Health
Insurance Plans
for Small Groups
(less than 50 employees)
from
Blue Cross of Idaho
Choose coverage
that fits.
Form No. 3-1022 (03-14)
Policy Form Numbers:
18-061-01/14
18-064-01/14
18-065-01/14
18-066-01/14
18-067-01/14
18-071-01/14
18-072-01/14
18-073-01/14
18-074-01/14
18-075-01/14
18-077-01/14
18-078-01/14
3-420-05/11
The Best Value
in Health
Insurance
As an Idaho employer, you have a difficult
job – balancing the need to manage
healthcare costs while still providing your
employees with a quality health insurance
plan that offers excellent service and the
tools to help them stay healthy.
We’re here to make your job
easier.
At Blue Cross of Idaho, we’re dedicated
to delivering the best value in health
insurance to our small business customers.
Our goal is to give your employees access
to quality care at affordable premiums.
We do this by providing:
• Extensive provider networks
• Integrated claims management
• Exceptional customer service
• Wellness tools and resources
• Flexible benefit plan design
In this guide, we’ll introduce you to our
product portfolio, describe the services
and resources we offer group members,
and explain how the Affordable Care Act
may impact your business.
We know you have options when you look
for health insurance. We’re confident you’ll
find that Blue Cross of Idaho offers the
best value in health coverage and useful
tools to help your employees – and your
business – stay healthy.
2
HEALTH INSURANCE PLANS from BLUE CROSS OF IDAHO – Small Groups
Blue cross of Idaho Health Insurance Plans
Choosing the Right Plan
Provider Network
Choosing the right coverage for your
employees and their families depends
on their healthcare needs and what your
budget will allow. Blue Cross of Idaho has
a variety of group medical plans available
for small businesses and their employees.
Coverage for dental, vision, employee
assistance program (EAP) and additional
wellness programs are also available.
You’ll get the best choice of doctors and
hospitals with Blue Cross of Idaho. As you
read the descriptions of each of the plans,
you’ll notice that Choice plans use our PPO network. Our Connect plans are supported by
the Saint Alphonsus Health Alliance Network
in southwestern Idaho and the Portneuf
Quality Alliance Network in eastern Idaho.
As you consider which plan is right for you,
check to make sure the healthcare providers
and facilities, such as hospitals, you like are
in the plan’s provider network. You can look
for specific doctors and hospitals through
our Find a Provider link on our homepage at
members.bcidaho.com.
We organize our small group plans into
three metal levels based on the amount of
coverage provided. These levels are bronze,
silver and gold. We offer different network
options within each level; PPO (preferred
provider organization), POS (point of
service) and our Connect plans which are
paired with ConnectedCare networks in
Southwestern and Eastern Idaho. All plans
include essential health benefits, such
as emergency room services, maternity
and newborn care, annual doctor visits,
prescription drugs and medical screenings.
Things to Consider
The metal plans differ based on the
percentage of health care cost paid by the
employee in deductibles, coinsurance and
copayments. In general, out-of-pocket
costs like deductibles are highest for
bronze plans and lower as you move from
silver to gold. Premium payments are lower
on the Bronze plans and gradually increase
in our Silver and Gold plans.
Please see the product table on the
following pages for a general benefit
outline of commonly used services.
Check out Blue Cross
of Idaho’s insurance
products for each metal
level to find the plan
that’s right for you.
Choose coverage that fits – bcidaho.com
3
Visit bcidaho.com/SBC for a Summary of Benefits and Coverage. Benefit grid
outlines coverage for in-network and out-of-network services for small groups.
Not a comprehensive list of benefits.
Metal level
Bronze
Plans
Bronze HSA Saver INDIVIDUAL
Bronze HSA Saver FAMILY
In-Network (Individual)Out-of-Network (Individual)
In-Network (Family)Out-of-Network (Family)
Deductible
Individual – $6,000
Individual – $6,000
Family – $12,000
Family – $12,000
Annual
Out-of-Pocket
Maximum Costs
Individual – $6,000
Individual – $8,000
Family – $12,000
Family – $16,000
Coinsurance
The individual deductible applies ONLY to an individual plan with one insured
member. If more than one member is insured on an individual HSA plan, the
family deductible applies and each family member contributes towards the
family deductible. Benefits for all family members begin after meeting the
family deductible.
You pay nothing. (Services may be
You pay 50% (Services may be subject
subject to deductible.)
to deductible.)
The claims of all family members accumulate toward the same family
deductible and out-of-pocket maximum. Benefits for all family members begin
after the family deductible is met.
You pay nothing. (Services may be
subject to deductible.)
You pay 50% (Services may be subject
to deductible.)
W h at You ’ l l Pay up to your a nnua l out - of- pocke t ma x i mum
Preventive Care
Services
Doctor’s Office
Visit
You pay nothing for covered
preventive care services.
