| Document Date: 2014-11-10 12:23:55
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Company PET / EPO / / Country United States / / Currency USD / / Facility hospital Imaging / Hospital Charges / Hospice In-Network Provider Out-of-Network Provider Limitations / / IndustryTerm adult dental services / physician services / use disorder outpatient services / co-insurance* inpatient / health outpatient services / term in-network / use disorder inpatient services / rehabilitation services / co-insurance payment / state insurance department / medical transportation / mental health services / inpatient services / room services / co-insurance* / co-insurance amounts / excluded services / covered services / treatment of diabetes / health inpatient services / pulmonary services / chiropractic services / to these services / Co-insurance / preventive services / / MedicalCondition Infertility / 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 / hospital stay Physician/surgeon / Governor / physician / / 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/nonstd-cdhp-cert / www.bcbsvt.com/mental-health-primary / www.bcbsvt.com/coveragewhiletraveling / www.cciio.cms.gov / /
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BCBSVT Blue Rewards Bronze CDHP Plan $5,000 / $10,000 Deductible, 50% co-insurance Pharmacy: $25 co-payment / 40% co-insurance / 60% co-insurance Summary of Benefits and Coverage: What this Plan Covers & What it Costs