BCBSVT Bronze Plan Plan Details for 2021- HealthPocket

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Applicant Info
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Zip Code	05401 (edit)
Applicant	6/29/1987 Male (edit)

Insurance Type	ACA (Obamacare)
Plan Name	BCBSVT Bronze Plan
Plan ID	hhs-13627VT0340005
Plan Year	2021
Insurance Provider	BlueCross BlueShield of Vermont
Metal Level	Expanded Bronze
Plan Type	EPO
Deductible	$6,250
Out-of-Pocket Maximum	$8,400
Plan Highlights

Costs for Medical Care
Primary Care Visit to Treat an Injury or Illness	$35 Copay after deductible
Specialist Visit	$90 Copay after deductible
Laboratory Outpatient and Professional Services	50.00% Coinsurance after deductible
X-rays and Diagnostic Imaging	50.00% Coinsurance after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans	50.00% Coinsurance after deductible
Deductible - Family	$12500 per group
Out-of-Pocket Maximum - Family	$16800 per group

Prescription drug coverage
Generic Drugs	$15 Copay
Preferred Brand Drugs	$85 Copay after deductible
Non-Preferred Brand Drugs	60.00% Coinsurance after deductible
Specialty Drugs	60.00% Coinsurance after deductible

Access to doctors and hospitals
Provider directory URL	http://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 Services	50.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)	50.00% Coinsurance after deductible
Inpatient Physician and Surgical Services	50.00% Coinsurance after deductible
Emergency Transportation or Ambulance Service	$100 Copay after deductible

Maternity
Prenatal and Postnatal Care	$35 Copay after deductible
Delivery and all inpatient services for maternity care	50.00% Coinsurance after deductible

Mental Health
Mental/Behavioral Health Outpatient Services	50.00% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services	50.00% Coinsurance after deductible
Substance use disorder outpatient services	50.00% Coinsurance after deductible
Substance use disorder inpatient services	50.00% 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 Children	Included
Eye Glasses for Children	Included
Routine Eye Exam for Adults	Not Covered

Child Dental Coverage
Child Dental Coverage - Routine Dental Care	Included
Child Dental Coverage - Basic Dental Care	Included
Child Dental Coverage - Orthodontia	Included
Child Dental Coverage - Major Dental Care	Included

Adult Dental Coverage
Adult Dental Coverage - Routine Dental Care	Not Covered
Adult Dental Coverage - Basic Dental Care	Not Covered
Adult Dental Coverage - Orthodontia	Not Covered
Adult Dental Coverage - Major Dental Care	Not Covered

Exclusions and Limitations
More Included Benefits	Other 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 Benefits	Outpatient Rehabilitation Services Nutritional Counseling Rehabilitative Occupational and Rehabilitative Physical Therapy Rehabilitative Speech Therapy
More Excluded Benefits	Acupuncture 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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ZIP Code
County
Applicant Info
Applicant
Date of birth
//
Gender
male
female
Income
$

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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.