BCBSVT Vermont Preferred Silver 73 Plan – EPO

Description

This plan has 73% cost sharing reduction [Popular Plan]

Health Care Plan Details

Network type	EPO
Deductible	$2,550 per person $2,550 per person
Out-of-pocket max	$7,550 per person $15,100 per family
Metal tier	Silver

Visit Copay

Primary care visit	first 4 visit(s) $0 then $30 copay after deductible
Specialist visit	$50 copay after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$50 copay after deductible
Emergency room	$400 copay after deductible
Ambulance	$50 copay after deductible
Hospital stay (facility)	$1,500 copay after deductible
Hospital stay (physician)	No charge after deductible
Outpatient procedure (facility)	$1,500 copay after deductible
Outpatient procedure (physician)	No charge after deductible
Physical rehabilitation	$40 copay after deductible

Maternitowny and Pregnancy

Labor, delivery, hospital stay

$1,500 copay after deductible

Pharmacy, Drugs, and Medication

Generic	$5 per script after deductible copay
Brand	40% after deductible
Non-preferred Brand	60% after deductible

Lab Tests and Diagnostic Procedures

X-rays	$50 copay after deductible
Imaging (CT/PET/MRI)	$1,500 copay after deductible
Blood work	$50 copay after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	first 4 visit(s) $0 then $0 copay after deductible
Psychiatric hospital stay	$1,500 copay after deductible

Health Plan Provider Information

Health Plan Benefits	https://d2ed110nmrd591.cloudfront.net/blobs/wb9G88CQGXhCEN8BHi8TRuao.pdf
Drug and medication plan formulary	https://www.bluecrossvt.org/pharmacies-medications