QUALIFIED HEALTH PLANS - For employers with 2-50 employees - Blue Cross of Idaho
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QUALIFIED HEALTH PLANS
For employers with 2-50 employees
Policy Form Numbers
18-136 (01/22) HSACCOC (01/22)
HSAPPOP (01/22) 18-144 (01/22)
18-141 (01/22) HSAPOSC (01/22)
Form No. 3-1022 (08-21)
Health plan options
for employers
Blue Cross of Idaho is committed to making healthcare easier to use, afford and understand
for our members and clients.
Our 2022 plan offerings aim to do just that.
We’re refining our employer plans and solutions so they better meet the needs of our clients’
employees and their families. We’re also working hard to simplify the healthcare journey for
members making their experience easier than ever before. These innovations for 2022 are
paired with our core set of network options, value-based contracts with providers, and clinical
solutions for members.
2
Blue Cross of Idaho | Qualified Health Plans for Small Groups
Medical plan options to meet the needs of all members
Your employees and their families likely all have different needs and priorities
when it comes to their healthcare. Some prefer to pay as little as possible for their
monthly health insurance premiums, while others would rather trade a higher
monthly premium for a lower annual deductible.
One size does not fit all when it comes to health plan offerings. But did you know that you can offer more
than one medical plan option for your employees?
Employers with fewer than 20 employees can offer up to three medical plans. Those with 20-50
employees can offer up to six medical plans.
It costs employers nothing to offer multiple plan options besides the share of premiums. Plus, Health
Savings Account (HSA) and Coordinated Care Organization (CCO) plans offer savings in premiums for
both employers and members.
When you offer options, you give employees more choices that fit their lifestyles and budgets, and meet
them where they are on their healthcare journey.
See our Consumer Driven Health brochure for more information on HSA plans and related options.
Different plan options for different members
For employees with greater healthcare needs: PPO plans
Employees with chronic conditions or other health challenges that require regular access
to care might benefit from a PPO plan. While their monthly premiums may be higher than
other plan options, they’ll enjoy a lower deductible and copays for office visits and care,
plus access to a full PPO network of providers.
For employees looking to save: HSA plans
Price-conscious employees who are looking to save money on healthcare and may not
need a great deal of care are a good fit for an HSA plan. These plans let members
access the large PPO network while helping them save on premium costs and get
valuable tax benefits.
For employees in Southwest and Eastern Idaho: CCO plans
Employees who live and work in Southwest or Eastern Idaho and want affordable
coverage and care coordination can take advantage of a CCO plan. A CCO plan
offers low monthly premiums and care from patient-centered PCPs in a regional
tailored network.
bcidaho.com
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Three networks, more options
Choice Network – Preferred Provider Organization (PPO)
Our statewide PPO partners with 100% of acute care hospitals and 96% of all healthcare providers
throughout the state.
Point Network – Point of Service (POS)
Our statewide POS managed care network relies on primary care providers (PCPs) to treat, coordinate
care and help members navigate the healthcare world.
Connect Network – Coordinated Care Organization (CCO)
Our regional and affordable CCO plans also partner with PCPs to treat members and refer them for
specialty care or other services as needed, saving members money while ensuring they get the care
they need.
Metal levels explained
Employers
B R O N Z E can choose from three
C A levels
TA ST P HIC
RO
of plans based on the amount of coverage
they provide. These plan levels depend on the monthly premium cost and the
percent of costs covered by the plan.
Note: All metal levels have the same essential health benefits, such as ER services, maternity and
newborn care, annual wellness visits and preventive care.
CA
S I LV E R BRO NZE TA ST P HIC
RO
BRONZE
Our Bronze plans come with our lowest premiums. For an average person,
Bronze plans pays about 60% of an average year’s medical costs.
CA
GOLD S I LV E R BRO NZE
SILVER
Our Silver plans offer employees more coverage for a slightly higher
premium. Silver plans pay about 70% of yearly costs for an average member.
GOLD
Gold plans combine low deductibles and greater coverage for employees.
These plans pay about 80% of average yearly medical costs.
4
Blue Cross of Idaho | Qualified Health Plans for Small Groups
Coordinated Care Organizations (CCO)
Our CCO plans place a PCP at the center of a member’s care. These PCPs
are part of a healthcare provider network. They treat members and help
them find specialty care or other services as needed.
CCO plan members don’t need a referral to get care from an in-network
specialist, but they do need a referral for out-of-network specialist care.
SOUTHWESTERN IDAHO
Saint Alphonsus Health Alliance
• More than 2,700 highly skilled providers, including those at
Saint Alphonsus Health System and many independent
providers across the Treasure Valley
• Seven medical centers, 13 outpatient and surgery facilities
and 43 urgent care clinics
• In-network providers located in Ada, Boise, Canyon, Elmore,
Gem, Owyhee, Payette, Valley and Washington counties
Independent Doctors of Idaho
• More than 650 independent providers, including PCPs and
specialists in orthopedics, gastroenterology, neurosurgery,
neurology, urology, psychiatry and more
• 12 hospitals and surgery centers and 32 urgent care centers
• In-network providers located in Ada, Boise, Canyon, Elmore,
Gem, Owyhee, Payette and Washington counties
SOUTHEASTERN IDAHO
Patient Quality Alliance
• More than 1,000 highly skilled healthcare providers, including
those at Portneuf Medical Center
• In-network providers located in Bannock, Bear Lake, Bingham,
Caribou, Franklin, Oneida and Power counties
Mountain View Network
• More than 1,300 highly skilled healthcare providers, including
those at Mountain View Hospital, Idaho Falls Community
Hospital and Madison Memorial Hospital
• Dozens of hospitals and surgery centers
• In-network providers located in Bingham, Bonneville, Butte,
Clark, Custer, Fremont, Jefferson, Lemhi, Madison and
Teton counties
bcidaho.com
5
Vital benefits to members and families
• $0 copayment for in-network primary care provider (PCP) and behavioral healthcare visits for
dependent children age 17 and younger on most plans
• MDLIVE: Members of all ages can get 24/7 non-emergency virtual care from anywhere through our
telehealth vendor MDLIVE
Solutions to help members get and stay healthy
Weight Management
Wondr Health – formerly known as Naturally Slim – is a clinically proven weight management and lifestyle
change program. Not a diet, Wondr Health helps participants learn how they eat, not what they eat, so
they can improve their physical and mental health while still enjoying the foods they love.
Diabetes Prevention Program
This program helps members decrease their risk of developing Type 2 diabetes. Through a 16-week
program, it teaches participants to make lasting lifestyle changes by eating healthier, doing more
physical activity and managing challenges that come up along the way.
Talk to your broker to learn more about these benefits.
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Blue Cross of Idaho | Qualified Health Plans for Small Groups
Tools to empower members while shopping for care
• NEW: ChoiceLocations – Members looking for care can find low-cost facilities that are highlighted in
our provider directory.
• SmartShopper: Members can use our online tools to shop for the most cost-effective places for care
when they need to have a medical procedure. Members who shop for and select low-cost facilities for
care may be eligible for a cash reward.
