BCBSVT Vermont Preferred Gold Plan – EPO
Network type: EPO
Coverage tier: Gold
Primary care visit: first 4 visit(s) $0 then $20 copay after deductible
Specialist visit: $40 copay after deductible
Urgent care visit: $40 copay after deductible
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | $1,250 per person $1,250 per person |
| Out-of-pocket max | $5,150 per person $10,300 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | first 4 visit(s) $0 then $20 copay after deductible |
| Specialist visit | $40 copay after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $40 copay after deductible |
| Emergency room | $250 copay after deductible |
| Ambulance | $40 copay after deductible |
| Hospital stay (facility) | $750 copay after deductible |
| Hospital stay (physician) | No charge after deductible |
| Outpatient procedure (facility) | $750 copay after deductible |
| Outpatient procedure (physician) | No charge after deductible |
| Physical rehabilitation | $40 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | $750 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 | $40 copay after deductible |
| Imaging (CT/PET/MRI) | $750 copay after deductible |
| Blood work | $40 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 | $750 copay after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/9mkQQnJgq6XCmxePT9SgG8aZ.pdf |
| Drug and medication plan formulary | https://www.bluecrossvt.org/pharmacies-medications |
