Plan Brochure
2022 Plan Comparison
2022 Drug Formulary
$0 Rx List (including contraceptives)
Provider Directory
- Overview
- Bright Health Bronze $0 Primary Care
- Bright Health Bronze $0 Medical Deductible
- Bright Health Bronze 7000 HSA
- Bright Health Bronze 8550
Bright Health Bronze Overview
Bright Health Bronze Plans have lower premiums and higher deductibles. These are best for healthy individuals who want to minimize their monthly premiums and are comfortable with the risk of a higher deductible in the event of a high-cost incident.
Advanced Premium Tax Credits (APTC) can be used to lower monthly premium payments if you quality.
Bright Health Bronze plans have been rated #2 and #4 by price and #1 in value and network in Cook County.
Bright Health has a total of 4 Bronze plans.
- Bronze 8550 – $8,550 individual deductible and 0% coinsurance.
- Bronze 7000 HSA – $7,000 individual deductible and 0% coinsurance.
- Bronze $0 Medical Deductible – $0 / $4,950 Rx individual deductible and 50% coinsurance
- Bronze $0 Primary Care – $7,200 individual deductible and 50% coinsurance
Bright Health Bronze $0 Primary Care
Download Summary of Benefits and Coverage here
Plan Guide here
Find a doctor here
| Important Questions | Answers | Why this Matters: |
| What is the overall deductible? | $7,200 Individual or $14,400 Family | See the Common Medical Events chart below for your costs for services this plan covers. Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. |
| Are there services covered before you meet your deductible? | Yes. Primary Care, Urgent Care and Generic Drugs are covered without a deductible. | This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/. |
| Are there other deductibles for specific services? | No | You don’t have to meet deductibles for specific services |
| What is the out-of-pocket limit for this plan? | $8,550 Individual or $17,100 Family | The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. |
| What is not included in the out-of-pocket limit? | Premiums, balance-billed charges, and health care this plan doesn’t cover. | Even though you pay these expenses, they don’t count toward the out-of-pocket limit. |
| Will you pay less if you use a network provider? | Yes. See https://brighthealthplan.com/provider-finder/ifp or call 1-855-827-4448 for a list of network providers. | This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. |
| Do you need a referral to see a specialist? | Yes | This plan will pay some or all of the costs to see a specialist for covered services but only if you have a referral before you see the specialist. |
| Common Medical Event | Services You May Need | Your cost if you use | Your cost if you use | Limitations & Exceptions, & Other Important Information |
| If you visit a health care provider’s office or clinic | Primary care visit to treat an injury or illness | No charge | Not covered | None |
| Specialist visit | 50% | Not covered | None | |
| Preventive care/screening/immunization | No charge | Not covered | You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. | |
| If you have a test | Diagnostic test (x-ray, blood work) | 50% | Not covered | Pre-authorization is required for Imaging (CT/PET/MRI). |
| Imaging (CT / PET scans, MRIs) | 50% | Not covered | Pre-authorization is required for Imaging (CT/PET/MRI). | |
| If you need drugs to treat your illness or condition. More information about prescription drug coverage is available at www.brighthealthplan.com | Generic drugs (Tier 2) | $25 | Not covered | Tier 1 drugs are Preventive medications that are of $0 cost to you. Copays shown reflect the cost per retail prescription for a 30-day supply. Mail Order copays are 2.5 times the Retail cost for a 90-day supply |
| Preferred brand drugs (Tier 3) | 50% | Not covered | ||
| Non-preferred brand drugs (Tier 4) | 50% | Not covered | ||
| Specialty drugs (Tier5) | 50% | Not covered | ||
| If you have outpatient surgery | Facility fee (e.g., ambulatory surgery center) | 50% | Not covered | Services require pre-authorization. |
| Physician/surgeon fees | 50% | Not covered | ||
| If you need immediate medical attention | Emergency room care | 50% | 50% | None |
| Emergency medical transportation | 50% | 50% | None | |
| Urgent care | $50 | $50 | None | |
| If you have a hospital stay | Facility fee (e.g., hospital room) | 50% | Not covered | Services require pre-authorization. |
| Physician/surgeon fee | 50% | Not covered | ||
| If you have mental health, behavioral health, or substance abuse needs | Outpatient services | 50% | Not covered | None |
| Inpatient services | 50% | Not covered | Services require pre-authorization. | |
