Blue Cross Blue Shield Vermont
Vermont Freedom Plan Benefits Summary

The chart below gives a summary of the benefits under Vermont Freedom Plan Direct-pay program. You'll see that there are several deductible options to choose from. Deductibles apply to most services, although you do not have to pay deductibles for many office visits. You pay your deductible once every calendar year, whether you use Preferred or Non-preferred providers. Other payments you must make vary depending on the providers you use.


 When you use Preferred Providers, you pay:When you use Non-preferred Providers, you pay:
Combined Deductible Options

Option A: $3,500 per member or $7,000 per family
Option B: $5,000 per member or $10,000 per family
Option C: $7,500 per member or $15,000 per family
Option D: $10,000 per member or $20,000 per family

Office Visits$30 Co-payment Deductible plus 30% coinsurance
Inpatient General Hospital ServicesDeductible plus 20% coinsuranceDeductible plus 30% coinsurance
Outpatient General Hospital ServicesDeductible plus 20% coinsuranceDeductible plus 30% coinsurance
Emergency Room ServicesDeductible plus 20% coinsuranceDeductible plus 30% coinsurance
Ambulance ServicesDeductible plus 20% coinsuranceDeductible plus 20% coinsurance
Private Duty NursingDeductible plus 20% coinsuranceDeductible plus 30% coinsurance
Durable Medical EquipmentDeductible plus 20% coinsuranceDeductible plus 30% coinsurance
Home CareDeductible plus 20% coinsuranceDeductible plus 30% coinsurance

Out-of-pocket Maximums

(After you pay this amount in one calendar year, BCBSVT covers services at 100% for the rest of the year.)

Option A: $9,500 per member or $19,000 per family
Option B: $11,000 per member or $22,000 per family
Option C: $13,500 per member or $27,000 per family
Option D: $17,000 per member or $34,000 per family

Option A: $12,500 per member or $25,000 per family
Option B: $14,000 per member or $28,000 per family
Option C: $18,750 per member or $37,500 per family
Option D: $23,500 per member or $47,000 per family

 When you use Network Providers, you pay:When you use Non-network providers, you pay:
Office Visits for Mental Health and Substance Abuse Services$30 Co-paymentNo coverage
Inpatient Mental Health and Substance Abuse Treatment ServicesDeductible plus 20% coinsuranceNo coverage
Prescription Drugs
  • $100 separate deductible, then
  • 40% for each generic prescription,
  • 50% for each prescription on our Preferred Brand-name drug list, or
  • 60% for each Non-preferred prescription, with an out-of-pocket limit of $5,000 in a calendar year.
No coverage
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Blue Cross Blue Shield Vermont