• ChoiceDocs: Members with plans in the PPO network can use our online provider directory to find
ChoiceDocs-designated providers. By visiting ChoiceDocs providers, members will pay a lower or –
depending on the plan – even no copayment.
Blue Cross of Idaho member app
Our member app helps members find care and keep track of their plan
in an easy-to-use mobile app.
With the app, members can:
• Search for care • Track claims for the entire family
• Access and send/fax member • Find FAQs and help resources
ID card from the app • And more!
Find the app in the App Store and Google Play Store.
Talk to your broker to learn more about these benefits.
Text message updates from Blue Cross of Idaho
Members can stay on top of their health with educational and informational text messages from
Blue Cross of Idaho.
Members who opt in to get text messages from Blue Cross of Idaho get:
• Updates on health plan benefits available for you
• Reminders for when it’s time to get preventive care
• Helpful tips on how to get and stay healthy
• Updates on COVID-19
Members can sign up for texts from Blue Cross of Idaho in one of two ways:
• Visit connectbcidaho.com/signup
• Text bluecrossidaho to 73-529
Reply “STOP” to any Blue Cross of Idaho text message and you will be removed from our contact list.
bcidaho.com
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AVAILABLE WITH ALL PLANS Talk to your broker to learn more about these benefits.
Cost Advisor Condition Support
This cost transparency tool lets you Care managers offer personal health
search for and compare providers, support to members with asthma,
hospitals and other healthcare costs side- diabetes, chronic obstructive pulmonary
by-side before you make appointments. disease, coronary artery disease and
congestive heart failure.
Blue Extras!sm
Blue Extras! offers discounted services, Behavioral Health Management
programs and products that will help you Members can get support from a case
with your health, wellness and fitness manager who ensures members get the
goals. These extras are provided by highest quality of care at the right
independent sources that have agreed to location for them.
offer discounted rates members.
Nurse Advice Line
Care Management This service lets members talk with a
This program supports members registered nurse 24/7 to help them
facing a complex health condition. make informed choices about their
Care managers work with members to health. While not a substitute for medical
help guide them through the maze of attention, members can use the Nurse
complex decision-making that may come Advice Line to get information about
with a serious health situation. medications, tests and procedures and
health topics.
Additional products and services for purchase
Dental Plans Well-Being Packages
Our dental plans have been structured to Blue Cross of Idaho launches its new
optimize healthy outcomes by increasing well-being platform with Sharecare in
access to care, reducing cost for services March 2022. Employers can select a
that treat disease and align covered well-being package option or an add-
services to support overall health and on product to get the most out of the
Sharecare platform while administering
utilization of medically necessary services.
a wellness program.
See our Group Dental Plans brochure for
more details on plan options. Employee Assistance Programs (EAP)
EAP can connect you and your family to
Vision Plans
face-to-face counseling professionals,
An annual well vision exam supports
referrals to community resources and
overall health and may reveal the first
indication of several chronic diseases. web-based tools to help you sort out
Our vision plans offer either free or work, personal or family issues.
low-cost WellVision Exams® with Vision COBRA
Service Plan (VSP) network providers. Group health continuation coverage
Members get the most out of their vision under the Consolidated Omnibus
benefit when they see a VSP provider for
Budget Reconciliation Act (COBRA)
corrective services, eyewear and contact
allows former employees and their
lenses. Beginning in 2022, vision care for
families to temporarily continue their
dependent children age 18 and younger
job-based health coverage at near-group
on an HSA plan is covered before the
deductible. See our Group Vision Plan rates. Available to employers with 20 or
brochure for more details. more employees.
Included with all medical plans for all group types Available to purchase as an add-on product or service
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Blue Cross of Idaho | Qualified Health Plans for Small Groups
Key terms
Coinsurance Out-of-Pocket Maximum
This is the employee’s share of the cost for The maximum amount a member will pay for
services, for example, “member pays 20%.” covered services from in-network healthcare
providers in the benefit period (the total of
Copayment copayments, coinsurance and deductibles).
A dollar amount that employees pay directly to a
doctor, hospital or pharmacy for certain services. Primary Care Provider
A physician who practices family medicine,
Deductible internal medicine, obstetrics or pediatric
The amount employees pay each year for out-of- medicine and is the primary medical connection
pocket expenses before their insurance begins for a member. In a POS or CCO network, the
to pay. Some plans have separate deductibles PCP coordinates care.
for medical care and prescription drugs.
Premium
In network The monthly amount members pay for the health
Healthcare providers who have contracted in insurance plan sponsored by a company.
your network to provide services at negotiated
rates. Employees who are in a CCO network will Prior Authorization
need a referral from their PCP to see an out-of- Services that must be approved before they take
network (OON) provider. place to ensure they are medically necessary.
Out of network Referral
Healthcare providers who have not contracted A request from a PCP to get care from a
with Blue Cross of Idaho. When members specialist or other types of medical services.
see OON healthcare providers, they will pay
more for services. OON providers can charge
members the difference between the allowed
amount and the remainder of the bill. A
member may have to pay the entire medical
bill if an OON provider does not request prior
authorization for certain services and payment is
denied by Blue Cross of Idaho.
bcidaho.com
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Our HSA plans are eligible for a Health Savings Account (HSA). That means they can be paired with a tax-advantaged
savings account used to pay for out-of-pocket medical expenses.
BRONZE HSA 6900 SILVER HSA 4400
NETWORKS PPO, POS, CCO PPO, POS, CCO
ANNUAL COSTS OUT-OF- OUT-OF-
IN-NETWORK IN-NETWORK
(what member pays) NETWORK NETWORK
$6,900 individual $17,100 individual $4,400 individual $13,200 individual
Deductible $13,800 family $34,200 family $8,800 family $26,400 family
0% after 0% after 0% after 0% after
Coinsurance deductible deductible deductible deductible
$6,900 individual $17,100 individual $4,400 individual $13,200 individual
Out-of-Pocket Maximum $13,800 family $34,200 family $8,800 family $26,400 family
COVERED SERVICES
Preventive Care/Screening No charge No charge
(for listed services)
Primary Care Office Visit
Specialist Office Visit
Telehealth (MDLive)
Diagnostic Lab and X-ray
Advanced Imaging
(CT/PET scans, MRIs)
Emergency Room
Services
No charge after No charge after
Inpatient Hospital No charge after deductible No charge after deductible
Facility and Services
deductible deductible
Outpatient Mental
Health/Substance Abuse
Services
Outpatient Surgery and
Professional Facilities2
Outpatient Rehabilitation
or Habilitation Services3
Maternity Care
Dependent Hearing Aids
PRESCRIPTION DRUGS
Covered Preventive No charge No charge
Preferred Generic
Non-Preferred Generic
Preferred Brand
No charge after deductible No charge after deductible
Non-Preferred Brand
Preferred Specialty
Non-Preferred Specialty
1
For treatment of emergency medical conditions as defined in the policy/contract, Blue Cross of Idaho will provide in-network benefits for covered services, even if they are
provided out-of-network. 2 In-network coinsurance applies for services from listed preferred facilities.3 Outpatient rehabilitation and habilitiation therapy services are EACH
limited to a combined physical therapy, speech therapy and occupational therapy total of 20 visits per member, per benefit period. Treatment for Autism Spectrum Disorder
is covered the same as any other condition, depending on the services rendered. Visit limits do not apply to Treatments for Autism Spectrum Disorder. 4 Mail order incentive
offers three-month supply for two copays (for specific maintenance drugs).
