BCBSVT Gold Plan – EPO
Network type: EPO
Coverage tier: Gold
Primary care visit: $20 copay
Specialist visit: $55 copay
Urgent care visit: $65 copay
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | $1,400 per person $1,400 per person |
| Out-of-pocket max | $5,600 per person $11,200 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $20 copay |
| Specialist visit | $55 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $65 copay |
| Emergency room | $150 copay after deductible |
| Ambulance | $75 copay |
| Hospital stay (facility) | 30% after deductible |
| Hospital stay (physician) | 30% after deductible |
| Outpatient procedure (facility) | 30% after deductible |
| Outpatient procedure (physician) | 30% after deductible |
| Physical rehabilitation | $35 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 30% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $15 per script copay |
| Brand | $60 per script after deductible copay |
| Non-preferred Brand | 50% after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 30% after deductible |
| Imaging (CT/PET/MRI) | 30% after deductible |
| Blood work | 30% after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | 30% after deductible |
| Psychiatric hospital stay | 30% after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/BooNmSKGiHQMaqG5yLDTum3h.pdf |
| Drug and medication plan formulary | https://www.bluecrossvt.org/pharmacies-medications |