| If you are pregnant | Office visits | No charge | Not covered | Delivery stays exceeding 48 hours for vaginal delivery or 96 hours for a cesarean delivery require preauthorization. |
| Childbirth/delivery professional services | 50% | Not covered | Delivery stays exceeding 48 hours for vaginal delivery or 96 hours for a cesarean delivery require preauthorization. | |
| Childbirth/delivery facility services | 50% | Not covered | Delivery stays exceeding 48 hours for vaginal delivery or 96 hours for a cesarean delivery require preauthorization. | |
| If you need help recovering or have other special health needs | Home health care | 50% | Not covered | Services require pre-authorization |
| Rehabilitation services | 50% | Not covered | ||
| Habilitation services | 50% | Not covered | ||
| Skilled nursing care | 50% | Not covered | ||
| Durable medical equipment | 50% | Not covered | Services require pre-authorization. | |
| Hospice service | 50% | Not covered | Services require pre-authorization. | |
| If your child needs dental or eye care | Children’s eye exam | No Charge | Not covered | Limited to 1 eye exam per calendar year through the end of the month in which the dependent child turns19. |
| Children’s glasses | No Charge | Not covered | Limited to 1 pair of glasses including standard frames and standard lenses, or a one-year supply of contact lenses through the end of the month in which the dependent child turns 19. | |
| Children’s dental check-up | Not Covered | Not Covered | Includes diagnostic and preventive services for dependent children through the end of the month in which the dependent child turns 19. Refer to the policy for covered services and limitations. |
Excluded Services & Other Covered Services:
| Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) |
|
| Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) |
|
Bright Health Bronze $0 Medical Deductible
Download Summary of Benefits and Coverage here
Plan Guide here
Find a doctor here
| Important Questions | Answers | Why this Matters: |
| What is the overall deductible? | $0 Individual or $0 Family | See the Common Medical Events chart below for your costs for services this plan covers. Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. |
| Are there services covered before you meet your deductible? | Yes. Primary Care, Specialty Care, Lab and Xray services, some Prescription Drugs, Urgent Care, Outpatient Mental Health, Inpatient and Outpatient Hospital care, and Pediatric Dental and Vision are covered before the deductible. | This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/. |
| Are there other deductibles for specific services? | Yes, Prescription Drugs. $4,950 Individual or $9,900 Family | You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services. |
| What is the out-of-pocket limit for this plan? | $8,550 Individual or $17,100 Family | The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. |
| What is not included in the out-of-pocket limit? | Premiums, balance-billed charges, and health care this plan doesn’t cover. | Even though you pay these expenses, they don’t count toward the out-of-pocket limit. |
| Will you pay less if you use a network provider? | Yes. See https://brighthealthplan.com/provider-finder/ifp or call 1-855-827-4448 for a list of network providers. | This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. |
| Do you need a referral to see a specialist? | Yes | This plan will pay some or all of the costs to see a specialist for covered services but only if you have a referral before you see the specialist. |
| Common Medical Event | Services You May Need | Your cost if you use | Your cost if you use | Limitations & Exceptions, & Other Important Information |
| If you visit a health care provider’s office or clinic | Primary care visit to treat an injury or illness | $50 | Not covered | None |
| Specialist visit | $100 | Not covered | None | |
| Preventive care/screening/immunization | No charge | Not covered | You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. | |
| If you have a test | Diagnostic test (x-ray, blood work) | Labs $50 per visit X-ray $100 per visit | Not covered | Pre-authorization is required for Imaging (CT/PET/MRI). |
| Imaging (CT / PET scans, MRIs) | $300 | Not covered | Pre-authorization is required for Imaging (CT/PET/MRI). | |
| If you need drugs to treat your illness or condition. More information about prescription drug coverage is available at www.brighthealthplan.com | Generic drugs (Tier 2) | $30 | Not covered | Tier 1 drugs are Preventive medications that are of $0 cost to you. Copays shown reflect the cost per retail prescription for a 30-day supply. Mail Order copays are 2.5 times the Retail cost for a 90-day supply |
