VADA Insurance Trust vs Vermont Health Connect - PDF document

1 VADA Insurance Trust vs Vermont Health C
VADA Insurance Trust vs Vermont Health Connect (BCBSVT Blue Rewards Only Plans) ��Page 1 VADA PLAN A VADA PLAN B VADA PLAN C Exchange - Blue Rewards Exchange - Blue Rewards Exchange - Blue Rewards VFP VFP VFP Gold Silver Catastrophic $750 Deductible $1,250 Deductible $2,750 Deductible $1,250 Ind / $2,500 Family $2,000 Ind / $4,000 Family $6,350 Ind / $12,700 Family DEDUCTIBLE in Network $750 Individual $1,250 Individual $2,750 Individual $1,250 Individual $2,000 Individual $6,350 Individual $1,500 Family $2,500 Family $5,500 Family $2,500 Family $4,000 Family $12,700 Family INDIVIDUAL COINSURANCE in Network n/a (except for child dental) n/a (except for child dental) n/a (except for child dental) $3,000 Individual $5,000 Individual $8,000 Individual $4,250 Individual (Rx Included) $6,250 Individual (Rx Included) $6,350 Individual (Rx Included) $6,000 Family $16,000 Family $8,500 Family (Rx Included) $12,500 Family (Rx Included) $12,700 Family (Rx Included) DEDUCTIBLE out of Network $1,500 Individual $2,500 Individual $5,500 Individual n/a n/a n/a $3,000 Family $5,000 Family $11,000 Family n/a n/a n/a COINSURANCE out of Network n/a n/a n/a $5,000 Individual $6,500 Individual $11,000 Individual n/a n/a n/a $10,000 Family $13,000 Family $22,000 Family n/a n/a n/a TYPES OF BENEFIT PREVENTIVE OFFICE VISITS No ChargeNo ChargeNo Charge PRIMARY CARE PHYSICIAN'S OFFICE VISITS $20 Copay* After Deductible $30 Copay* After Deductible No Charge After Deductible n/aSPECIALIST OFFICE VISITS $30 Copay* After Deductible $50 Copay* After Deductible No Charge After Deductible DIAGNOSTIC TESTING(Includes laboratory and x-ray) $30 CopayAfter Deductible $50 CopayAfter Deductible No ChargeAfter Deductible INPATIENT CARE(Precertification required for all Plans) $500 CopayAfter Deductible $1,750 CopayAfter Deductible No ChargeAfter Deductible HOSPITAL OUTPATIENT CARE $500 CopayAfter Deductible $1,750 CopayAfter Deductible No ChargeAfter Deductible OUTPATIENT PHYSICAL, OCCUPATIONAL AND SPEECH THERAY(Frequency limits apply) $30 Copay After Deductible $50 Copay After Deductible No Charge After Deductible AMBULATORY SURGERY $500 CopayAfter Deductible $1,750 CopayAfter Deductible No ChargeAfter Deductible EMERGENCY ROOM PHYSICIAN $0 Copay$0 Copay No ChargeAfter Deductible HOSPITAL EMERGENCY ROOM $250 CopayAfter Deductible $250 Copay after Deductible No ChargeAfter Deductible *Deductible and copays do not apply to the first 3 primary care, mental health and substance abuse visits (including routine lab services) combined up to a total of 9 visits per family. 20% 30% 20% after Deductible, 0% after the OOP Maximum has been met20% after Deductible, 0% after the OOP Maximum has been met20% after Deductible, 0% after the OOP Maximum has been met TOTAL ANNUAL in Network OUT-OF-POCKET (OOP) MAXIMUMS plus $1250 Ind/$2500 Rx Ded TOTAL ANNUAL out of NetworkOUT-OF-POCKET (OOP) MAXIMUMSNo Charge$25 CopayNo Deductible or Coinsurance$50 CopayNo Deductible or Coinsurance$250 Copay VADA Insurance Trust vs Vermont Health Connect (BCBSVT Blue Rewards Only Plans) ��Page 2 VADA PLAN A VADA PLAN B VADA PLAN C Exchange - Blue Rewards Exchange - Blue Rewards Exchange - Blue Rewards VFP VFP VFP Gold Silver Catastrophic $750 Deductible $1,250 Deductible $2,750 Deductible $1,2

