Insurance - Medical

Eligibility Enrollment Waiting Periods Medical Insurance Dental Insurance Vision Insurance Monthly Health Insurance Premiums Mental Health, Substance Abuse and Employee Assistance Program (EAP) Benefits

When Coverage Ends COBRA When You Retire Basic and Supplemental Life Insurance NCPERS Supplemental Insurance Programs Disability: Short and Long Term

4. Medical Insurance

Summary of Medical Benefits

Blue Cross of Idaho - Traditional
Annual Deductible	$350 per person maximum, $1,050 family aggregate
Out of Pocket Maximum (each policy year)	$4,300 per person, $350 + $3,950 $8,600 family aggregate, $1,050 + $7,550 (co-insurance and deductible combined)
Physician’s services, outpatient	Plan pays 80% of Allowable Charges, after deductible.
Hospital Care	Plan pays 80% of Allowable Charges, after deductible.
Ambulance transportation	Plans pays 80% of Allowable Charges, after deductible.
Chiropractic services	Plan pays 80% of Allowable Charges, after deductible, for contracting providers Plan pays 50% of Allowable Charges, after deductible, for non-contracting providers Limited to $500 per year per insured per benefit period
Mammography (Preventive Screening Mammogram)	Covered under wellness benefits (if maximum dollar limit is exhausted, mammogram is subject to deductible and co-insurance)
Mammography (All other diagnostic mammograms)	Plan pays 80% of Allowable Charges, after deductible
Mental Health/substance abuse treatment	Provided through Business Psychology Associates (BPA) 1-877-427-2327
Emergency Room Visit	Plan pays 80% of Allowable Charges, after deductible
Prescription Drugs, per 30 day supply	In-network pharmacies: Co-payments Generic - $12 Brand - No generic equivalent - $18 Brand with generic equivalent - $40 plus difference between brand and generic Dispensing: 34-day supply per co-payment Maintenance drugs - 2 co-payments per 90 day supply (1-34 day supply - one co-payment; 35-90 day supply - 2 co-payments) Non-network Pharmacies: $25 co-payment plus 20% of balance
Wellness/Preventive Services	Specifically listed preventive care covered services are covered at 100%, up to $250 maximum benefit per insured When the maximum has been met, specifically listed preventive care covered services are subject to deductible and coinsurance Preventive care services not specifically listed are subject to deductible and coinsurance Specific Services: Well baby and well child care; routine or scheduled examiniations, including Rubella and PKU tests; adult annual exams, including pap tests, fecal occult blood test, PSA tests and cholesterol panel. Immunizations. No travel vaccines.

Blue Cross of Idaho - PPO - In-Network
Annual Deductible	$250 per person maximum $750 family aggregate
Out of Pocket Maximum (each policy year)	$3,250 per person $6,750 family aggregate
Physician Office Visit	$20 co-payment (office exam only, other services subject to deductible and coinsurance)
Hospital Care	Plan pays 85% of Allowable Charges, after deductible
Ambulance transportation	Plan pays 85% of Allowable Charges, after deductible
Chiropractic services	Plan pays 85% of Allowable Charges, after deductible
Mammography (Preventive Screening Mammogram)	$20 co-payment
Mammography (All other diagnostic mammograms)	Plan pays 85% of Allowable Charges, after deductible
Mental Health/substance abuse treatment	Provided through Business Psychology Associates (BPA) 1-877-427-2327
Emergency Room Visit	Plan pays 85% of Allowable Charges, after deductible
Prescription Drugs, per 30 day supply	In-Network pharmacies: Co-payments Generic - $12 Brand - No generic equivalent - $18 Brand with generic equivalent - $40 plus difference between brand and generic Dispensing: 34-day supply per co-payment Maintenance drugs - 2 co-payments per 90 day supply (1-34 day supply - one co-payment; 35-90 day supply - 2 co-payments) Non-network pharmacies: $25 co-payment plus 20% of balance
Wellness/Preventive Services	$20 co-payment, then 100% for specifically listed benefits Preventive care services not specifically listed are subject to deductible and coinsurance Specific Services: Well baby and well child care; routine or scheduled examinations, including Rubella and PKU tests; adult annual exams, including pap tests, fecal occult blood tests, PSA tests and cholesterol panel. Immunizations. No travel vaccines.

Blue Cross of Idaho - PPO - Out-of-Network
Annual Deductible	$500 per person maximum $1,500 family aggregate
Out of Pocket Maximum (each policy year)	$6,500 per person $13,500 family aggregate
Physician Office Visit	Plan pays 70% of Allowable Charges, after deductible
Hospital Care	Plan pays 70% of Allowable Charges, after deductible
Ambulance transportation	Plan pays 70% of Allowable Charges, after deductible
Chiropractic services	Plan pays 50% of Allowable Charges, after deductible
Mammography (Preventive Screening Mammogram)	Plan pays 70% of Allowable Charges, after deductible
Mammography (All other diagnostic mammograms)	Plan pays 70% of Allowable Charges, after deductible
Mental Health/substance abuse treatment	Provided through Business Psychology Associates (BPA) 1-877-427-2327
Prescription Drugs, per 30 day supply	In-network pharmacies: Co-payments Generic - $12 Brand - No generic equivalent - $18 Brand with generic equivalent - $40 plus difference between brand and generic Dispensing: 34-day supply per co-payment Maintenance drugs - 2 co-payments per 90 day supply (1-34 day supply - one co-payment; 35-90 day supply - 2 co-payments) Non-network pharmacies: $25 co-payment plus 20% of balance
Wellness/Preventive Services	No wellness benefits except for screening mammography services at 70% of Allowable Charges, after deductible

Participating Providers

For the Traditional Plan, after you pay an annual deductible, the plan generally pays 80% of most allowable charges. You can use any provider you want, but you may save money when you use providers who belong to the State plan network. Most benefits are paid based on Allowable Charges, which means they'll accept plan benefits plus your share (any deductible, coinsurance or co-payments) of the costs as payments in full.

To find Participating Medical Providers, please contact Blue Cross of Idaho, 1-800-627-1188 or go on-line http://bcidaho.com

Filing Claims

After you enroll, you will receive an identification card from Blue Cross of Idaho. Whenever you receive services from a participating provider, just show your ID card. The provider will bill the plan on your behalf. When you use a nonparticipating provider, you may have to make a claim for reimbursement. Submit a detailed invoice from your provider. Be sure to include your name, subscriber identification number and the name of your employer to the following address:

Blue Cross of Idaho
PO Box 7408
Boise, ID 83707

Contact Information

We recommend you contact the carrier prior to having any services performed.

General Information:
State of Idaho’s Office of Insurance Management,
http://www2.state.id.us/adm/insurance/group_index.htm
1-800-531-0597, 332-1860, ogi@adm.state.id.us

Medical Plans:
Blue Cross of Idaho
Group Number: 10040000
Customer Service: 208-331-8897 or 1-866-804-2253
Wellpoint Pharmacy Management: 1-800-962-7378, Bin: 610053
http://bcidaho.com

Human Resource Services, Boise State University