You pay costs up to your deductible
and then 50%.
You pay nothing for covered
preventive care services.
You pay costs up to your deductible
and then 50%.
You pay costs up to your deductible
and then you pay nothing.
You pay costs up to your deductible
and then 50%.
You pay costs up to your deductible
and then you pay nothing.
You pay costs up to your deductible
and then 50%.
Prescription Drugs
You pay nothing for covered preventive prescriptions.
For other generic and brand-name prescriptions, you pay costs up to your in-network deductible and then you pay nothing.
Immunizations
Inpatient Hospital
Stays
Emergency Room
Visit
Maternity
You pay nothing for covered immunizations.
You pay costs up to your deductible
and then you pay nothing.
You pay costs up to your deductible
and then 50%.
You pay costs up to your deductible
and then you pay nothing.
You pay costs up to your deductible
and then 50%. 1
You pay costs up to your deductible
and then you pay nothing.
You pay costs up to your deductible
and then 50%. 1
You pay costs up to your deductible
and then you pay nothing.
You pay costs up to your deductible
and then 50%.
You pay costs up to your deductible
and then you pay nothing.
You pay costs up to your deductible
and then 50%.
You pay costs up to your deductible
and then you pay nothing.
You pay costs up to your deductible
and then 50%.
You pay costs up to your deductible
and then you pay nothing.
You pay costs up to your deductible
and then 50%.
You pay nothing for one eye exam, one
pair of eyeglasses or contact lenses
and one eyeglasses frame per benefit
period.
You pay 50% for one eye exam, one
pair of eyeglasses or contact lenses
and one eyeglasses frame per benefit
period.
You pay costs up to your deductible
and then you pay nothing.
You pay costs up to your deductible
and then 50%.
You pay nothing for one eye exam, one
pair of eyeglasses or contact lenses
and one eyeglasses frame per benefit
period.
You pay costs up to your deductible
and then you pay nothing.
You pay 50% for one eye exam, one
pair of eyeglasses or contact lenses
and one eyeglasses frame per benefit
period.
You pay costs up to your deductible
and then 50%.
You pay costs up to your deductible
and then you pay nothing.
You pay costs up to your deductible
and then 50%.
You pay costs up to your deductible
and then you pay nothing.
You pay costs up to your deductible
and then 50%.
You pay costs up to your deductible
and then you pay nothing.
You pay costs up to your deductible
and then 50%.
You pay costs up to your deductible
and then you pay nothing.
You pay costs up to your deductible
and then 50%.
Outpatient Mental
Health Services
Pediatric Vision
Care (For plan members
under age 19)
You pay nothing for covered immunizations.
You pay costs up to your deductible
and then you pay nothing.
Physician, Surgical
& Medical Services
Diabetes Education
Services
Chiropractic Care
Up to a combined in- and out-of-network total of 18 visits
per member, per benefit period.
You pay costs up to your deductible
and then you pay nothing.
Outpatient
Rehabilitation
Services
You pay costs up to your deductible
and then 50%.
You pay costs up to your deductible
and then 50%.
Up to a combined in- and out-of-network total of 18 visits
per member, per benefit period.
You pay costs up to your deductible
and then you pay nothing.
You pay costs up to your deductible
and then 50%.
Limited to a combined total of 20 visits
per member, per benefit period.
Physical Therapy (PT) Occupational
Therapy (OT) Speech Therapy (ST)
You pay costs up to your deductible
and then you pay nothing.
Diagnostic X-Ray
and Lab Services
You pay costs up to your deductible
and then 50%.
You pay costs up to your deductible
and then you pay nothing.
You pay costs up to your deductible
and then 50%.
For treatment of emergency medical conditions as defined in the policy, Blue Cross of Idaho will provide in-network benefits for covered services.
1
4
HEALTH INSURANCE PLANS from BLUE CROSS OF IDAHO – Small Groups
Blue cross of Idaho Health Insurance Plans
Metal level
Bronze
Bronze Choice 3000
Bronze Point 3000
Bronze Connect 3000*
Plans
In-NetworkOut-of-Network
Deductible
Individual - $3,000
Family - $6,000
Individual - $3,000
Family - $6,000
Annual
Out-of-Pocket
Maximum Costs
Individual - $6,000
Family - $12,000
Individual - $8,000
Family - $16,000
Coinsurance
(Separate $6,000 Individual / $12,000 Family
Prescription Out-of-Pocket Maximum)
You pay 30% of the cost of your
care. (Services may be subject to
deductible.)
You pay 50% of the cost of your
care. (Services may be subject to
deductible.)
