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BCBSVT Blue Rewards Silver CDHP Plan 2019

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

Plan id 13627VT0390002-04
CSR Variation Type 73% AV Level Silver Plan
Insurance Company What is this? Blue Cross and Blue Shield of Vermont
Plan Type What is this? EPO
Plan Metal Level What is this? Silver
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.)
$3,550
Extra Deductible for Drugs What is this?
Doctor Visits
Doctor Visit - Preventive Care No Charge
Doctor Visit - Primary Care No Charge after deductible
Doctor Visit - Specialist No Charge after deductible
Doctor Visit - Well Baby Visits and Care No Charge after deductible
Other Practitioner Office Visit (Nurse, Physician Assistant) No Charge after deductible
Hospital
Inpatient Hospital Facility No Charge after deductible
Inpatient Hospital Physician/Surgeon No Charge after deductible
Outpatient Hospital Facility No Charge after deductible
Outpatient Hospital Physician/Surgeon No Charge after deductible
Inpatient Maternity Services No Charge after deductible
Emergency
Emergency Room Services No Charge after deductible
Emergency Medical Transportation No Charge after deductible
Urgent Care Centers or Facilities No Charge after deductible
Drugs
Plan's Drug Formulary What is this? View Plan's Drug Formulary
Generic Drug on Formulary in a Local Pharmacy No Charge after deductible
Preferred Brand Drug on Formulary in a Local Pharmacy No Charge after deductible
Non-Preferred Brand Drug on Formulary in a Local Pharmacy No Charge after deductible
Specialty Drug on Formulary in a Local Pharmacy No Charge after deductible
Tests & Imaging
Diagnostic Tests (Blood work) No Charge after deductible
X-Rays No Charge after deductible
Imaging (CT/PET Scans, MRI, etc) No Charge after deductible
Mental/Behavioral Health
Mental/Behavioral Health Inpatient Services No Charge after deductible
Mental/Behavioral Health Outpatient Services No Charge after deductible
Substance Use Disorder Inpatient No Charge after deductible
Substance Use Disorder Outpatient No Charge after deductible
Vision/Hearing Aids
Routine Eye Exam for Child No Charge after deductible
Eye Glasses for Child No Charge after deductible
Routine Eye Exam - Adult Not Covered
Hearing Aids Not Covered
Child Dental Coverage
Dental Check-Up for Children No Charge after deductible
Basic Dental Care – Child Coinsurance: No Charge after deductible
Major Dental Care – Child Coinsurance: No Charge after deductible
Orthodontia – Child Coinsurance: No Charge after deductible
Adult Dental Coverage
Basic Dental Care – Adult Not Covered
Major Dental Care – Adult Not Covered
Orthodontia – Adult Not Covered
Accidental Dental No Charge after deductible
Home and Nursing Care
Home Health Care Services No Charge after deductible
Skilled Nursing Care - Facility No Charge after deductible
Rehabilitative and habilitative services
Habilitation Services No Charge after deductible
Outpatient Rehabilitation Services No Charge after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy No Charge after deductible
Rehabilitative Speech Therapy No Charge after deductible
Other Services What is this?
Is HSA Eligible? Yes
Allergy Testing No Charge after deductible
Chemotherapy No Charge after deductible
Chiropractic No Charge after deductible
Diabetes Education No Charge
Dialysis No Charge after deductible
Durable Medical Equipment No Charge after deductible
Hospice Service No Charge after deductible
Infusion Therapy No Charge after deductible
Nutritional Counseling No Charge after deductible
Prosthetic Devices No Charge after deductible
Radiation No Charge after deductible
Reconstructive Surgery No Charge after deductible
Routine Foot Care Not Covered
Treatment for Temporomandibular Joint Disorders No Charge after deductible
Transplant No Charge 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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