| Document Date: 2014-11-10 12:20:46
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Company EPO / PET / / Country United States / / Currency USD / / Facility Deductible Pharmacy / Hospital Charges / hospital Not / / IndustryTerm use disorder outpatient services / rehabilitation services / co-insurance payment / co-insurance* / co-insurance amounts / facility services / treatment of diabetes / health equipment / chiropractic services / Co-insurance / preventive services / adult dental services / physician services / health outpatient services / term in-network / use disorder inpatient services / state insurance department / medical transportation / routine lab services / mental health services / inpatient services / room services / excluded services / covered services / health inpatient services / pulmonary services / to these services / to some services / / MedicalCondition Substance use disorder / injury / illness / Infertility / pulmonary services / diabetes / / MedicalTreatment Immunization / chiropractic / Acupuncture / counseling / surgery / Cosmetic Surgery / occupational therapy / Home infusion therapy / Bariatric surgery / / Organization U.S. Department of Health and Human Services / Employee Benefits Security Administration / U.S. Department of Labor / / / Position Physician /surgeon / care physician / physician / Governor / / Technology x-ray / / URL www.bcbsvt.com / www.bcbsvt.com/preventive / www.bcbsvt.com/nonstd-copay-cert / www.bcbsvt.com/glossary / www.bcbsvt.com/findadoctor / www.dol.gov/ebsa / www.bcbsvt.com/rxcenter / www.bcbsvt.com/coveragewhiletraveling / www.bcbsvt.com/mental-health-primary / www.cciio.cms.gov / /
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BCBSVT Blue Rewards Silver Plan $30 PCP / $50 Specialist co-payment, $2,000 / $4,000 Deductible Pharmacy: $5 co-payment / 40% co-insurance / 60% co-insurance Summary of Benefits and Coverage: What this Plan Covers & What