W h at You ’ l l Pay up to your a nnua l
o u t -o f -p o c k e t m a xi mum
Preventive Care
Services
Doctor’s Office
Visit
Prescription Drugs
Immunizations
Inpatient Hospital
Stays
Emergency Room
Visit
Maternity
Outpatient Mental
Health Services
Pediatric Vision
Care (For plan members
under age 19)
Physician, Surgical
& Medical Services
Diabetes Education
Services
Chiropractic Care
You pay nothing for covered
preventive care services.
You pay costs up to your deductible
and then 50%.
You pay costs up to your deductible
You pay costs up to your deductible
and then you pay $30 copayment for
and then 50%.
primary care office visits, you pay $50
copayment for specialist office visits.
(Bronze Connect members must have
referral for non-PCP visits.)
You pay $10 copayment for generic drugs. You pay costs up to a separate
$250 individual/$500 family deductible for brandname and specialty drugs
and then: $30 for preferred brand-name, $45 for non-preferred brand-name,
$100 for specialty drugs. Generic prescriptions are not subject to deductible,
but this plan has a separate $6,000 Individual / $12,000 Family Prescription
Out-of-Pocket Maximum.
Premium
The amount you pay each month for your health
insurance plan.
Deductible
The amount you pay each year for out-of-pocket
expenses before the health insurer picks up expenses.
You won’t have to pay any deductible for some
services.
Coinsurance
Your share of the costs you pay, calculated as a
percentage. (For example, you pay 20 percent,
insurance pays 80 percent).
You pay nothing for covered immunizations.
You pay costs up to your deductible
and then 50%.
You pay costs up to your deductible,
30% and $150 copayment.
You pay costs up to your deductible,
50% and $150 copayment. 1
You pay costs up to your deductible
and then 30%.
You pay costs up to your deductible
and then 50%.
You pay costs up to your deductible
and then you pay $30 copayment for
outpatient psychotherapy services.
For facility and other professional
services, you pay costs up to your
deductible and then 30%.
You pay nothing for one eye exam, one
pair of eyeglasses or contact lenses
and one eyeglasses frame per benefit
period.
You pay costs up to your deductible
and then 30%.
You pay costs up to your deductible
and then 50%.
You pay costs up to your deductible
and then $30 copayment.
You pay costs up to your deductible
and then 50%.
Money you pay for health-related services in addition
to your monthly premium. Depending on your
health insurance plan, these may include an annual
deductible, coinsurance, and copayments for doctor
visits and prescriptions.
You pay costs up to your deductible
and then 30%.
You pay costs up to your deductible
and then 50%.
Out-of-Pocket Maximum
You pay costs up to your deductible
and then 30%.
You pay 50% for one eye exam, one
pair of eyeglasses or contact lenses
and one eyeglasses frame per benefit
period.
You pay costs up to your deductible
and then 50%.
You pay costs up to your deductible
and then 50%.
Limited to a combined total of 20 visits
per member, per benefit period.
Physical Therapy (PT) Occupational
Therapy (OT) Speech Therapy (ST)
Diagnostic X-Ray
and Lab Services
Key terms
You pay costs up to your deductible
and then 30%.
Up to a combined in- and out-of-network
total of 18 visits per member, per benefit period.
Outpatient
Rehabilitation
Services
Provider networks in southwest and southeast Idaho
support the Bronze, Silver, Gold Connect plans and
members must visit doctors or hospitals within a
specific service area and receive referrals to see
specialists from a Primary Care Provider (PCP).
See Connect description on Page 3.
You pay costs up to your deductible
and then 30%.
You pay costs up to your deductible
and then 50%.
Copayment
A flat fee you pay for services such as a doctor visit,
emergency room visit, or prescription medication.
Network
The group of physicians, hospitals and other providers
that an insurer has contracted with to deliver medical
services to its members.
Out-of-Pocket Expenses
After your premium payments, the most in a year you
will pay for covered healthcare services.
The cost of your care
When you use in-network providers, your cost of
care is lower because even when you are paying
your deductible, you only pay Blue Cross of Idaho’s
discounted fee.
*Our Connect plans are supported by the Saint Alphonsus Health Alliance Network in southwestern Idaho and the Portneuf Quality Alliance Network in eastern Idaho.
When you choose managed care through ConnectedCare networks, you must choose a primary care physician from these networks to serve as your care coordinator.
You must obtain a referral from your PCP to see a specialist.
For treatment of emergency medical conditions as defined in the policy, Blue Cross of Idaho will provide in-network benefits for covered services.
1
Choose coverage that fits – bcidaho.com
5
Visit bcidaho.com/SBC for a Summary of Benefits and Coverage. Benefit grid
outlines coverage for in-network and out-of-network services for small groups.
Not a comprehensive list of benefits.