10Blue Cross of Idaho | Qualified Health Plans for Small Groups
Our HSA plans are eligible for a Health Savings Account (HSA). That means they can be paired with a tax-advantaged
savings account used to pay for out-of-pocket medical expenses.
SILVER HSA 2800 GOLD HSA 3000
NETWORKS PPO, POS, CCO PPO, CCO
ANNUAL COSTS OUT-OF- OUT-OF-
IN-NETWORK IN-NETWORK
(what member pays) NETWORK NETWORK
$2,800 individual $8,400 individual $3,000 individual $9,000 individual
Deductible $5,600 family $16,800 family $6,000 family $18,000 family
20% after 50% after 0% after 0% after
Coinsurance deductible deductible deductible deductible
$5,750 individual $17,250 individual $3,000 individual $9,000 individual
Out-of-Pocket Maximum $11,500 family $34,500 family $6,000 family $18,000 family
COVERED SERVICES
Preventive Care/Screening No charge No charge
(for listed services)
Primary Care Office Visit
Deductible and
Specialist Office Visit Deductible and coinsurance
Telehealth (MDLive) coinsurance
Diagnostic Lab and X-ray
$250 copay, then $250 copay, then
Advanced Imaging deductible and deductible and
(CT/PET scans, MRIs) coinsurance coinsurance
Emergency Room Deductible, then Deductible, then
Services $350 copay $350 copay1
No charge after
Inpatient Hospital No charge after deductible
Facility and Services
Deductible and deductible
Outpatient Mental coinsurance
Health/Substance Abuse
Services
Deductible, then
Outpatient Surgery and 10% coinsurance Deductible and
Professional Facilities2 for specific listed coinsurance
services
Outpatient Rehabilitation
or Habilitation Services3
Deductible and
Maternity Care coinsurance
Dependent Hearing Aids
PRESCRIPTION DRUGS
Covered Preventive No charge No charge
Medical deductible,
Preferred Generic then $10 copay4
Medical deductible,
Non-Preferred Generic then $20 copay4
Medical deductible,
Preferred Brand then $35 copay4
No charge after deductible
Medical deductible,
Non-Preferred Brand then $50 copay4
Medical deductible,
Preferred Specialty then 30% copay4
Medical deductible,
Non-Preferred Specialty then 50% copay4
1
For treatment of emergency medical conditions as defined in the policy/contract, Blue Cross of Idaho will provide in-network benefits for covered services, even if they are
provided out-of-network. 2 In-network coinsurance applies for services from listed preferred facilities.3 Outpatient rehabilitation and habilitiation therapy services are EACH
limited to a combined physical therapy, speech therapy and occupational therapy total of 20 visits per member, per benefit period. Treatment for Autism Spectrum Disorder
is covered the same as any other condition, depending on the services rendered. Visit limits do not apply to Treatments for Autism Spectrum Disorder. 4 Mail order incentive
offers three-month supply for two copays (for specific maintenance drugs).
bcidaho.com
11Please visit bcidaho.com/SBC for a Summary of Benefits and Coverage. Benefit grids outline common in-network and
out-of-network services for small groups. This is not a comprehensive list of benefits.
BRONZE 6500 BRONZE 7500 BRONZE 8550 – Deductible First
NETWORKS PPO, POS, CCO PPO, POS, CCO PPO, POS, CCO
ANNUAL COSTS OUT-OF- OUT-OF- OUT-OF-
IN-NETWORK IN-NETWORK IN-NETWORK
(what member pays) NETWORK NETWORK NETWORK
$6,500 individual $17,100 individual $7,500 individual $17,100 individual $8,550 individual $17,100 individual
Deductible $13,000 family $34,200 family $15,000 family $34,200 family $17,100 family $34,200 family
Coinsurance 40% 50% 40% 50% 0% 0%
$8,550 individual $25,650 individual $8,550 individual $25,650 individual $8,550 individual $17,100 individual
Out-of-Pocket Maximum $17,100 family $51,300 family $17,100 family $51,300 family $17,100 family $34,200 family
COVERED SERVICES
Preventive Care/Screening No charge No charge No charge
(for listed services)
Pediatric Office Visits
(includes outpatient $0 copay $0 copay
behavioral health)
ChoiceDocs ChoiceDocs
Primary Care Office Visit copay: $30 copay: $30
Copay: $50 Copay: $50
Deductible and Deductible and
ChoiceDocs: coinsurance coinsurance
deductible, then Deductible and
Specialist Office Visit $50 copay
coinsurance
Copay: deductible,
then $80
Telehealth (MDLive) $10 copay $10 copay
Deductible and Deductible and
Diagnostic Lab and X-ray coinsurance coinsurance
No charge after
$250 copay, then $250 copay, then $250 copay, then $250 copay, then No charge after deductible
Advanced Imaging deductible and deductible and deductible and deductible and deductible
(CT/PET scans, MRIs) coinsurance coinsurance coinsurance coinsurance
Deductible, then Deductible, then Deductible, then Deductible, then
Emergency Room Services $350 copay $350 copay1 $350 copay $350 copay1
Inpatient Hospital Deductible and Deductible and
Facility and Services coinsurance coinsurance
Outpatient Mental Health/ $50 copay $50 copay
Substance Abuse Services
Deductible, then Deductible, then
Outpatient Surgery and 30% for specific deductible and 30% for specific Deductible and
Professional Facilities2 listed services coinsurance listed services coinsurance
Outpatient Rehabilitation
or Habilitation Services3
Deductible and Deductible and
Maternity Care coinsurance coinsurance
Dependent Hearing Aids
PRESCRIPTION DRUGS
Covered Preventive $0 copay $0 copay $0 copay
Preferred Generic $20 copay 4
$10 copay 4
$20 copay4
Non-Preferred Generic $30 copay4 $20 copay4 $30 copay4
Medical deductible, Medical deductible,
Preferred Brand then $35 copay4 then $35 copay4
Medical deductible, Medical deductible,
Non-Preferred Brand then $50 copay4 then $50 copay4
No charge after deductible
Medical deductible, Medical deductible,
Preferred Specialty then 30% coinsurance then 30% coinsurance
Medical deductible, Medical deductible,
Non-Preferred Specialty then 50% coinsurance then 50% coinsurance
1
For treatment of emergency medical conditions as defined in the policy/contract, Blue Cross of Idaho will provide in-network benefits for covered services, even if they are
provided out-of-network. 2 In-network coinsurance applies for services from listed preferred facilities.3 Outpatient rehabilitation and habilitiation therapy services are EACH
limited to a combined physical therapy, speech therapy and occupational therapy total of 20 visits per member, per benefit period. Treatment for Autism Spectrum Disorder
is covered the same as any other condition, depending on the services rendered. Visit limits do not apply to Treatments for Autism Spectrum Disorder. 4 Mail order incentive
offers three-month supply for two copays (for specific maintenance drugs).
