BCBSVT Platinum Plan – EPO
Network type: EPO
Coverage tier: Platinum
Primary care visit: $15 copay
Specialist visit: $40 copay
Urgent care visit: $50 copay
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | $450 per person $450 per person |
| Out-of-pocket max | $1,500 per person $3,000 per family |
| Metal tier | Platinum |
Visit Copay
| Primary care visit | $15 copay |
| Specialist visit | $40 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $50 copay |
| Emergency room | $100 copay after deductible |
| Ambulance | $60 copay |
| Hospital stay (facility) | 10% after deductible |
| Hospital stay (physician) | 10% after deductible |
| Outpatient procedure (facility) | 10% after deductible |
| Outpatient procedure (physician) | 10% after deductible |
| Physical rehabilitation | $40 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 10% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $10 per script copay |
| Brand | $50 per script copay |
| Non-preferred Brand | 50% coinsurance |
Lab Tests and Diagnostic Procedures
| X-rays | 10% after deductible |
| Imaging (CT/PET/MRI) | 10% after deductible |
| Blood work | 10% after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | 10% after deductible |
| Psychiatric hospital stay | 10% after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/TwnpUvHkpAPMjucjswDkpx5t.pdf |
| Drug and medication plan formulary | https://www.bluecrossvt.org/pharmacies-medications |
