BridgeSpan Health

BridgeSpan Cascade Select Gold

Plan Overview

Medical Deductible
  • Individual: $500
  • Family: $1,000
  • Per Person: $500
Prescription Drug Deductible
  • Individual: $0
  • Family: $0
  • Per Person: $0
Combined Medical and Drug Out of Pocket Maximum
  • Individual: $5,250
  • Family: $10,500
  • Per Person: $5,250

Office Visit

Primary Doctor
  • CoPay: $15.00
  • CoInsurance: Not Applicable
  • Covered: Covered
Specialist
  • CoPay: $40.00
  • CoInsurance: Not Applicable
  • Covered: Covered

Prescription Drug Information

Preferred Brand Drugs
  • CoPay: $60.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Limit Quantity: 30
  • Limit Unit : Days per Month
  • Benefit Explanation: Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill.
Non Preferred Brand Drugs
  • CoPay: $100.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Limit Quantity: 30
  • Limit Unit : Days per Month
  • Benefit Explanation: Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill.
Generic Drugs
  • CoPay: $10.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Limit Quantity: 30
  • Limit Unit : Days per Month
  • Benefit Explanation: Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill. 53732WA0790024 both WAF010, WAF013 apply; 53732WA0790028 both WAF017, WAF014 apply; 53732WA0790029 both WAF018, WAF015 apply
Specialty Drugs
  • CoPay: $100.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Limit Quantity: 30
  • Limit Unit : Days per Month
  • Benefit Explanation: First fill allowed at a retail pharmacy. Additional fills must be provided at a specialty pharmacy. Coverage is limited to a 30-day supply for specialty and self-administrable cancer chemotherapy medications from a specialty pharmacy per fill or refill.

Inpatient Coverage

Hospital Services
  • CoPay: $525.00 Copay per Day
  • CoInsurance: Not Applicable
  • Covered: Covered
Inpatient Services
  • CoPay: $525.00
  • CoInsurance: Not Applicable
  • Covered: Covered

Emergency and Urgent Care

Emergency Room
  • CoPay: $450.00 Copay after deductible
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: Out of service area coverage is available.
Urgent Care Facility
  • CoPay: $35.00
  • CoInsurance: Not Applicable
  • Covered: Covered

Maternity

Labor and Delivery Hospital Stay
  • CoPay: $525.00
  • CoInsurance: Not Applicable
  • Covered: Covered
Pre and Postnatal Office Visit
  • CoPay: $525.00
  • CoInsurance: Not Applicable
  • Covered: Covered

Vision

Routine Eye Exams For Children
  • CoPay: No Charge
  • CoInsurance: No Charge
  • Covered: Covered
  • Limit Quantity: 1
  • Limit Unit : Exam(s) per Year

Major Dental Care

Routine Dental Checkups for Children
  • Covered: Not Covered
Basic Dental Care - Child
  • Covered: Not Covered
Major Dental Care - Child
  • Covered: Not Covered
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