12Blue Cross of Idaho | Qualified Health Plans for Small Groups
Our managed care CCO plans are supported by the Saint Alphonsus Health Alliance (SAHA) and Independent Doctors
of Idaho (IDID) in Southwestern Idaho, and the Patient Quality Alliance (PQA) and Mountain View Network (MVN) in
Eastern Idaho.
SILVER 4000 SILVER 4500 SILVER 5000
NETWORKS PPO, POS, CCO PPO, POS, CCO PPO, POS, CCO
ANNUAL COSTS OUT-OF- OUT-OF- OUT-OF-
IN-NETWORK IN-NETWORK IN-NETWORK
(what member pays) NETWORK NETWORK NETWORK
$4,000 individual $12,000 individual $4,500 individual $13,500 individual $5,000 individual $15,000 individual
Deductible $8,000 family $24,000 family $9,000 family $27,000 family $10,000 family $30,000 family
Coinsurance 40% 50% 30% 50% 20% 50%
$7,900 individual $23,700 individual $8,200 individual $24,600 individual $8,300 individual $24,900 individual
Out-of-Pocket Maximum $15,800 family $47,400 family $16,400 family $49,200 family $16,600 family $49,800 family
COVERED SERVICES
Preventive Care/Screening No charge No charge No charge
(for listed services)
Pediatric Office Visits
(includes outpatient $0 copay $0 copay $0 copay
behavioral health)
ChoiceDocs ChoiceDocs ChoiceDocs
Primary Care Office Visit copay: $20 Deductible and copay: $10 Deductible and copay: $10 Deductible and
Copay: $40 coinsurance Copay: $30 coinsurance Copay: $30 coinsurance
ChoiceDocs ChoiceDocs ChoiceDocs
Specialist Office Visit copay: $40 copay: $30 copay: $30
Copay: $60 Copay: $50 Copay: $50
Telehealth (MDLive) $10 copay $10 copay $10 copay
Deductible and Deductible and Deductible and
Diagnostic Lab and X-ray coinsurance coinsurance coinsurance
$250 copay, then $250 copay, then $250 copay, then $250 copay, then $250 copay, then $250 copay, then
Advanced Imaging deductible and deductible and deductible and deductible and deductible and deductible and
(CT/PET scans, MRIs) coinsurance coinsurance coinsurance coinsurance coinsurance coinsurance
Emergency Room Deductible, then Deductible, then Deductible, then Deductible, then Deductible, then Deductible, then
Services $350 copay $350 copay1 $350 copay $350 copay1 $350 copay $350 copay1
Inpatient Hospital Deductible and Deductible and Deductible and
Facility and Services coinsurance coinsurance coinsurance
Outpatient Mental
Health/Substance Abuse $40 copay $30 copay $30 copay
Services
Outpatient Surgery and Deductible, then Deductible and Deductible, then Deductible and Deductible, then Deductible and
Professional Facilities2 30% for specific coinsurance 20% for specific coinsurance 10% for specific coinsurance
listed services listed services listed services
Outpatient Rehabilitation
or Habilitation Services3
Deductible and Deductible and Deductible and
Maternity Care coinsurance coinsurance coinsurance
Dependent Hearing Aids
PRESCRIPTION DRUGS
Covered Preventive $0 copay $0 copay $0 copay
Preferred Generic $10 copay4 $10 copay4 $10 copay4
Non-Preferred Generic $20 copay4 $20 copay4 $20 copay4
Preferred Brand $35 copay4 $35 copay4 $35 copay4
Separate $500 Rx deductible, Separate $500 Rx deductible, Separate $500 Rx deductible,
Non-Preferred Brand then $50 copay4 then $50 copay5 then $50 copay4
Separate $500 Rx deductible, Separate $500 Rx deductible, Separate $500 Rx deductible,
Preferred Specialty then 30% coinsurance then 30% coinsurance then 30% coinsurance
Separate $500 Rx deductible, Separate $500 Rx deductible, Separate $500 Rx deductible,
Non-Preferred Specialty then 50% coinsurance then 50% coinsurance then 50% coinsurance
1
For treatment of emergency medical conditions as defined in the policy/contract, Blue Cross of Idaho will provide in-network benefits for covered services, even if they are
provided out-of-network. 2 In-network coinsurance applies for services from listed preferred facilities.3 Outpatient rehabilitation and habilitiation therapy services are EACH
limited to a combined physical therapy, speech therapy and occupational therapy total of 20 visits per member, per benefit period. Treatment for Autism Spectrum Disorder
is covered the same as any other condition, depending on the services rendered. Visit limits do not apply to Treatments for Autism Spectrum Disorder. 4 Mail order incentive
offers three-month supply for two copays (for specific maintenance drugs).
bcidaho.com
13Your employees with CCO plans will select a primary care provider (PCP) from the plan’s provider network to serve as
their care coordinator. Employees no longer need a referral to see in-network specialists. They do need a referral to see
OON providers.
SILVER 5500 SILVER 6500
NETWORKS PPO, POS, CCO PPO, POS, CCO
ANNUAL COSTS OUT-OF- OUT-OF-
IN-NETWORK IN-NETWORK
(what member pays) NETWORK NETWORK
$5,500 individual $16,300 individual $6,500 individual $16,300 individual
Deductible $11,000 family $32,600 family $13,000 family $32,600 family
Coinsurance 30% 50% 30% 50%
$7,350 individual $22,050 individual $7,350 individual $22,050 individual
Out-of-Pocket Maximum $14,700 family $44,100 family $14,700 family $44,100 family
COVERED SERVICES
Preventive Care/Screening No charge No charge
(for listed services)
Pediatric Office Visits
(includes outpatient $0 copay $0 copay
behavioral health)
ChoiceDocs ChoiceDocs
Primary Care Office Visit copay: $10 Deductible and copay: $20 Deductible and
Copay: $30 coinsurance Copay: $40 coinsurance
ChoiceDocs ChoiceDocs
Specialist Office Visit copay: $30 copay: $40
Copay: $50 Copay: $60
Telehealth (MDLive) $10 copay $10 copay
Deductible and Deductible and
Diagnostic Lab and X-ray coinsurance coinsurance
$250 copay, then $250 copay, then $250 copay, then $250 copay, then
Advanced Imaging deductible and deductible and deductible and deductible and
(CT/PET scans, MRIs) coinsurance coinsurance coinsurance coinsurance
Emergency Room Deductible, then Deductible, then Deductible, then Deductible, then
Services $350 copay $350 copay1 $350 copay $350 copay1
Inpatient Hospital Deductible and Deductible and
Facility and Services coinsurance coinsurance
Outpatient Mental
Health/Substance Abuse $30 copay $40 copay
Services
Deductible, then Deductible and Deductible, then Deductible and
Outpatient Surgery and 20% for specific 20% for specific
Professional Facilities2 coinsurance coinsurance
listed services listed services
Outpatient Rehabilitation
or Habilitation Services3
Deductible and Deductible and
Maternity Care coinsurance coinsurance
Dependent Hearing Aids
PRESCRIPTION DRUGS
Covered Preventive $0 copay $0 copay
Preferred Generic $10 copay 4
$10 copay4
Non-Preferred Generic $20 copay4 $20 copay4
Medical deductible,
Preferred Brand $35 copay4 then $35 copay4
Separate $500 Rx deductible, Medical deductible,
Non-Preferred Brand then $50 copay4 then $50 copay4
Separate $500 Rx deductible, Medical deductible,
Preferred Specialty then 30% coinsurance then 30% coinsurance
Separate $500 Rx deductible, Medical deductible,
Non-Preferred Specialty then 50% coinsurance then 50% coinsurance
1
For treatment of emergency medical conditions as defined in the policy/contract, Blue Cross of Idaho will provide in-network benefits for covered services, even if they are
provided out-of-network. 2 In-network coinsurance applies for services from listed preferred facilities).3 Outpatient rehabilitation and habilitiation therapy services are EACH
limited to a combined physical therapy, speech therapy and occupational therapy total of 20 visits per member, per benefit period. Treatment for Autism Spectrum Disorder
is covered the same as any other condition, depending on the services rendered. Visit limits do not apply to Treatments for Autism Spectrum Disorder. 4 Mail order incentive
offers three-month supply for two copays (for specific maintenance drugs).
