BCBSVT Bronze Plan – EPO
Network type: EPO
Coverage tier: Bronze
Primary care visit: $35 copay
Specialist visit: $90 copay
Urgent care visit: $100 copay after deductible
Description
Health Care Plan Details
Network type | EPO |
Deductible | $6,450 per person $6,450 per person |
Out-of-pocket max | $9,450 per person $18,900 per family |
Metal tier | Bronze |
Visit Copay
Primary care visit | $35 copay |
Specialist visit | $90 copay |
Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
Urgent care | $100 copay after deductible |
Emergency room | 50% after deductible |
Ambulance | $100 copay after deductible |
Hospital stay (facility) | 50% after deductible |
Hospital stay (physician) | 50% after deductible |
Outpatient procedure (facility) | 50% after deductible |
Outpatient procedure (physician) | 50% after deductible |
Physical rehabilitation | $90 copay |
Maternitowny and Pregnancy
Labor, delivery, hospital stay | 50% after deductible |
Pharmacy, Drugs, and Medication
Generic | $20 per script copay |
Brand | $85 per script after deductible copay |
Non-preferred Brand | 60% after deductible |
Lab Tests and Diagnostic Procedures
X-rays | 50% after deductible |
Imaging (CT/PET/MRI) | 50% after deductible |
Blood work | 50% after deductible |
Mental and Psychiatric Health Care
Mental Health outpatient services | 50% after deductible |
Psychiatric hospital stay | 50% after deductible |
Health Plan Provider Information
Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/r2SWCHZZxaiCHXVwyo6dNZPH.pdf |
Drug and medication plan formulary | https://www.bluecrossvt.org/pharmacies-medications |