| Preferred brand drugs (Tier 3) | $200 | Not covered | ||
| Non-preferred brand drugs (Tier 4) | 50% | Not covered | ||
| Specialty drugs (Tier5) | 50% | Not covered | ||
| If you have outpatient surgery | Facility fee (e.g., ambulatory surgery center) | $1,000 | Not covered | Services require pre-authorization. |
| Physician/surgeon fees | $300 | Not covered | ||
| If you need immediate medical attention | Emergency room care | $1,000 | $1,000 | None |
| Emergency medical transportation | 50% | 50% | None | |
| Urgent care | $50 | $50 | None | |
| If you have a hospital stay | Facility fee (e.g., hospital room) | $2,500 per day | Not covered | Copay applies to first 2 days of hospitalization. Services require pre-authorization. |
| Physician/surgeon fee | $300 | Not covered | ||
| If you have mental health, behavioral health, or substance abuse needs | Outpatient services | $50 | Not covered | None |
| Inpatient services | $2,500 | Not covered | Copay applies to first 2 days of hospitalization. Services require pre-authorization. | |
| If you are pregnant | Office visits | No charge | Not covered | Copay applies to first 2 days of hospitalization. Delivery stays exceeding 48 hours for vaginal delivery or 96 hours for a cesarean delivery require preauthorization. |
| Childbirth/delivery professional services | No charge | Not covered | Copay applies to first 2 days of hospitalization. Delivery stays exceeding 48 hours for vaginal delivery or 96 hours for a cesarean delivery require preauthorization. | |
| Childbirth/delivery facility services | $2,500 per day | Not covered | Copay applies to first 2 days of hospitalization. Delivery stays exceeding 48 hours for vaginal delivery or 96 hours for a cesarean delivery require preauthorization. | |
| If you need help recovering or have other special health needs | Home health care | 50% | Not covered | Services require pre-authorization
Copay applies per day up to 2 days. Services require pre-authorization. . |
| Rehabilitation services | $100 | Not covered | ||
| Habilitation services | $100 | Not covered | ||
| Skilled nursing care | $2,500 per day | Not covered | ||
| Durable medical equipment | 50% | Not covered | Services require pre-authorization. | |
| Hospice service | 50% | Not covered | Services require pre-authorization. | |
| If your child needs dental or eye care | Children’s eye exam | No Charge | Not covered | Limited to 1 eye exam per calendar year through the end of the month in which the dependent child turns19. |
| Children’s glasses | No Charge | Not covered | Limited to 1 pair of glasses including standard frames and standard lenses, or a one-year supply of contact lenses through the end of the month in which the dependent child turns 19. | |
| Children’s dental check-up | Not Covered | Not Covered | Includes diagnostic and preventive services for dependent children through the end of the month in which the dependent child turns 19. Refer to the policy for covered services and limitations. |
Excluded Services & Other Covered Services:
| Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) |
|
| Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) |
|
Bright Health Bronze 7000 HSA
Download Summary of Benefits and Coverage here
Plan Guide here
Find a doctor here
| Important Questions | Answers | Why this Matters: |
| What is the overall deductible? | $7,000 Individual or $14,000 Family | See the Common Medical Events chart below for your costs for services this plan covers. Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. |
| Are there services covered before you meet your deductible? | No. You will have to meet the deductible before the plan pays for any services. | This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/. |
| Are there other deductibles for specific services? | No | You don’t have to meet deductibles for specific services. |
| What is the out-of-pocket limit for this plan? | $7,000 Individual or $14,000 Family | The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. |
| What is not included in the out-of-pocket limit? | Premiums, balance-billed charges, and health care this plan doesn’t cover. | Even though you pay these expenses, they don’t count toward the out-of-pocket limit. |
| Will you pay less if you use a network provider? | Yes. See https://brighthealthplan.com/provider-finder/ifp or call 1-855-827-4448 for a list of network providers. | This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. |
| Do you need a referral to see a specialist? | Yes | This plan will pay some or all of the costs to see a specialist for covered services but only if you have a referral before you see the specialist. |
