222
Silver
EPO

Silver 4000 is a Silver EPO plan by Bright HealthCare.

Locations

Silver 4000 is offered in the following counties.

Plan Overview

This is a plan overview for 2022 version of Silver 4000 12379FL0010222.
Insurer: Bright HealthCare
Network Type: EPO
Metal Type: Silver
HSA Eligible?: No
Plan ID: 12379FL0010222

Cost-Sharing Overview

Silver 4000 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 Silver 4000?

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

Silver 4000 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 Silver 4000 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

Silver 4000 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
$35.00 / N/A /
Specialist Visit
Covered
N/A / 40.00% Coinsurance after deductible /
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
N/A / 40.00% Coinsurance after deductible /
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
N/A / 40.00% Coinsurance after deductible /
Outpatient Surgery Physician/Surgical Services
Covered
N/A / 40.00% Coinsurance after deductible /
Hospice Services
Covered
N/A / 40.00% Coinsurance after deductible /
Routine Dental Services (Adult)
Not Covered
/ /
Infertility Treatment
Not Covered
/ /
Long-Term/Custodial Nursing Home Care
Not Covered
/ /
Private-Duty Nursing
Not Covered
/ /
Routine Eye Exam (Adult)
Not Covered
/ /
Urgent Care Centers or Facilities
Covered
$50.00 / N/A /
Home Health Care Services
Covered
N/A / 40.00% Coinsurance after deductible / 20 Days per Year
Emergency Room Services
Covered
N/A / 40.00% Coinsurance after deductible /
Emergency Transportation/Ambulance
Covered
N/A / 40.00% Coinsurance after deductible /
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
N/A / 40.00% Coinsurance after deductible /
Inpatient Physician and Surgical Services
Covered
N/A / 40.00% Coinsurance after deductible /
Bariatric Surgery
Not Covered
/ /
Cosmetic Surgery
Not Covered
/ /
Skilled Nursing Facility
Covered
N/A / 40.00% 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 / 40.00% Coinsurance after deductible /
Mental/Behavioral Health Outpatient Services
Covered
N/A / 40.00% Coinsurance after deductible /
Mental/Behavioral Health Inpatient Services
Covered
N/A / 40.00% Coinsurance after deductible /
Substance Abuse Disorder Outpatient Services
Covered
N/A / 40.00% Coinsurance after deductible /
Substance Abuse Disorder Inpatient Services
Covered
N/A / 40.00% Coinsurance after deductible /
Generic Drugs
Covered
$15.00 / N/A /
Preferred Brand Drugs
Covered
N/A / 40.00% Coinsurance after deductible /
Non-Preferred Brand Drugs
Covered
N/A / 40.00% Coinsurance after deductible /
Specialty Drugs
Covered
N/A / 40.00% Coinsurance after deductible /
Outpatient Rehabilitation Services
Covered
N/A / 40.00% Coinsurance after deductible / 35 Days per Year Combined limit for Occupational Therapy, Physical Therapy, Speech Therapy, and Chiropractic Manipulations.
Habilitation Services
Covered
N/A / 40.00% Coinsurance after deductible /
Chiropractic Care
Covered
N/A / 40.00% Coinsurance after deductible / 35 Days per Year Combined limit for Occupational Therapy, Physical Therapy, Speech Therapy, and Chiropractic Manipulations.
Durable Medical Equipment
Covered
N/A / 40.00% Coinsurance after deductible /
Hearing Aids
Not Covered
/ /
Imaging (CT/PET Scans, MRIs)
Covered
N/A / 40.00% 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 / 40.00% 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 / 40.00% 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
N/A / 40.00% Coinsurance after deductible /
X-rays and Diagnostic Imaging
Covered
N/A / 40.00% Coinsurance after deductible /
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
Not Covered
/ /
Orthodontia – Adult
Not Covered
/ /
Major Dental Care – Adult
Not Covered
/ /
Abortion for Which Public Funding is Prohibited
Not Covered
/ /
Transplant
Covered
N/A / 40.00% Coinsurance after deductible /
Accidental Dental
Covered
N/A / 40.00% Coinsurance after deductible /
Dialysis
Covered
N/A / 40.00% Coinsurance after deductible /
Allergy Testing
Covered
N/A / 40.00% Coinsurance after deductible /
Chemotherapy
Covered
N/A / 40.00% Coinsurance after deductible /
Radiation
Covered
N/A / 40.00% Coinsurance after deductible /
Diabetes Education
Covered
No Charge / N/A /
Prosthetic Devices
Covered
N/A / 40.00% Coinsurance after deductible /
Infusion Therapy
Covered
N/A / 40.00% Coinsurance after deductible /
Treatment for Temporomandibular Joint Disorders
Covered
N/A / 40.00% 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 / 40.00% Coinsurance after deductible /

Free Preventive Services

There is no copayment or coinsurance for any of the following Silver 4000 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 Silver 4000 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 Silver 4000?

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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