2 50 Ind / $2,500 Family $2,000 Ind / $4,0
50 Ind / $2,500 Family $2,000 Ind / $4,000 Family $6,350 Ind / $12,700 Family URGENT CARE $30 CopayAfter Deductible $50 CopayAfter Deductible No ChargeAfter Deductible AMBULANCE IN OR OUT-OF-SERVICE AREA $30 CopayAfter Deductible $50 CopayAfter Deductible No ChargeAfter Deductible HOME and HOSPICE CARE SERVICES Home Health: $30 Copay After Deductible; Hospice: No Charge Home Health: $50 Copay After Deductible; Hospice: No Charge No Charge After Deductible OUTPATIENT MENTAL HEALTH AND SUBSTANCE ABUSE OFFICE VISITS $30 CopayAfter Deductible $50 CopayAfter Deductible No ChargeAfter Deductible INPATIENT CARE, MENTAL HEALTH AND SUBSTANCE ABUSE (Prior approval required for all Plans) $500 Copay After Deductible $1,750 Copay After Deductible No Charge After Deductible CHIROPRACTIC VISITS (Prior approval required after 12 visits for all Plans) $30 CopayAfter Deductible $50 CopayAfter Deductible No ChargeAfter Deductible DURABLE MEDICAL EQUIPMENT (Prior approval may be required for all Plans) $30 CopayAfter Deductible $50 CopayAfter Deductible No ChargeAfter Deductible VISON EXAM - One exam per person per year $30 Copay After Deductible for Exam & $30 Copay After Deductible for Glasses $50 Copay After Deductible for Exam & $50 Copay After Deductible for Glasses $No Charge after Deductible for Exam & No Charge after Deductible for Glasses Dental EXAM PRESCRIPTION DRUG DEDUCTIBLEn/an/an/a PRESCRIPTION MAIL ORDER DEPENDENTS UNAPPROVED Rates for November 2013 - October 2014 VADAPLAN A VADAPLAN B VADAPLAN C Exchange - Blue Rewards Gold Exchange - Blue RewardsSilver Exchange - Blue RewardsCatastrophic One Person: $486.00 $452.00 $388.00 $460.37 $395.26 $213.68 Two Person: $972.00 $904.00 $776.00 $920.74 $790.52 $427.36 Adult & Child or Childrenn/an/an/a $888.51 $762.85 $412.40 Family: $1,350.00 $1,257.00 $1,082.00 $1,293.64 $1,110.68 $600.44 Covered to age 26 n/a Generic: $5 Copay After Deductible per 30 day supplyPreferred: 40% Coinsurance After Deductible per 30 day supplyNon-Preffered: 60% Coinsurance After Deductible per 30 day supplyn/a Class 1: No Charge; Class II: 30% Coinsurance, Class III: 50% Coinsurance Child (up to age 21) Coverage Only 20% after Deductible, 0% after the OOP Maximum has been metGeneric: $15 Copay per 30 day supplyPreferred: $40 Copay per 30 day supplyNon-Preferred: $60 Copay per 30 day supplyBenefits provided for up to a 90-day supply for most prescription drugs.Generic: $5 Copay After Deductible per 30 day supplyPreferred: 40% Coinsurance After Deductible per 30 day supplyNon-Preffered: 60% Coinsurance After Deductible per 30 day supplyGeneric: No Charge After Deductible per 30 day supplyPreferred: No Charge After Deductible per 30 day supplyNon-Preffered: No Charge After Deductible per 30 day supply20% after Deductible, 0% after the OOP Maximum has been met$50 Copay$50 Copay$20 Copay: Exam Only for Child and Adult20% after Deductible, 0% after the OOP Maximum has been met Child (up to age 21) Coverage Only $50 Copay20% after Deductible, 0% after the OOP Maximum has been met$100 Deductible Per Person Per YearPRESCRIPTION DRUGS COPAYS - Some prescription drugs require prior approval. Prescription drug out-of-pocket limit: $1,250 Individual/$2,500 Two-Person/Family per year. Covered to age 26 3 month supply for 2.5 copays Approved Rates for January 2014 - December 2014 through VNC