BCBSVT Bronze Plan Plan Details for 2021- HealthPocket
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BCBSVT Bronze Plan

$568.00/mo
View BrochureSummary of BenefitsProvider Directory

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Zip Code05401
Applicant6/27/1987 Male
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameBCBSVT Bronze Plan
Plan IDhhs-13627VT0340006
Plan Year2021
Insurance ProviderBlueCross BlueShield of Vermont
Metal LevelExpanded Bronze
Plan TypeEPO
Deductible$8,400
Out-of-Pocket Maximum$8,400
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness$40 Copay
Specialist Visit$100 Copay
Laboratory Outpatient and Professional ServicesNo Charge after deductible
X-rays and Diagnostic ImagingNo Charge after deductible
Diagnostic Imaging such as MRIs, CT, and PET scansNo Charge after deductible
Deductible - Family$16800 per group
Out-of-Pocket Maximum - Family$16800 per group

Prescription drug coverage

Generic Drugs$30 Copay
Preferred Brand DrugsNo Charge after deductible
Non-Preferred Brand DrugsNo Charge after deductible
Specialty DrugsNo Charge 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 ServicesNo Charge after deductible
Inpatient Hospital Services (e.g., Hospital Stay)No Charge after deductible
Inpatient Physician and Surgical ServicesNo Charge after deductible
Emergency Transportation or Ambulance ServiceNo Charge after deductible

Maternity

Prenatal and Postnatal CareNo Charge after deductible
Delivery and all inpatient services for maternity careNo Charge after deductible

Mental Health

Mental/Behavioral Health Outpatient ServicesNo Charge after deductible
Mental/Behavioral Health Inpatient ServicesNo Charge after deductible
Substance use disorder outpatient servicesNo Charge after deductible
Substance use disorder inpatient servicesNo Charge 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
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
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
Dental Care - Adult
Abortion for Which Public Funding is Prohibited
Long-Term/Custodial Nursing Home Care
PremiumPlan NameDeductible
from $259BCBSVT Catastrophic Plan$8,550.00Select
from $562BCBSVT Vermont Preferred Bronze Plan$8,550.00Select
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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.

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