| Document Date: 2013-10-22 08:34:53
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Company PET / MedGroup / / Country United States / / Currency USD / / Facility hospital Imaging / Hospital Charges / / IndustryTerm physician services / use disorder outpatient services / co-insurance* inpatient / supply retail / health outpatient services / term in-network / use disorder inpatient services / rehabilitation services / co-insurance payment / to preventive services / state insurance department / medical transportation / inpatient services / room services / co-insurance* / co-insurance amounts / excluded services / covered services / treatment of diabetes / health equipment / health inpatient services / pulmonary services / to these services / Co-insurance / preventive services / / MedicalCondition pulmonary services / Substance use disorder / diabetes / injury / illness / / MedicalTreatment Immunization / Cosmetic Surgery / occupational therapy / home infusion therapy / chiropractic / Acupuncture / counseling / surgery / 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 / Governor / illness Specialist / physician / / Product Wellness Drugs / / Technology x-ray / / URL www.bcbsvt.com/preventive / www.bcbsvt.com/glossary / www.bcbsvt.com/findadoctor / www.dol.gov/ebsa / www.bcbsvt.com/rxcenter / www.bcbsvt.com/coveragewhiletraveling / www.bcbsvt.com/comp_cert / www.cciio.cms.gov / /
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Consumer Directed Health Plan (CDHP) - Comprehensive $3,250/$6,500 deductible, 20% co-insurance Wellness Drugs: $15 co-payment/$40 co-payment/$60 co-payment Summary of Benefits and Coverage: What this Plan Covers & What