14Blue Cross of Idaho | Qualified Health Plans for Small Groups
Our managed care CCO plans are supported by the Saint Alphonsus Health Alliance (SAHA) and Independent Doctors
of Idaho (IDID) in Southwestern Idaho, and the Patient Quality Alliance (PQA) and Mountain View Network (MVN) in
Eastern Idaho.
GOLD 600 GOLD 1100 GOLD 1500
NETWORKS PPO, POS, CCO PPO, POS, CCO PPO, POS, CCO
ANNUAL COSTS OUT-OF- OUT-OF- OUT-OF-
IN-NETWORK IN-NETWORK IN-NETWORK
(what member pays) NETWORK NETWORK NETWORK
$600 individual $1,800 individual $1,100 individual $3,300 individual $1,500 individual $4,500 individual
Deductible $1,200 family $3,600 family $2,200 family $6,600 family $3,000 family $9,000 family
Coinsurance 30% 50% 20% 50% 20% 50%
$7,000 individual $21,000 individual $6,200 individual $18,600 individual $6,700 individual $20,100 individual
Out-of-Pocket Maximum $14,000 family $42,000 family $12,400 family $37,200 family $13,400 family $40,200 family
COVERED SERVICES
Preventive Care/Screening No charge No charge No charge
(for listed services)
Pediatric Office Visits
(includes outpatient $0 copay $0 copay $0 copay
behavioral health)
ChoiceDocs ChoiceDocs ChoiceDocs
Primary Care Office Visit copay: $20 Deductible and copay: $10 Deductible and copay: $10 Deductible and
Copay: $40 coinsurance Copay: $30 coinsurance Copay: $30 coinsurance
ChoiceDocs ChoiceDocs ChoiceDocs
Specialist Office Visit copay: $40 copay: $30 copay: $30
Copay: $60 Copay: $50 Copay: $50
Telehealth (MDLive) $10 copay $10 copay $10 copay
Deductible and Deductible and Deductible and
Diagnostic Lab and X-ray coinsurance coinsurance coinsurance
$250 copay, then $250 copay, then $250 copay, then $250 copay, then $250 copay, then $250 copay, then
Advanced Imaging deductible and deductible and deductible and deductible and deductible and deductible and
(CT/PET scans, MRIs) coinsurance coinsurance coinsurance coinsurance coinsurance coinsurance
Emergency Room Deductible, then Deductible, then Deductible, then Deductible, then Deductible, then Deductible, then
Services $350 copay $350 copay1 $350 copay $350 copay1 $350 copay $350 copay1
Inpatient Hospital Deductible and Deductible and Deductible and
Facility and Services coinsurance coinsurance coinsurance
Outpatient Mental
Health/Substance Abuse $40 copay $30 copay $30 copay
Services
Deductible, then Deductible, then
Deductible, then Deductible and Deductible and Deductible and
Outpatient Surgery and 20% for specific 10% for specific 10% for specific
Professional Facilities2 coinsurance listed services coinsurance listed services coinsurance
listed services
Outpatient Rehabilitation
or Habilitation Services3
Deductible and Deductible and Deductible and
Maternity Care coinsurance coinsurance coinsurance
Dependent Hearing Aids
PRESCRIPTION DRUGS
Covered Preventive $0 copay $0 copay $0 copay
Preferred Generic $10 copay 4
$10 copay 4
$10 copay4
Non-Preferred Generic $20 copay4 $20 copay4 $20 copay4
Preferred Brand $35 copay4 $35 copay4 $35 copay4
Separate $500 Rx deductible,
Non-Preferred Brand $50 copay4 $50 copay4
then $50 copay5
Separate $500 Rx deductible,
Preferred Specialty 30% coinsurance 30% coinsurance
then 30% coinsurance
Separate $500 Rx deductible,
Non-Preferred Specialty 50% coinsurance 50% coinsurance
then 50% coinsurance
1
For treatment of emergency medical conditions as defined in the policy/contract, Blue Cross of Idaho will provide in-network benefits for covered services, even if they are
provided out-of-network. 2 In-network coinsurance applies for services from listed preferred facilities.3 Outpatient rehabilitation and habilitiation therapy services are EACH
limited to a combined physical therapy, speech therapy and occupational therapy total of 20 visits per member, per benefit period. Treatment for Autism Spectrum Disorder
is covered the same as any other condition, depending on the services rendered. Visit limits do not apply to Treatments for Autism Spectrum Disorder. 4 Mail order incentive
offers three-month supply for two copays (for specific maintenance drugs).
bcidaho.com
15Your employees with CCO plans will select a primary care provider (PCP) from the plan’s provider network to serve as
their care coordinator. Employees no longer need a referral to see in-network specialists. The do need a referral to see
OON providers.
