You are currently viewing 2019 plans. You can view 2020 plans here.


BCBSVT Standard Bronze 2019

Which medical plans are best for you? Use Vermont Plan Comparison Tool 2019 to find out.

Plan id 13627VT0340005-02
CSR Variation Type Zero Cost Sharing Plan Variation
Insurance Company What is this? Blue Cross and Blue Shield of Vermont
Plan Type What is this? EPO
Plan Metal Level What is this? Bronze
Link to Plan's Doctor Directory What is this? View Plan's Doctor Directory
Summary of Benefits and Coverage What is this? View Summary of Benefits and Coverage
Estimated Monthly Premium Savings (APTC) What is this?
Monthly Premium Cost after Subtracting the Estimated Subsidy
(Subsidies are not available for Catastrophic Plans)
Benefits and Coverage (assuming you use preferred providers) expand

(Note: For a more detailed and accurate explanation of the benefits offered by this plan please refer to the Summary of Benefits and Coverage [SBC]. The benefits are described in more detail in the SBC and it will include additional information about those benefits. Some nuances about the benefits like visit limits and other details are not listed below. You should refer to the SBC for those details about the plan. Click on the "View Summary of Benefits and Coverage" link above to view the SBC.)

In-Network Deductible What is this?
(Note: Unless excepted in the plan's benefit description, you must pay all the costs up to the deductible amount before the plan begins to pay for covered services you use. There may be additional details about the deductible that are not shown below. Please refer to the SBC for additional details.)
$0
Extra Deductible for Drugs What is this? $0
Doctor Visits
Doctor Visit - Preventive Care Copay: $0.00; Coinsurance: 0.00%
Doctor Visit - Primary Care Copay: $0.00; Coinsurance: 0.00%
Doctor Visit - Specialist Copay: $0.00; Coinsurance: 0.00%
Doctor Visit - Well Baby Visits and Care Copay: $0.00; Coinsurance: 0.00%
Other Practitioner Office Visit (Nurse, Physician Assistant) Copay: $0.00; Coinsurance: 0.00%
Hospital
Inpatient Hospital Facility Copay: $0.00; Coinsurance: 0.00%
Inpatient Hospital Physician/Surgeon Copay: $0.00; Coinsurance: 0.00%
Outpatient Hospital Facility Copay: $0.00; Coinsurance: 0.00%
Outpatient Hospital Physician/Surgeon Copay: $0.00; Coinsurance: 0.00%
Inpatient Maternity Services Copay: $0.00; Coinsurance: 0.00%
Emergency
Emergency Room Services Copay: $0.00; Coinsurance: 0.00%
Emergency Medical Transportation Copay: $0.00; Coinsurance: 0.00%
Urgent Care Centers or Facilities Copay: $0.00; Coinsurance: 0.00%
Drugs
Plan's Drug Formulary What is this? View Plan's Drug Formulary
Generic Drug on Formulary in a Local Pharmacy Copay: $0.00; Coinsurance: 0.00%
Preferred Brand Drug on Formulary in a Local Pharmacy Copay: $0.00; Coinsurance: 0.00%
Non-Preferred Brand Drug on Formulary in a Local Pharmacy Copay: $0.00; Coinsurance: 0.00%
Specialty Drug on Formulary in a Local Pharmacy Copay: $0.00; Coinsurance: 0.00%
Tests & Imaging
Diagnostic Tests (Blood work) Copay: $0.00; Coinsurance: 0.00%
X-Rays Copay: $0.00; Coinsurance: 0.00%
Imaging (CT/PET Scans, MRI, etc) Copay: $0.00; Coinsurance: 0.00%
Mental/Behavioral Health
Mental/Behavioral Health Inpatient Services Copay: $0.00; Coinsurance: 0.00%
Mental/Behavioral Health Outpatient Services Copay: $0.00; Coinsurance: 0.00%
Substance Use Disorder Inpatient Copay: $0.00; Coinsurance: 0.00%
Substance Use Disorder Outpatient Copay: $0.00; Coinsurance: 0.00%
Vision/Hearing Aids
Routine Eye Exam for Child Copay: $0.00; Coinsurance: 0.00%
Eye Glasses for Child Copay: $0.00; Coinsurance: 0.00%
Routine Eye Exam - Adult Not Covered
Hearing Aids Not Covered
Child Dental Coverage
Dental Check-Up for Children Copay: $0.00; Coinsurance: 0.00%
Basic Dental Care – Child Copay: $0.00; Coinsurance: 0.00%
Major Dental Care – Child Copay: $0.00; Coinsurance: 0.00%
Orthodontia – Child Copay: $0.00; Coinsurance: 0.00%
Adult Dental Coverage
Basic Dental Care – Adult Not Covered
Major Dental Care – Adult Not Covered
Orthodontia – Adult Not Covered
Accidental Dental Copay: $0.00; Coinsurance: 0.00%
Home and Nursing Care
Home Health Care Services Copay: $0.00; Coinsurance: 0.00%
Skilled Nursing Care - Facility Copay: $0.00; Coinsurance: 0.00%
Rehabilitative and habilitative services
Habilitation Services Copay: $0.00; Coinsurance: 0.00%
Outpatient Rehabilitation Services Copay: $0.00; Coinsurance: 0.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy Copay: $0.00; Coinsurance: 0.00%
Rehabilitative Speech Therapy Copay: $0.00; Coinsurance: 0.00%
Other Services What is this?
Is HSA Eligible? No
Allergy Testing Copay: $0.00; Coinsurance: 0.00%
Chemotherapy Copay: $0.00; Coinsurance: 0.00%
Chiropractic Copay: $0.00; Coinsurance: 0.00%
Diabetes Education Copay: $0.00; Coinsurance: 0.00%
Dialysis Copay: $0.00; Coinsurance: 0.00%
Durable Medical Equipment Copay: $0.00; Coinsurance: 0.00%
Hospice Service Copay: $0.00; Coinsurance: 0.00%
Infusion Therapy Copay: $0.00; Coinsurance: 0.00%
Nutritional Counseling Copay: $0.00; Coinsurance: 0.00%
Prosthetic Devices Copay: $0.00; Coinsurance: 0.00%
Radiation Copay: $0.00; Coinsurance: 0.00%
Reconstructive Surgery Copay: $0.00; Coinsurance: 0.00%
Routine Foot Care Not Covered
Treatment for Temporomandibular Joint Disorders Copay: $0.00; Coinsurance: 0.00%
Transplant Copay: $0.00; Coinsurance: 0.00%
Weight Loss Programs Not Covered
Wellness Programs What is this?
Asthma Program Available
Heart Disease Program Available
Depression Program Available
Diabetes Program Available
High Blood Pressure & Cholesterol Program Available
Low Back Pain Program Available
Pain Management Program Available
Pregnancy Program Available
Weight Loss Programs Available
Out-of-Network - See Summary of Benefits and Coverage What is this? View Summary of Benefits and Coverage
^ Back to Top