Bright Advantage Health Dollars Plan (HMO)
H4709 - 001 - 0
(0 / 5)
Bright Advantage Health Dollars Plan (HMO) is a Medicare Advantage (Part C) Plan by Bright Health.
This page features plan details for 2022 Bright Advantage Health Dollars Plan (HMO) H4709 – 001 – 0 available in Daytona, Orlando, and Southwest Florida.
IMPORTANT: This page features the 2022 version of this plan. See the 2024 version using the link below:
No 2024 version found. You can use the location links below to find 2024 plans in your area.
Locations
Bright Advantage Health Dollars Plan (HMO) is offered in the following locations.
Plan Overview
Bright Advantage Health Dollars Plan (HMO) offers the following coverage and cost-sharing.
| Insurer: | Bright Health |
| Health Plan Deductible: | $0 |
| MOOP: | $3,450.00 |
| Drugs Covered: | Yes |
Ready to sign up for Bright Advantage Health Dollars Plan (HMO) ?
Premium Breakdown
Bright Advantage Health Dollars Plan (HMO) has a monthly premium of $0. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.| Part B | Part C | Part D | Part B Give Back | Total |
|---|---|---|---|---|
| $170.10 | $0.00 | $0.00 | $0.00 | $170.10 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
- You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.
Drug Info
Bright Advantage Health Dollars Plan (HMO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $0.00 |
| Initial Coverage Limit: | $4,430.00 |
| Catastrophic Coverage Limit: | $7,050.00 |
| Drug Benefit Type: | Enhanced |
| Gap Coverage: | Yes |
| Formulary Link: | Formulary Link |
Part D Premium Reduction
The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs. The table below shows how the LIS impacts the Part D premium of this plan.| Part D | LIS 25% | LIS 50% | LIS 75% | LIS Full |
|---|---|---|---|---|
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
Initial Coverage Phase
After you pay your $0.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $4,430.00. Once you reach that amount, you will enter the next coverage phase.
30 Day
60 Day
90 Day
30 Day
60 Day
90 Day
Gap Coverage Phase
After your total drug costs (including what this plan has paid and what you have paid) reach $4,430.00, you will pay no more than the amounts below for any drug tier until you reach $7,050.00.
30 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | |||
| 6 (Select Care Drugs) | $0.00 copay |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $0.00 copay | ||
| 6 (Select Care Drugs) | $0.00 copay | $0.00 copay |
| Tier | Cost |
|---|---|
| All other tiers (Generic) | 25% |
| All other tiers (Brand-name) | 25% |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,050.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.
| Tier | Cost |
|---|---|
| Generic | $4.15 copay or 5% (whichever costs more) |
| Brand-name | $10.35 copay or 5% (whichever costs more) |
Additional Benefits
Bright Advantage Health Dollars Plan (HMO) also provides the following benefits.
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
| In-Network: No |
Dental (comprehensive)
| Diagnostic services: | $0 copay (authorization required) |
| Endodontics: | $25-720 copay (authorization required) |
| Extractions: | $70-140 copay (authorization required) |
| Non-routine services: | $0-300 copay (authorization required) |
| Periodontics: | $0-780 copay (authorization required) |
| Prosthodontics, other oral/maxillofacial surgery, other services: | $0-1,110 copay (authorization required) |
| Restorative services: | $25-400 copay (authorization required) |
Dental (preventive)
| Cleaning: | $0 copay (limits may apply) |
| Dental x-ray(s): | $0 copay (limits may apply) |
| Fluoride treatment: | $0 copay (limits may apply) |
| Oral exam: | $0 copay (limits may apply) |
Diagnostic procedures/lab services/imaging
| Diagnostic radiology services (e.g., MRI): | $0-50 copay (authorization required) |
| Diagnostic tests and procedures: | $0-50 copay (authorization required) |
| Lab services: | $0 copay (authorization required) |
| Outpatient x-rays: | $0 copay (authorization required) |
Doctor visits
| Primary: | $0 copay |
| Specialist: | $0 copay (authorization required) |
Emergency care/Urgent care
| Emergency: | $0-50 copay per visit (always covered) |
| Urgent care: | $0 copay |
Foot care (podiatry services)
| Foot exams and treatment: | $0 copay (authorization required) |
| Routine foot care: | Not covered |
Ground ambulance
| $0-200 copay |
Health plan deductible
| $0.00 |
Health plan deductibles (other)
| In-Network: No |
Hearing
| Fitting/evaluation: | $0 copay (limits may apply) |
| Hearing aids: | $149 copay (limits may apply) (authorization required) |
| Hearing exam: | $0 copay |
Hospital coverage (inpatient)
| $50 per day for days 1 through 5 $0 per day for days 6 through 90 (authorization required) |
Hospital coverage (outpatient)
| $0-160 copay per visit (authorization required) |
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
| $3,450 In-network |
Medical equipment/supplies
| Diabetes supplies: | $0 copay (authorization required) |
| Durable medical equipment (e.g., wheelchairs, oxygen): | 0-20% coinsurance per item (authorization required) |
| Prosthetics (e.g., braces, artificial limbs): | 0-20% coinsurance per item (authorization required) |
Medicare Part B drugs
| Chemotherapy: | 20% coinsurance (authorization required) |
| Other Part B drugs: | 20% coinsurance (authorization required) |
Mental health services
| Inpatient hospital – psychiatric: | $100 per day for days 1 through 5 $0 per day for days 6 through 90 (authorization required) |
| Outpatient group therapy visit with a psychiatrist: | $0 copay (authorization required) |
| Outpatient group therapy visit: | $0 copay (authorization required) |
| Outpatient individual therapy visit with a psychiatrist: | $0 copay (authorization required) |
| Outpatient individual therapy visit: | $0 copay (authorization required) |
Optional supplemental benefits
| No |
Preventive care
| $0 copay (authorization required) |
Rehabilitation services
| Occupational therapy visit: | $10 copay (authorization required) |
| Physical therapy and speech and language therapy visit: | $10 copay (authorization required) |
Skilled Nursing Facility
| $0 per day for days 1 through 30 $178 per day for days 31 through 100 (authorization required) |
Transportation
| $0 copay (authorization required) |
Vision
| Contact lenses: | $0 copay (limits may apply) (authorization required) |
| Eyeglass frames: | $0 copay (limits may apply) (authorization required) |
| Eyeglass lenses: | $0 copay (limits may apply) (authorization required) |
| Eyeglasses (frames and lenses): | Not covered |
| Other: | Not covered |
| Routine eye exam: | $0 copay (limits may apply) |
| Upgrades: | $0 copay (limits may apply) (authorization required) |
Wellness programs (e.g., fitness, nursing hotline)
| Covered (authorization required) |
Ready to sign up for Bright Advantage Health Dollars Plan (HMO) ?