BCBSVT Bronze CDHP Plan Plan Details for 2021- HealthPocket

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Zip Code05401
Applicant6/27/1987 Male
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameBCBSVT Bronze CDHP Plan
Plan IDhhs-13627VT0350002
Plan Year2021
Insurance ProviderBlueCross BlueShield of Vermont
Metal LevelExpanded Bronze
Plan TypeEPO
Deductible$5,500
Out-of-Pocket Maximum$6,900
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness50.00% Coinsurance after deductible
Specialist Visit50.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services50.00% Coinsurance after deductible
X-rays and Diagnostic Imaging50.00% Coinsurance after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans50.00% Coinsurance after deductible
Deductible - Family$11000 per group
Out-of-Pocket Maximum - Family$13800 per group

Prescription drug coverage

Generic Drugs$12 Copay after deductible
Preferred Brand Drugs40.00% Coinsurance after deductible
Non-Preferred Brand Drugs60.00% Coinsurance after deductible
Specialty Drugs60.00% Coinsurance after deductible

Access to doctors and hospitals

Provider directory URLhttp://www.bcbsvt.com/member/MemberBenefits/directories/Participating_Providers.pdf
Does this plan have access to a national provider network?Yes
Is a referral required to see a Specialist?Not Covered
Does this plan cover services outside plan service area?Yes - Members may use preferred providers nationally through the BlueCard network.
Does this plan cover services outside the country?Yes - All members traveling outside the U.S. have access to the BlueCard Worldwide program.

Hospital services

Emergency Room Services50.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)50.00% Coinsurance after deductible
Inpatient Physician and Surgical Services50.00% Coinsurance after deductible
Emergency Transportation or Ambulance Service50.00% Coinsurance after deductible

Maternity

Prenatal and Postnatal Care50.00% Coinsurance after deductible
Delivery and all inpatient services for maternity care50.00% Coinsurance after deductible

Mental Health

Mental/Behavioral Health Outpatient Services50.00% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services50.00% Coinsurance after deductible
Substance use disorder outpatient services50.00% Coinsurance after deductible
Substance use disorder inpatient services50.00% Coinsurance after deductible

Medical Management Programs

Does this plan offer disease managment programs?Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs
Does this plan offer a wellness program?Included

Vision Coverage

Routine Eye Exam for ChildrenIncluded
Eye Glasses for ChildrenIncluded
Routine Eye Exam for AdultsNot Covered

Child Dental Coverage

Child Dental Coverage - Routine Dental CareIncluded
Child Dental Coverage - Basic Dental CareIncluded
Child Dental Coverage - OrthodontiaIncluded
Child Dental Coverage - Major Dental CareIncluded

Adult Dental Coverage

Adult Dental Coverage - Routine Dental CareNot Covered
Adult Dental Coverage - Basic Dental CareNot Covered
Adult Dental Coverage - OrthodontiaNot Covered
Adult Dental Coverage - Major Dental CareNot Covered

Exclusions and Limitations

More Included BenefitsOther Practitioner Office Visit (Nurse, Physician Assistant)
Preventive Care/Screening/Immunization
Skilled Nursing Facility
Bariatric Surgery
Private-Duty Nursing
Imaging (CT/PET Scans, MRIs)
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Outpatient Surgery Physician/Surgical Services
Urgent Care Centers or Facilities
Inpatient Physician and Surgical Services
Home Health Care Services
Habilitation Services
Durable Medical Equipment
Hospice Services
Dental Check-Up for Children
Chiropractic Care
Dental Anesthesia
Diabetes Care Management
Mental Health Other
Accidental Dental
Allergy Testing
Chemotherapy
Diabetes Education
Dialysis
Infusion Therapy
Laboratory Outpatient and Professional Services
Prosthetic Devices
Radiation
Reconstructive Surgery
Transplant
Treatment for Temporomandibular Joint Disorders
Well Baby Visits and Care
Bones/Joints
Clinical Trials
Nutrition/Formulas
Off Label Prescription Drugs
Outpatient Contraceptive Services Including Sterilizations
Prescription Drugs Other
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
More Limited BenefitsOutpatient Rehabilitation Services
Nutritional Counseling
Rehabilitative Occupational and Rehabilitative Physical Therapy
Rehabilitative Speech Therapy
More Excluded BenefitsAcupuncture
Cosmetic Surgery
Hearing Aids
Infertility Treatment
Long Term Care
Weight Loss Programs
Routine Foot Care
Non-Emergency Care When Traveling Outside the U.S.
Dental Care - Adult
Abortion for Which Public Funding is Prohibited
Long-Term/Custodial Nursing Home Care
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  • Phone Number
    (802) 847-2884
  • Office Locations
    111 Colchester Avenue, East Pavilion 5
    Burlington, VT 05401
111 Colchester Avenue, East Pavilion 5 Burlington VT, 05401

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HealthPocket.com is a free information source. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan. While on our site, if you click on a plan or link, you may be directed to one of our partners who offers health insurance products. HealthPocket, Inc. is part of the Benefytt Technologies, Inc. family of companies.