Monthly premium
Your monthly payment for your health plan coverage.
Employee
$1,138.18
per monthEmployee & Spouse
$2,276.36
per monthEmployee & Child(ren)
$2,196.69
per monthFamily
$3,198.29
per monthGold Plan
Plan Costs & Overview
Deductible amount
The dollar amount you pay for services and/or medications before your plan begins to pay a larger portion of your costs.
Employee
After Deductible
$1,400
per yearEmployee & Spouse
Employee & Child(ren)
Family
After Deductible
$2,800
per yearDeductible type
There are two deductible types, stacked and aggregate. Members enrolled in an individual-only plan are not impacted, but if a family member is added onto the plan at a later date, it will change how the plan pays benefits.
On a stacked plan, once an individual meets their deductible or out-of-pocket limit, the plan pays accordingly, even on a two-person or family plan. With an aggregate plan, the full deductible or out-of-pocket limit must be met collectively by members on the plan before benefits are paid.
Stacked
Out-of-pocket maximum
The maximum amount you will pay for covered services (medical or prescriptions) during a plan year. Once you meet this limit, your plans pays 100% of covered health care costs for the rest of the plan year.
Employee
After Deductible
$5,600
per yearEmployee & Spouse
Employee & Child(ren)
Family
After Deductible
$11,200
per yearHealth Savings Account (HSA) compatibility
A Health Savings Account (HSA) is a tax-free savings account that can be used to pay for IRS-approved medical expenses that are not covered by a member’s health plan. HSAs work in conjunction with an HSA-eligible health plan that meets IRS guidelines.
Not Compatible
Health Reimbursement Arrangement (HRA) compatibility
Health Reimbursement Arrangements (HRA) are administered and funded by employers to help employees pay for out-of-pocket health care expenses like deductibles, office visits, hospital stays, and prescription drug costs.
Compatible
Network type
A network type determines the network of providers and facilities available in a health plan. For example, all of our Qualified Health plans have an Exclusive Provider Organization (EPO) network which allows access to the preferred BlueCard® network of providers & facilities in Vermont and nationwide.
EPO
Summary of Benefits and Coverage (SBC)
Prescription Drugs
Prescription drug deductible
The amount you pay toward the cost of medications before your plan will begin to pay costs.
$200 (Employee only); $400 (couple and family)
Prescription out-of-pocket maximum
A limit on the amount you will pay for covered prescriptions in a calendar year. Once you meet this limit, we will pay for 100% of covered costs for the rest of the calendar year. Some plans may have a separate prescription out-of-pocket maximum, or it may be combined with the overall out-of-pocket maximum.
Employee
After Deductible
$1,600
per yearEmployee & Spouse
Employee & Child(ren)
Family
After Deductible
$3,200
per yearGeneric prescription drugs
A generic drug is a medication created to be the same as an existing approved brand-name drug.
Before Deductible
$15
co-payAfter Deductible
$15
co-payPreferred brand prescription drugs
Brand-name drugs that are listed on our formulary drug list (drugs covered by your plan).
Before Deductible
Full price
After Deductible
$60
co-payNon-preferred brand prescription drugs
A medication that has been determined to have an alternate drug available that is clinically equivalent such as a generic equivalent.
Before Deductible
Full price
After Deductible
50%
co-insuranceGeneric wellness drugs
Generic medication for select conditions such as asthma, antidepressants, cardiovascular/heart disease, diabetes, smoking deterrents, and more.
Before Deductible
$15
co-payAfter Deductible
$15
co-payPreferred wellness drugs
Preferred brand medications for select conditions such as asthma, antidepressants, cardiovascular/heart disease, diabetes, smoking deterrents, and more.
Before Deductible
Full price
After Deductible
$60
co-payNon-preferred wellness drugs
Preferred brand medications for select conditions such as asthma, antidepressants, cardiovascular/heart disease, diabetes, smoking deterrents, and more.
Before Deductible
Full price
After Deductible
50%
co-insuranceOffice Visits
Preventive care
Services used to find or reduce your risks when you do not have symptoms, signs, or specific increased risk for the condition being targeted. They may include immunizations, screenings, counseling, or medications that can prevent or find a condition.
$0
Screening
A test that helps find diseases and conditions early, such as diabetic screenings, colonoscopies, mammograms, and more,. Routine health screenings are recommended for people throughout life as part of preventive care.
$0
Immunization
Vaccinations for adults and children.
$0
Primary Care & Mental Health
Primary Care: A visit to a healthcare provider who provides primary, routine care services.
Mental Health: A visit to a healthcare provider for routine, office-based mental health and/or substance use disorder treatment.
Before Deductible
3 visits per member at $0, then $20
After Deductible
$20
co-paySpecialist
A visit to a healthcare provider that is considered a medical specialist, such as an orthopedic surgeon or cardiologist.
Before Deductible
$55
co-payAfter Deductible
$55
co-payChiropractor
A visit to a licensed chiropractic provider to treat and prevent neuromusculoskeletal disorders.
Before Deductible
$35
co-payAfter Deductible
$35
co-payOutpatient Physical Therapy
A visit to a healthcare provider for therapy that relieves pain of an acute condition, restores function, and prevents disability following disease, injury, or loss of body part.
Before Deductible
$35
co-payAfter Deductible
$35
co-payNutritional Counseling
A visit to a healthcare provider that helps you assess your dietary habits and create an individual action plan for ongoing self-care.
Before Deductible
$55
co-payAfter Deductible
$55
co-payOutpatient Speech and Occupational Therapy
Speech therapy services provide treatment of swallowing, speech-language and cognitive-communication disorders. Occupational therapy services promote the restoration of a physically disabled person’s ability to accomplish the ordinary tasks of daily living or the requirements of their particular occupation.
Before Deductible
$55
co-payAfter Deductible
$55
co-payHospital Services
Urgent Care
Health care services that are necessary to treat a condition or illness of an individual that if not treated within 24 hours would cause risk.
Before Deductible
$65
co-payAfter Deductible
$65
co-payEmergency Room Care
Care for illness or injuries that need immediate attention and care.
Before Deductible
Full price
After Deductible
$150
co-payEmergency Medical Transportation
Transportation provided to the nearest facility or hospital, such as by an ambulance service.
Before Deductible
$75
co-payAfter Deductible
$75
co-payDiagnostic Testing
Tests ordered by your provider to learn or determine more about a specific condition or disease. These services can include labs, x-rays, testing, and other procedures. These tests can be performed in an office and in an outpatient hospital.
Before Deductible
Full price
After Deductible
30%
co-insuranceOutpatient Hospital Care
Outpatient care in a General Hospital or ambulatory surgical center that does not require an overnight stay. Services may include surgery, diagnostic services, advanced imaging (MRI, CT, or PET scan), treatments (such as chemotherapy), or other types of procedures.
Before Deductible
Full price
After Deductible
30%
co-insuranceInpatient Hospital Stay
Medical care when you get admitted to a health care facility, like a hospital or other type of inpatient facility and spend at least one night.
Before Deductible
Full price
After Deductible
30%
co-insuranceEnrollment & Help
Enrollment & Help
Ready to enroll? You can enroll through our Online Enrollment Form or download a PDF of our enrollment form to complete and send back to us.
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