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BridgeSpan Health Company   -   Silver HDHP 3000

Deductible & Out-of-Pocket
In Network
Out-of-Network
Deductible
Out-of-pocket max
Doctor Visit
In Network
Out-of-Network
Additional Information
Primary Care Visit
10.00% Coinsurance after deductible
50.00% Coinsurance after deductible
Specialist Visit
10.00% Coinsurance after deductible
50.00% Coinsurance after deductible
Other Practitioner Office Visit (Nurse, Physician Assistant)
10.00% Coinsurance after deductible
50.00% Coinsurance after deductible
Preventive Care/Screening/Immunization
No Charge
50.00% Coinsurance after deductible
Tests
In Network
Out-of-Network
Additional Information
Laboratory Outpatient and Professional Services
10.00% Coinsurance after deductible
50.00% Coinsurance after deductible
X-rays and Diagnostic Imaging
10.00% Coinsurance after deductible
50.00% Coinsurance after deductible
Imaging (CT/PET scans, MRIs)
10.00% Coinsurance after deductible
50.00% Coinsurance after deductible
Drugs
In Network
Out-of-Network
Additional Information
Generic Drugs
10.00% Coinsurance after deductible
10.00% Coinsurance after deductible
Preferred Brand Drugs
25.00% Coinsurance after deductible
25.00% Coinsurance after deductible
Non-Preferred Brand Drugs
50.00% Coinsurance after deductible
50.00% Coinsurance after deductible
Specialty Drugs
40.00% Coinsurance after deductible
90.00% Coinsurance after deductible
Outpatient
In Network
Out-of-Network
Additional Information
Outpatient Facility Fee
10.00% Coinsurance after deductible
50.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services
10.00% Coinsurance after deductible
50.00% Coinsurance after deductible
Urgent Care
In Network
Out-of-Network
Additional Information
Emergency Room Services
10.00% Coinsurance after deductible
10.00% Coinsurance after deductible
Emergency Transportation/Ambulance
10.00% Coinsurance after deductible
10.00% Coinsurance after deductible
Urgent Care
10.00% Coinsurance after deductible
50.00% Coinsurance after deductible
Hospital
In Network
Out-of-Network
Additional Information
Inpatient Hospital Services
10.00% Coinsurance after deductible
50.00% Coinsurance after deductible
Inpatient Physician and Surgical Services
10.00% Coinsurance after deductible
50.00% Coinsurance after deductible
Mental / Behavioral Health
In Network
Out-of-Network
Additional Information
Mental/Behavioral Health Outpatient Services
10.00% Coinsurance after deductible
50.00% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services
10.00% Coinsurance after deductible
50.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services
10.00% Coinsurance after deductible
50.00% Coinsurance after deductible
Substance Abuse Disorder Inpatient Services
10.00% Coinsurance after deductible
50.00% Coinsurance after deductible
Pregnancy
In Network
Out-of-Network
Additional Information
Prenatal and Postnatal Care
10.00% Coinsurance after deductible
50.00% Coinsurance after deductible
Delivery and All Inpatient Services for Maternity Care
10.00% Coinsurance after deductible
50.00% Coinsurance after deductible
Other Special Needs
In Network
Out-of-Network
Additional Information
Home Healthcare Services
10.00% Coinsurance after deductible
50.00% Coinsurance after deductible
Outpatient Rehabilitation Services
10.00% Coinsurance after deductible
50.00% Coinsurance after deductible
Habilitation Services
10.00% Coinsurance after deductible
50.00% Coinsurance after deductible
Skilled Nursing Facility
10.00% Coinsurance after deductible
50.00% Coinsurance after deductible
Durable Medical Equipment
10.00% Coinsurance after deductible
50.00% Coinsurance after deductible
Hospice Services
10.00% Coinsurance after deductible
50.00% Coinsurance after deductible
Chiropractic Care
10.00% Coinsurance after deductible
50.00% Coinsurance after deductible
Acupuncture
Not covered
Not covered
Rehabilitative Speech Therapy
10.00% Coinsurance after deductible
50.00% Coinsurance after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy
10.00% Coinsurance after deductible
50.00% Coinsurance after deductible
Well Baby Visits and Care
No Charge
50.00% Coinsurance after deductible
Allergy Testing
10.00% Coinsurance after deductible
50.00% Coinsurance after deductible
Diabetes Education
0.00% Coinsurance after deductible
50.00% Coinsurance after deductible
Nutritional Counseling
10.00% Coinsurance after deductible
50.00% Coinsurance after deductible
Children's Vision
In Network
Out-of-Network
Additional Information
Eye Exam for Children
No Charge
No Charge
Eye Glasses for Children
50.00% Coinsurance
50.00% Coinsurance
Dental
In Network
Out-of-Network
Additional Information
Accidental Dental
10.00% Coinsurance after deductible
50.00% Coinsurance after deductible
Basic Dental Care (Adult)
Not covered
Not covered
Basic Dental Care (Child)
20.00% Coinsurance
20.00% Coinsurance
Dental Check Up (Child)
No Charge
No Charge
Major Dental Care (Adult)
Not covered
Not covered
Major Dental Care (Child)
50.00% Coinsurance
50.00% Coinsurance
Orthodontia (Adult)
Not covered
Not covered
Orthodontia (Child)
50.00% Coinsurance
50.00% Coinsurance
Routine Dental Services (Adult)
Not covered
Not covered

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