GOLD 2000 GOLD 3000
NETWORKS PPO, POS, CCO PPO, POS, CCO
ANNUAL COSTS OUT-OF- OUT-OF-
IN-NETWORK IN-NETWORK
(what member pays) NETWORK NETWORK
$2,000 individual $6,000 individual $3,000 individual $9,000 individual
Deductible $4,000 family $12,000 family $6,000 family $18,000 family
Coinsurance 20% 50% 20% 50%
$4,600 individual $13,800 individual $4,600 individual $13,800 individual
Out-of-Pocket Maximum $9,200 family $27,600 family $9,200 family $27,600 family
COVERED SERVICES
Preventive Care/Screening No charge No charge
(for listed services)
Pediatric Office Visits
(includes outpatient $0 copay $0 copay
behavioral health)
ChoiceDocs ChoiceDocs
Primary Care Office Visit copay: $0 Deductible and copay: $0 Deductible and
Copay: $20 coinsurance Copay: $20 coinsurance
ChoiceDocs ChoiceDocs
Specialist Office Visit copay: $20 copay: $20
Copay: $40 Copay: $40
Telehealth (MDLive) $10 copay $10 copay
Deductible and Deductible and
Diagnostic Lab and X-ray coinsurance coinsurance
$250 copay, then $250 copay, then $250 copay, then $250 copay, then
Advanced Imaging deductible and deductible and deductible and deductible and
(CT/PET scans, MRIs) coinsurance coinsurance coinsurance coinsurance
Emergency Room Deductible, then Deductible, then Deductible, then Deductible, then
Services $350 copay $350 copay1 $350 copay $350 copay1
Inpatient Hospital Deductible and Deductible and
Facility and Services coinsurance coinsurance
Outpatient Mental PPO copay: $0 PPO copay: $0
Health/Substance Abuse POS/CCO POS/CCO
Services copay: $20 copay: $20
Deductible, then
Deductible, then Deductible and Deductible and
Outpatient Surgery and 10% for specific 10% for specific
Professional Facilities2 coinsurance listed services coinsurance
listed services
Outpatient Rehabilitation
or Habilitation Services3
Deductible and Deductible and
Maternity Care coinsurance coinsurance
Dependent Hearing Aids
PRESCRIPTION DRUGS
Covered Preventive $0 copay $0 copay
Preferred Generic $10 copay 4
$10 copay4
Non-Preferred Generic $20 copay4 $20 copay4
Preferred Brand $35 copay4 $35 copay4
Separate $500 Rx deductible,
Non-Preferred Brand $50 copay4
then $50 copay4
Separate $500 Rx deductible,
Preferred Specialty 30% coinsurance
then 30% coinsurance
Separate $500 Rx deductible,
Non-Preferred Specialty 50% coinsurance
then 50% coinsurance
1
For treatment of emergency medical conditions as defined in the policy/contract, Blue Cross of Idaho will provide in-network benefits for covered services, even if they are
provided out-of-network. 2 In-network coinsurance applies for services from listed preferred facilities.3 Outpatient rehabilitation and habilitiation therapy services are EACH
limited to a combined physical therapy, speech therapy and occupational therapy total of 20 visits per member, per benefit period. Treatment for Autism Spectrum Disorder
is covered the same as any other condition, depending on the services rendered. Visit limits do not apply to Treatments for Autism Spectrum Disorder. 4 Mail order incentive
offers three-month supply for two copays (for specific maintenance drugs).
16Blue Cross of Idaho | Qualified Health Plans for Small Groups
Exclusions and Limitations Section
In addition to the exclusions and limitations listed elsewhere in this Policy, Q.For telephone consultations, and all computer or Internet
the following exclusions and limitations apply to the entire Policy, unless communications, except as provided by MDLIVE or in connection with
otherwise specified. Telehealth Virtual Care Services.
I. GENERAL EXCLUSIONS AND LIMITATIONS R. For failure to keep a scheduled visit or appointment; for completion
of a claim form; for interpretation services; or for personal mileage,
There are no benefits for services, supplies, drugs or other charges that transportation, food or lodging expenses unless specified as a Covered
are: Service in this Policy, or for mileage, transportation, food or lodging
expenses billed by a Physician or other Professional Provider.
A. Not Medically Necessary. If services requiring Prior Authorization by
Blue Cross of Idaho are performed by a Contracting Provider and benefits S. For Inpatient admissions that are primarily for Diagnostic Services
are denied as not Medically Necessary, the cost of said services are not or Therapy Services; or for Inpatient admissions when the Insured
the financial responsibility of the Insured. However, the Insured could be is ambulatory and/or confined primarily for bed rest, special diet,
financially responsible for services found to be not Medically Necessary environmental change or for treatment not requiring continuous bed care.
when provided by a Noncontracting Provider.
T. For Inpatient or Outpatient Custodial Care; or for Inpatient or
B. In excess of the Maximum Allowance. Outpatient services consisting mainly of educational therapy, behavioral
modification, self care or self help training, except as specified as a
C. For hospital Inpatient or Outpatient care for extraction of teeth or other
Covered Service in this Policy.
dental procedures, unless necessary to treat an Accidental Injury or unless
an attending Physician certifies in writing that the Insured has a non U. For any cosmetic foot care, including but not limited to, treatment
dental, life endangering condition which makes hospitalization necessary of corns, calluses, and toenails (except for surgical care of ingrown or
to safeguard the Insured’s health and life. Diseased toenails).
D. Not prescribed by or upon the direction of a Physician or other V. Related to Dentistry or Dental Treatment, even if related to a medical
Professional Provider; or which are furnished by any individuals or facilities condition; or orthoptics, eyeglasses or contact Lenses, or the vision
other than Licensed General Hospitals, Physicians, and other Providers. examination for prescribing or fitting eyeglasses or contact Lenses, unless
specified as a Covered Service in this Policy.
E. Investigational in nature.
W. For hearing aids or examinations for the prescription or fitting of
F. Provided for any condition, Disease, Illness or Accidental Injury to
hearing aids, except as specified as a Covered Service in this Policy.
the extent that the Insured is entitled to benefits under occupational
coverage, obtained or provided by or through the employer under state X. For any treatment of sexual dysfunction, or sexual inadequacy,
or federal Workers’ Compensation Acts or under Employer Liability including erectile dysfunction and/or impotence, except as related to a
Acts or other laws providing compensation for work related injuries or prostatectomy.
conditions. This exclusion applies whether or not the Insured claims such
benefits or compensation or recovers losses from a third party. Y. Made by a Licensed General Hospital for the Insured’s failure to
vacate a room on or before the Licensed General Hospital’s established
G. Provided or paid for by any federal governmental entity or unit except discharge hour.
when payment under this Policy is expressly required by federal law, or
provided or paid for by any state or local governmental entity or unit Z. Not directly related to the care and treatment of an actual condition,
where its charges therefore would vary, or are or would be affected by the Illness, Disease or Accidental Injury.
existence of coverage under this Policy.
AA. Furnished by a facility that is primarily a nursing home, a
H. Provided for any condition, Accidental Injury, Disease or Illness suffered convalescent home, or a rest home.
as a result of any act of war or any war, declared or undeclared.