| Common Medical Event | Services You May Need | Your cost if you use | Your cost if you use | Limitations & Exceptions, & Other Important Information |
| If you visit a health care provider’s office or clinic | Primary care visit to treat an injury or illness | 0% | Not covered | None |
| Specialist visit | 0% | Not covered | None | |
| Preventive care/screening/immunization | No charge | Not covered | You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. | |
| If you have a test | Diagnostic test (x-ray, blood work) | 0% | Not covered | Pre-authorization is required for Imaging (CT/PET/MRI). |
| Imaging (CT / PET scans, MRIs) | 0% | Not covered | Pre-authorization is required for Imaging (CT/PET/MRI). | |
| If you need drugs to treat your illness or condition. More information about prescription drug coverage is available at www.brighthealthplan.com | Generic drugs (Tier 2) | 0% | Not covered | Tier 1 drugs are Preventive medications that are of $0 cost to you. Copays shown reflect the cost per retail prescription for a 30-day supply. Mail Order copays are 2.5 times the Retail cost for a 90-day supply |
| Preferred brand drugs (Tier 3) | 0% | Not covered | ||
| Non-preferred brand drugs (Tier 4) | 0% | Not covered | ||
| Specialty drugs (Tier5) | 0% | Not covered | ||
| If you have outpatient surgery | Facility fee (e.g., ambulatory surgery center) | 0% | Not covered | Services require pre-authorization. |
| Physician/surgeon fees | 0% | Not covered | ||
| If you need immediate medical attention | Emergency room care | 0% | 0% | None |
| Emergency medical transportation | 0% | 0% | None | |
| Urgent care | 0% | 0% | None | |
| If you have a hospital stay | Facility fee (e.g., hospital room) | 0% | Not covered | Services require pre-authorization. |
| Physician/surgeon fee | 0% | Not covered | ||
| If you have mental health, behavioral health, or substance abuse needs | Outpatient services | 0% | Not covered | None |
| Inpatient services | 0% | Not covered | Preauthorization required | |
| If you are pregnant | Office visits | 0% | Not covered | Delivery stays exceeding 48 hours for vaginal delivery or 96 hours for a cesarean delivery require preauthorization. |
| Childbirth/delivery professional services | 0% | Not covered | Delivery stays exceeding 48 hours for vaginal delivery or 96 hours for a cesarean delivery require preauthorization. | |
| Childbirth/delivery facility services | 0% | Not covered | Delivery stays exceeding 48 hours for vaginal delivery or 96 hours for a cesarean delivery require preauthorization. | |
| If you need help recovering or have other special health needs | Home health care | 0% | Not covered | Services require pre-authorization. |
| Rehabilitation services | 0% | Not covered | ||
| Habilitation services | 0% | Not covered | ||
| Skilled nursing care | 0% | Not covered | ||
| Durable medical equipment | 0% | Not covered | Services require pre-authorization. | |
| Hospice service | 0% | Not covered | Services require pre-authorization. | |
| If your child needs dental or eye care | Children’s eye exam | No Charge | Not covered | Limited to 1 eye exam per calendar year through the end of the month in which the dependent child turns19. |
| Children’s glasses | No Charge | Not covered | Limited to 1 pair of glasses including standard frames and standard lenses, or a one-year supply of contact lenses through the end of the month in which the dependent child turns 19. | |
| Children’s dental check-up | Not Covered | Not Covered | Includes diagnostic and preventive services for dependent children through the end of the month in which the dependent child turns 19. Refer to the policy for covered services and limitations. |
Excluded Services & Other Covered Services:
| Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) |
|
| Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) |
|
Bright Health Bronze 8550
Download Summary of Benefits and Coverage here
Plan Guide here
Find a doctor here
| Important Questions | Answers | Why this Matters: |
| What is the overall deductible? | $8,550 Individual or $17,100 Family | See the Common Medical Events chart below for your costs for services this plan covers. Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. |
| Are there services covered before you meet your deductible? | Yes. Primary Care, Urgent Care and Generic Drugs are covered without a deductible. | This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/. |
| Are there other deductibles for specific services? | No | You don’t have to meet deductibles for specific services. |
