Bronze 5300 HSA (2022) - Pasco - FL

Bronze 5300 HSA (2022) - Pasco - FL

  56 InfoPreferred Score Good

specifications

  • Premium 430.38 Dollar(s)
  • Deductibles 5300 Dollar(s)
  • Out of Pocket Maximum 7050 Dollar(s)
  • Covered Benefits 31 out of 40

Key Features

$ 430.38
Premium
Good
$ 5300
Deductibles
Good
$ 7050
Out of Pocket Maximum
Very Good
31 / 40
Covered Benefits
Good

  • Overview

    Plan ID: 12379FL0010028
    Plan Type: EPO
    Metal Level: Bronze
    Covered Benefits: 31
    County: Pasco
    FIPS County Code: 12101
    State: FL
    SM Rating: 56

  • Cost of Medical Sharing

    Premium: 430.38
    EHB Premium: 430.38
    EHB Percent of Total Premium: 100
    Deductibles: 5300
    Out of Pocket Maximum: 7050

  • Cost Sharing

    Adult Dental Care Details: Benefit Not Covered
    Child Dental Care Details: $50
    Child Dental Check Up: No Charge
    Adult Major Dental Care: Benefit Not Covered
    Child Major Dental Care: $690 Copay after deductible
    Adult Routine Dental Services: Benefit Not Covered
    Eye Glasses for Children: No Charge After Deductible
    Adult Routine Eye Exam Details: Benefit Not Covered
    Child Routine Eye Exam Details: No Charge
    Hearing Aids Details: Benefit Not Covered
    Bariatric Surgery: Benefit Not Covered
    Chemotherapy: 50% Coinsurance after deductible
    Chiropractic Care: 50% Coinsurance after deductible
    Dialysis: 50% Coinsurance after deductible
    Durable Medical Equipment: 50% Coinsurance after deductible
    Emergency Room Services: 50% Coinsurance after deductible
    Emergency Transportation Ambulance: 50% Coinsurance after deductible
    Habilitation Services: 50% Coinsurance after deductible
    Imaging (CT, Pet, MRIS Scan): 50% Coinsurance after deductible
    Infertility Treatment: Benefit Not Covered
    Inpatient Hospital Services: 50% Coinsurance after deductible
    Inpatient Physician and Surgical Services: 50% Coinsurance after deductible
    Laboratory Outpatient and Professional Services: 50% Coinsurance after deductible
    Mental Behavioral Health Inpatient Services: 50% Coinsurance after deductible
    Mental Behavioral Health Outpatient Services: No Charge After Deductible
    Adult Orthodontia: Benefit Not Covered
    Child Orthodontia: $2800 Copay after deductible
    Outpatient Facility Fee: 50% Coinsurance after deductible
    Outpatient Rehabilitation Services: 50% Coinsurance after deductible
    Outpatient Surgery Services: 50% Coinsurance after deductible
    Preventive Care Screening Immunization: No Charge
    Primary Care Visit: $50 Copay after deductible
    Private Duty Nursing: Benefit Not Covered
    Skilled Nursing Facility: 50% Coinsurance after deductible
    Specialist Visit: $100 Copay after deductible
    XRays and Diagnostic Imaging: 50% Coinsurance after deductible

  • Prescription Drug Coverage

    List of Covered Drugs URL: https://brighthealthcare.com/individual-and-family/drug-search
    Generic Drugs: $20 Copay after deductible
    Non Preferred Brand Drugs: 50% Coinsurance after deductible
    Preferred Brand Drugs: 50% Coinsurance after deductible
    Specialty Drugs: 50% Coinsurance after deductible

  • Benefits

    Dental Benefits: 3
    Vision Benefits: 2
    Hearing Benefits: 0
    Other Benefits: 26
    Adult Dental Care:
    Child Dental Care: 1
    Adult Routine Eye Exam:
    Child Routine Eye Exam: 1
    Hearing Aids:
    National Network Available:
    Health Savings Account Eligibility: 1
    Disease Management Programs: Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure and High Cholesterol, Low Back Pain, Pregnancy

  • Plan Documents

    Provider Directory URL: https://brighthealthcare.com/search?lob=hasIfp
    Benefits Summary URL: https://cdn1.brighthealthplan.com/docs/2022_SBCs/SBC_ENG_BRIGHTHEALTH_12379FL0010028_01_20220101.pdf
    Brochure URL: https://cdn1.brighthealthplan.com/docs/commercial-resources/IFP2022_PlanBrochure_FL_en_es.pdf

  • Policy Issuer Details

    Eligible Dependents: Self, Spouse, Child, Stepson or Stepdaughter, Brother or Sister, Life Partner, Foster Child, Ward
    Issuer: Bright HealthCare
    Issuer ID: 12379
    Area: Rating Area 51

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