AB. For Acute Care, Rehabilitative care, diagnostic testing, except
I. Furnished by a Provider who is related to the Insured by blood or as specified as a Covered Service in this Policy; for Mental or Nervous
marriage and who ordinarily dwells in the Insured’s household. Conditions and Substance Use Disorder or Addiction services not
recognized by the American Psychiatric and American Psychological
J. Received from a dental, vision, or medical department maintained by Associations.
or on behalf of an employer, a mutual benefit association, labor union,
trust or similar person or group. AC. For any of the following:
K. For Surgery intended mainly to improve appearance or for 1. For appliances, splints or restorations necessary to increase vertical
complications arising from Surgery intended mainly to improve tooth dimensions or restore the occlusion, except as specified as a
appearance, except for: Covered Service in this Policy;
1. Reconstructive Surgery necessary to treat an Accidental Injury, infection 2. For orthognathic Surgery, including services and supplies to augment
or other Disease of the involved part; or or reduce the upper or lower jaw;
2. Reconstructive Surgery to correct Congenital Anomalies in an Insured 3. For implants in the jaw; for pain, treatment, or diagnostic testing
who is a dependent child. or evaluation related to the misalignment or discomfort of the
temporomandibular joint (jaw hinge), including splinting services and
3. Benefits for reconstructive Surgery to correct an Accidental Injury supplies;
are available even though the accident occurred while the Insured was
covered under a prior insurer’s coverage. 4. For alveolectomy or alveoloplasty when related to tooth extraction.
L. Rendered prior to the Insured’s Effective Date. AD. For weight control or treatment of obesity or morbid obesity, even
if Medically Necessary, including but not limited to Surgery for obesity,
M. For personal hygiene, comfort, beautification (including non-surgical except as specifically provided by the Weight Management Program
services, drugs, and supplies intended to enhance the appearance) even listed as a Covered Service in the Policy. For reversals or revisions of
if prescribed by a Physician. Surgery for obesity, except when required to correct a life-endangering
condition.
N. For exercise or relaxation items or services even if prescribed by a
Physician, including but not limited to, air conditioners, air purifiers, AE. For use of operating, cast, examination, or treatment rooms or for
humidifiers, physical fitness equipment or programs, spas, hot tubs, equipment located in a Contracting or Noncontracting Provider’s office or
whirlpool baths, waterbeds or swimming pools. facility, except for Emergency room facility charges in a Licensed General
Hospital unless specified as a Covered Service in this Policy.
O.For convenience items including but not limited to Durable Medical
Equipment such as bath equipment, cold therapy units, duplicate items, AF. For the reversal of sterilization procedures, including but not limited
home traction devices, or safety equipment. to, vasovasostomies or salpingoplasties.
P. For relaxation or exercise therapies, including but not limited to,
educational, recreational, art, aroma, dance, sex, sleep, electro sleep,
vitamin, chelation, homeopathic, or naturopathic, massage, or music even
if prescribed by a Physician.
bcidaho.com
17AG. Treatment for reproductive procedures, including but not limited AX. For alterations or modifications to a home or vehicle.
to, ovulation induction procedures and pharmaceuticals, artificial
insemination, in vitro fertilization, embryo transfer or similar procedures, AY. For special clothing, including shoes (unless permanently attached
or procedures that in any way augment or enhance an Insured’s to a brace).
reproductive ability, including but not limited to laboratory services, AZ. Provided to a person enrolled as an Eligible Dependent, but who
radiology services or similar services related to treatment for reproduction no longer qualifies as an Eligible Dependent due to a change in eligibility
procedures. status that occurred after enrollment.
AH. For Transplant services and Artificial Organs, except as specified as AAA. Provided outside the United States, which if had been provided in
a Covered Service under this Policy. the United States, would not be a Covered Service under this Policy.
AI. For acupuncture. AAB. For Outpatient cardiac Rehabilitation, unless specified as a Covered
AJ. For surgical procedures that alter the refractive character of the eye, Service in this Policy.
including but not limited to, radial keratotomy, myopic keratomileusis, AAC. For complications arising from the acceptance or utilization of
Laser-In-Situ Keratomileusis (LASIK), and other surgical procedures of the services, supplies or procedures that are not a Covered Service.
refractive keratoplasty type, to cure or reduce myopia or astigmatism,
even if Medically Necessary, unless specified as a Covered Service in AAD. For the use of Hypnosis, as anesthesia or other treatment, except as
a Vision Benefits Section of this Policy, if any. Additionally, reversals, specified as a Covered Service.
revisions, and/or complications of such surgical procedures are excluded,
except when required to correct an immediately life endangering AAE. For dental implants, appliances (with the exception of sleep apnea
condition. devices), and/or prosthetics, and/or treatment related to Orthodontia,
even when Medically Necessary unless specified as a Covered Service in
AK. For Hospice, except as specified as a Covered Service in this Policy. this Policy.
AL. For pastoral, spiritual, bereavement, or marriage counseling. AAF. For arch supports, orthopedic shoes, and other foot devices, unless
specified as a Covered Service in this Policy.
AM. For homemaker and housekeeping services or home delivered
meals. AAG. For wigs.
AN. For the treatment of injuries sustained while committing a felony, AAH. For cranial molding helmets, unless used to protect post cranial
voluntarily taking part in a riot, or while engaging in an illegal act or vault surgery.
occupation, unless such injuries are a result of a medical condition or
domestic violence. AAI. For surgical removal of excess skin that is the result of weight loss or
gain, including but not limited to association with prior weight reduction
AO. For treatment or other health care of any Insured in connection (obesity) Surgery.
with an Illness, Disease, Accidental Injury or other condition which would
otherwise entitle the Insured to Covered Services under this Policy, if AAJ. For the purchase of Therapy or Service Dogs/Animals and the cost
and to the extent those benefits are payable to or due the Insured under of training/maintaining said animals.
any medical payments provision, no fault provision, uninsured motorist
provision, underinsured motorist provision, or other first party or no fault AAK. For procedures including but not limited to breast augmentation,
provision of any automobile, homeowner’s, or other similar policy of liposuction, Adam’s apple reduction, rhinoplasty and facial reconstruction
insurance, contract, or underwriting plan. and other procedures considered cosmetic in nature.
In the event Blue Cross of Idaho (BCI) for any reason makes payment for AAL. Any newly FDA approved Prescription Drug, biological agent,
or otherwise provides benefits excluded by the above provisions, it shall or other agent until it has been reviewed and implemented by BCI’s
succeed to the rights of payment or reimbursement of the compensated Pharmacy and Therapeutics Committee.
Provider, the Insured, and the Insured’s heirs and personal representative AAM. For the treatment of injuries sustained while operating a motor
against all insurers, underwriters, self insurers or other such obligors vehicle under the influence of alcohol and/or narcotics. For purposes of
contractually liable or obliged to the Insured, or his or her estate for this Policy exclusion, “Under the influence” as it relates to alcohol means
such services, supplies, drugs or other charges so provided by BCI in having a whole blood alcohol content of .08 or above or a serum blood
connection with such Illness, Disease, Accidental Injury or other condition. alcohol content of .10 or above as measured by a laboratory approved
AP. For which an Insured would have no legal obligation to pay in the by the State Police or a laboratory certified by the Centers for Medicare
absence of coverage under this Policy or any similar coverage; or for and Medicaid Services. For purposes of this Policy exclusion, “Under the
which no charge or a different charge is usually made in the absence of influence” as it relates to narcotics means impairment of driving ability
insurance coverage; or charges in connection with work for compensation caused by the use of narcotics not prescribed or administered by a
or charges; or for which reimbursement or payment is contemplated Physician.
under an agreement with a third party. AAN. All services, supplies, devices and treatment that are not FDA
AQ. For a routine or periodic mental or physical examination that is approved.
not connected with the care and treatment of an actual Illness, Disease AAO. Any services, interventions occurring within the framework of
or Accidental Injury or for an examination required on account of an educational program or institution; or provided in or by a school/
employment; or related to an occupational injury; for a marriage license; educational setting; or provided as a replacement for services that are the
or for insurance, school or camp application; or for sports participation responsibility of the educational system.
physicals; or a screening examination including routine hearing
examinations, except as specified as a Covered Service in this Policy. II. PRESCRIPTION DRUG EXCLUSIONS AND
AR. For immunizations, except as specified as a Covered Service in this
LIMITATIONS
Policy. In addition to any other exclusions and limitations of this Policy, the
following exclusions and limitations apply to Prescription Drug Services.