| What is the out-of-pocket limit for this plan? | $8,550 Individual or $17,100 Family | The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. |
| What is not included in the out-of-pocket limit? | Premiums, balance-billed charges, and health care this plan doesn’t cover. | Even though you pay these expenses, they don’t count toward the out-of-pocket limit. |
| Will you pay less if you use a network provider? | Yes. See https://brighthealthplan.com/provider-finder/ifp or call 1-855-827-4448 for a list of network providers. | This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. |
| Do you need a referral to see a specialist? | Yes | This plan will pay some or all of the costs to see a specialist for covered services but only if you have a referral before you see the specialist. |
| Common Medical Event | Services You May Need | Your cost if you use | Your cost if you use | Limitations & Exceptions, & Other Important Information |
| If you visit a health care provider’s office or clinic | Primary care visit to treat an injury or illness | $25 first 2 visits, then 0% | Not covered | $25 for the first 2 visits, then no charge after deductible |
| Specialist visit | 0% | Not covered | None | |
| Preventive care/screening/immunization | No charge | Not covered | You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. | |
| If you have a test | Diagnostic test (x-ray, blood work) | 0% | Not covered | Pre-authorization is required for Imaging (CT/PET/MRI). |
| Imaging (CT / PET scans, MRIs) | 0% | Not covered | Pre-authorization is required for Imaging (CT/PET/MRI). | |
| If you need drugs to treat your illness or condition. More information about prescription drug coverage is available at www.brighthealthplan.com | Generic drugs (Tier 2) | $25 | Not covered | Tier 1 drugs are Preventive medications that are of $0 cost to you. Copays shown reflect the cost per retail prescription for a 30-day supply. Mail Order copays are 2.5 times the Retail cost for a 90-day supply |
| Preferred brand drugs (Tier 3) | 0% | Not covered | ||
| Non-preferred brand drugs (Tier 4) | 0% | Not covered | ||
| Specialty drugs (Tier5) | 0% | Not covered | ||
| If you have outpatient surgery | Facility fee (e.g., ambulatory surgery center) | 0% | Not covered | Services require pre-authorization. |
| Physician/surgeon fees | 0% | Not covered | ||
| If you need immediate medical attention | Emergency room care | 0% | 0% | None |
| Emergency medical transportation | 0% | 0% | None | |
| Urgent care | 0% | $50 | None | |
| If you have a hospital stay | Facility fee (e.g., hospital room) | 0% | Not covered | Services require pre-authorization. |
| Physician/surgeon fee | 0% | Not covered | ||
| If you have mental health, behavioral health, or substance abuse needs | Outpatient services | 0% | Not covered | None |
| Inpatient services | 0% | Not covered | Preauthorization required | |
| If you are pregnant | Office visits | No charge | Not covered | Delivery stays exceeding 48 hours for vaginal delivery or 96 hours for a cesarean delivery require preauthorization. |
| Childbirth/delivery professional services | 0% | Not covered | Delivery stays exceeding 48 hours for vaginal delivery or 96 hours for a cesarean delivery require preauthorization. | |
| Childbirth/delivery facility services | 0% | Not covered | Delivery stays exceeding 48 hours for vaginal delivery or 96 hours for a cesarean delivery require preauthorization. | |
| If you need help recovering or have other special health needs | Home health care | 0% | Not covered | Services require pre-authorization. |
| Rehabilitation services | 0% | Not covered | ||
| Habilitation services | 0% | Not covered | ||
| Skilled nursing care | 0% | Not covered | ||
| Durable medical equipment | 0% | Not covered | Services require pre-authorization. | |
| Hospice service | 0% | Not covered | Services require pre-authorization. | |
| If your child needs dental or eye care | Children’s eye exam | No Charge | Not covered | Limited to 1 eye exam per calendar year through the end of the month in which the dependent child turns19. |
| Children’s glasses | No Charge | Not covered | Limited to 1 pair of glasses including standard frames and standard lenses, or a one-year supply of contact lenses through the end of the month in which the dependent child turns 19. | |
| Children’s dental check-up | Not Covered | Not Covered | Includes diagnostic and preventive services for dependent children through the end of the month in which the dependent child turns 19. Refer to the policy for covered services and limitations. |
Excluded Services & Other Covered Services:
| Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) |
|
| Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) |
|