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BCBSVT Standard Bronze 2019

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

Plan id 13627VT0340005-03
CSR Variation Type Limited 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)
Cost in a Good Year: Estimated Yearly Cost to You if Your Health Care Usage is Low
(for Very Healthy Consumers "Low" is Defined as Only Preventive Care) What is this?
Your Chances of Having a Good Year--a Year with No More Than Low-Usage What is this?
Cost in an Average Year: Average for People Like You What is this?
Cost in a Bad Year: Estimate for People Like You in a High-Health Care Usage Year What is this?
Your Chances of Having a Bad Year--a Year with Very High Usage What is this?
Actual Maximum Out-of-Pocket (includes premiums) What is this?
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.)
$5,500
Extra Deductible for Drugs What is this? $900
Doctor Visits
Doctor Visit - Preventive Care No Charge
Doctor Visit - Primary Care Copay: $35.00 Copay after deductible
Doctor Visit - Specialist Copay: $90.00 Copay after deductible
Doctor Visit - Well Baby Visits and Care Copay: $35.00 Copay after deductible
Other Practitioner Office Visit (Nurse, Physician Assistant) Copay: $90.00 Copay after deductible
Hospital
Inpatient Hospital Facility Coinsurance: 50.00% Coinsurance after deductible
Inpatient Hospital Physician/Surgeon Coinsurance: 50.00% Coinsurance after deductible
Outpatient Hospital Facility Coinsurance: 50.00% Coinsurance after deductible
Outpatient Hospital Physician/Surgeon Coinsurance: 50.00% Coinsurance after deductible
Inpatient Maternity Services Coinsurance: 50.00% Coinsurance after deductible
Emergency
Emergency Room Services Coinsurance: 50.00% Coinsurance after deductible
Emergency Medical Transportation Copay: $100.00 Copay after deductible
Urgent Care Centers or Facilities Copay: $100.00 Copay after deductible
Drugs
Plan's Drug Formulary What is this? View Plan's Drug Formulary
Generic Drug on Formulary in a Local Pharmacy Copay: $20.00 Copay after deductible
Preferred Brand Drug on Formulary in a Local Pharmacy Copay: $85.00 Copay after deductible
Non-Preferred Brand Drug on Formulary in a Local Pharmacy Coinsurance: 60.00% Coinsurance after deductible
Specialty Drug on Formulary in a Local Pharmacy Coinsurance: 60.00% Coinsurance after deductible
Tests & Imaging
Diagnostic Tests (Blood work) Coinsurance: 50.00% Coinsurance after deductible
X-Rays Coinsurance: 50.00% Coinsurance after deductible
Imaging (CT/PET Scans, MRI, etc) Coinsurance: 50.00% Coinsurance after deductible
Mental/Behavioral Health
Mental/Behavioral Health Inpatient Services Coinsurance: 50.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services Coinsurance: 50.00% Coinsurance after deductible
Substance Use Disorder Inpatient Coinsurance: 50.00% Coinsurance after deductible
Substance Use Disorder Outpatient Coinsurance: 50.00% Coinsurance after deductible
Vision/Hearing Aids
Routine Eye Exam for Child Copay: $90.00 Copay after deductible
Eye Glasses for Child Copay: $90.00 Copay after deductible
Routine Eye Exam - Adult Not Covered
Hearing Aids Not Covered
Child Dental Coverage
Dental Check-Up for Children No Charge
Basic Dental Care – Child Coinsurance: 30.00% Coinsurance after deductible
Major Dental Care – Child Coinsurance: 50.00% Coinsurance after deductible
Orthodontia – Child Coinsurance: 50.00% Coinsurance after deductible
Adult Dental Coverage
Basic Dental Care – Adult Not Covered
Major Dental Care – Adult Not Covered
Orthodontia – Adult Not Covered
Accidental Dental Coinsurance: 50.00% Coinsurance after deductible
Home and Nursing Care
Home Health Care Services Coinsurance: 50.00% Coinsurance after deductible
Skilled Nursing Care - Facility Coinsurance: 50.00% Coinsurance after deductible
Rehabilitative and habilitative services
Habilitation Services Coinsurance: 50.00% Coinsurance after deductible
Outpatient Rehabilitation Services Copay: $90.00 Copay after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy Copay: $90.00 Copay after deductible
Rehabilitative Speech Therapy Copay: $90.00 Copay after deductible
Other Services What is this?
Is HSA Eligible? No
Allergy Testing Coinsurance: 50.00% Coinsurance after deductible
Chemotherapy Coinsurance: 50.00% Coinsurance after deductible
Chiropractic Copay: $35.00 Copay after deductible
Diabetes Education No Charge
Dialysis Coinsurance: 50.00% Coinsurance after deductible
Durable Medical Equipment Coinsurance: 50.00% Coinsurance after deductible
Hospice Service Coinsurance: 50.00% Coinsurance after deductible
Infusion Therapy Coinsurance: 50.00% Coinsurance after deductible
Nutritional Counseling Copay: $90.00 Copay after deductible
Prosthetic Devices Coinsurance: 50.00% Coinsurance after deductible
Radiation Coinsurance: 50.00% Coinsurance after deductible
Reconstructive Surgery Coinsurance: 50.00% Coinsurance after deductible
Routine Foot Care Not Covered
Treatment for Temporomandibular Joint Disorders Coinsurance: 50.00% Coinsurance after deductible
Transplant Coinsurance: 50.00% Coinsurance after deductible
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
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