AS. For breast reduction Surgery or Surgery for gynecomastia. No benefits are available under this Policy for the following:
AT. For nutritional supplements. A. Drugs used for the termination of early pregnancy, and complications
AU. For replacements or nutritional formulas except, when administered arising therefrom, except when required to correct an immediately life-
enterally due to impairment in digestion and absorption of an oral diet endangering condition.
and is the sole source of caloric need or nutrition in an Insured, or except B. Over-the-counter drugs other than insulin, even if prescribed by a
as specified as a Covered Service in this Policy. Physician. Notwithstanding this exclusion, BCI, through the determination
AV. For vitamins and minerals, unless required through a written of the BCI Pharmacy and Therapeutics Committee may choose to cover
prescription and cannot be purchased over the counter. certain over-the-counter medications when Prescription Drug benefits are
provided under this Policy. Such approved over-the-counter medications
AW. For an elective abortion, except to preserve the life of the female must be identified by BCI in writing and will specify the procedures for
upon whom the abortion is performed. obtaining benefits for such approved over-the-counter medications.
18Blue Cross of Idaho | Qualified Health Plans for Small Groups
Please note that the fact a particular over-the-counter drug or medication Covered Services, benefits for medical complications to the donor arising
is covered does not require BCI to cover or otherwise pay or reimburse from Transplant Surgery will be allowed under the donor’s policy.
the Insured for any other over-the-counter drug or medication.
H. Costs related to the search for a suitable donor.
C. Charges for the administration or injection of any drug, except for
vaccinations listed on the Prescription Drug Formulary. I. No benefits are available for services, expenses, or other obligations of
or for a deceased donor (even if the donor is an Insured).
D. Therapeutic devices or appliances, including hypodermic needles,
syringes, support garments, and other non-medicinal substances except IV. Hospice Exclusions and Limitations
Diabetic Supplies, regardless of intended use.
In addition to any other exclusions and limitations of this Policy, the
E. Drugs labeled “Caution—Limited by Federal Law to Investigational following exclusions and limitations apply to Hospice Services. No
Use,” or experimental drugs, even though a charge is made to the benefits are available under this Policy for the following:
Insured.
A. Hospice Services not included in a Hospice Plan of Treatment and not
F. Immunization agents, except for vaccinations listed on the Prescription provided or arranged and billed through a Hospice.
Drug Formulary, biological sera, blood or blood plasma. Benefits may be
B. Continuous Skilled Nursing Care except as specifically provided as a
available under the Major Medical Benefits Section of this Policy.
part of Respite Care or Continuous Crisis Care.
G. Medication that is to be taken by or administered to an Insured, in
C. Hospice benefits provided during any period of time in which an
whole or in part, while the Insured is an Inpatient in a Licensed General
Insured is receiving Home Health Skilled Nursing Care benefits.
Hospital, rest home, sanatorium, Skilled Nursing Facility, extended care
facility, convalescent hospital, nursing home, or similar institution which V. Pediatric Vision Care Exclusions and Limitations
operates or allows to operate on its premises, a facility for dispensing
pharmaceuticals. In addition to any other exclusions and limitations of this Policy, the
following exclusions and limitations apply to Pediatric Vision Care
H. Any prescription refilled in excess of the number specified by the Benefits Section. No benefits are available for professional services or
Physician, or any refill dispensed after one (1) year from the Physician’s materials connected with:
original order.
A. Orthoptics or other vision training and any associated supplemental
I. Any Prescription Drug, biological or other agent, which is: testing; Plano Lenses; or two (2) pair of eyeglasses in place of bifocals.
a) Prescribed primarily to aid or assist the Insured in weight loss, including B. Replacement of Lenses, Frames or Contact Lenses furnished hereunder
all anorectics, whether amphetamine or nonamphetamine. that are lost or broken (Lenses, Frames or Contact Lenses are only
replaced at the normal intervals when Covered Services are otherwise
b) Prescribed primarily to retard the rate of hair loss or to aid in the
available).
replacement of lost hair.
C. Medical or surgical treatment of the eye(s).
c) Prescribed primarily to increase fertility, including but not limited to,
drugs which induce or enhance ovulation. D. Any eye examination or any corrective eyewear required by an
employer as a condition of employment.
d) Prescribed primarily for personal hygiene, comfort, beautification, or
for the purpose of improving appearance. E. Low vision aids.
e) Prescribed primarily to increase growth, including but not limited to, VI. Preexisting Condition Waiting Period
growth hormone.
There is no preexisting condition waiting period for benefits available
f) Provided by or under the direction of a Home Intravenous Therapy under this Policy.
Company, Home Health Agency or other Provider approved by BCI.
Benefits are available for this Therapy Service under the Major Medical
Benefits Section of this Policy.
J. Lost, stolen, broken or destroyed Prescription Drugs except in the case
of loss due directly to a natural disaster.
III. TRANSPLANT EXCLUSIONS AND LIMITATIONS
In addition to any other exclusions and limitations of this Policy, the
following exclusions and limitations apply to Transplant or Autotransplant
services. No benefits are available under this Policy for the following:
A. Transplants of brain tissue or brain membrane, intestine, pituitary and
adrenal glands, hair Transplants, or any other Transplant not specifically
named as a Covered Service in this section; or for Artificial Organs
including but not limited to, artificial hearts or pancreases.
B. Any eligible expenses of a donor related to donating or transplanting
an organ or tissue unless the recipient is an Insured who is eligible to
receive benefits for Transplant services.
C. The cost of a human organ or tissue that is sold rather than donated to
the recipient.
D. Transportation costs including but not limited to, Ambulance
Transportation Service or air service for the donor, or to transport a
donated organ or tissue.
E. Living expenses for the recipient, donor, or family members, except as
specifically listed as a Covered Service in this Policy.
F. Costs covered or funded by governmental, foundation or charitable
grants or programs; or Physician fees or other charges, if no charge is
generally made in the absence of insurance coverage.
G. Any complication to the donor arising from a donor’s Transplant
Surgery is not a covered benefit under the Insured Transplant recipient’s
Policy. If the donor is a BCI Insured, eligible to receive benefits for
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