Metal level
SILVER
Plans
Silver HSA Saver INDIVIDUAL
Silver HSA Saver FAMILY
In-Network (Individual)Out-of-Network (Individual)
In-Network (Individual)Out-of-Network (Individual)
Deductible
Individual - $2,000
Individual - $2,000
Family - $4,000
Family - $4,000
Annual
Out-of-Pocket
Maximum Costs
Individual - $5,000
Individual - $7,000
Family - $10,000
Family - $14,000
Coinsurance
The individual deductible applies ONLY to an individual plan with one insured
member. If more than one member is insured on an individual HSA plan, the
family deductible applies and each family member contributes towards the
family deductible. Benefits for all family members begin after meeting the
family deductible.
You pay 20% of the cost of your
You pay 40% of the cost of your
care. (Services may be subject to
care. (Services may be subject to
deductible.)
deductible.)
The claims of all family members accumulate toward the same family
deductible and out-of-pocket maximum. Benefits for all family members begin
after the family deductible is met.
You pay 20% of the cost of your
care. (Services may be subject to
deductible.)
You pay 40% of the cost of your
care. (Services may be subject to
deductible.)
W h at Yo u ’ l l Pay up to your a nnua l out - of- pocke t ma x i mum
Preventive Care
Services
Doctor’s Office
Visit
Prescription Drugs
Immunizations
Inpatient Hospital
Stays
Emergency Room
Visit
Maternity
Outpatient Mental
Health Services
Pediatric Vision
Care (For plan members
under age 19)
Physician, Surgical
& Medical Services
Diabetes Education
Services
Chiropractic Care
You pay nothing for covered
preventive care services.
You pay costs up to your deductible
and then 40%.
You pay nothing for covered
preventive care services.
You pay costs up to your deductible
and then 40%.
You pay costs up to your deductible
and then 20%.
You pay costs up to your deductible
and then 40%.
You pay costs up to your deductible
and then 20%.
You pay costs up to your deductible
and then 40%.
You pay nothing for covered generic and brand-name preventive prescriptions.
For other generic and brand-name prescriptions, you pay costs up to your innetwork deductible and then you pay 20% coinsurance.
You pay nothing for covered immunizations.
You pay costs up to your deductible
and then 40%.
You pay costs up to your deductible
and then 20%.
You pay costs up to your deductible
and then 40%.
You pay costs up to your deductible,
20% and $150 copayment.
You pay costs up to your deductible,
40% and $150 copayment. 1
You pay costs up to your deductible,
20% and $150 copayment.
You pay costs up to your deductible,
40% and $150 copayment. 1
You pay costs up to your deductible
and then 20%.
You pay costs up to your deductible
then 40%.
You pay costs up to your deductible
and then 20%.
You pay costs up to your deductible
then 40%.
You pay costs up to your deductible
and then 20%.
You pay costs up to your deductible
and then 40%.
You pay costs up to your deductible
and then 20%.
You pay costs up to your deductible
and then 40%.
You pay nothing for one eye exam, one
pair of eyeglasses or contact lenses
and one eyeglasses frame per benefit
period.
You pay costs up to your deductible
and then 20%.
You pay 50% for one eye exam, one
pair of eyeglasses or contact lenses
and one eyeglasses frame per benefit
period.
You pay costs up to your deductible
and then 40%.
You pay nothing for one eye exam, one
pair of eyeglasses or contact lenses
and one eyeglasses frame per benefit
period.
You pay costs up to your deductible
and then 20%.
You pay 50% for one eye exam, one
pair of eyeglasses or contact lenses
and one eyeglasses frame per benefit
period.
You pay costs up to your deductible
and then 40%.
You pay $30 copayment, then costs up You pay costs up to your deductible
to your deductible and 20%.
and then 40%.
You pay $30 copayment, then costs up You pay costs up to your deductible
to your deductible and 20%.
and then 40%.
You pay costs up to your deductible
and then 20%.
You pay costs up to your deductible
and then 20%.
You pay costs up to your deductible
and then 20%.
You pay costs up to your deductible
and then 40%.
You pay costs up to your deductible
and then 40%.
Limited to a combined total of 20 visits
per member, per benefit period
Physical Therapy (PT) Occupational
Therapy (OT) Speech Therapy (ST)
Diagnostic X-Ray
and Lab Services
You pay nothing for covered immunizations.
You pay costs up to your deductible
and then 20%.
Up to a combined in- and out-of-network total of 18 visits
per member, per benefit period.
Outpatient
Rehabilitation
Services
You pay nothing for covered generic and brand-name preventive prescriptions.
For other generic and brand-name prescriptions, you pay costs up to your innetwork deductible and then you pay 20% coinsurance.
You pay costs up to your deductible
and then 20%.
You pay costs up to your deductible
and then 40%.
You pay costs up to your deductible
and then 40%.
Up to a combined in- and out-of-network total of 18 visits
per member, per benefit period.
You pay costs up to your deductible
and then 20%.
You pay costs up to your deductible
and then 40%.
Limited to a combined total of 20 visits
per member, per benefit period
You pay costs up to your deductible
and then 20%.
You pay costs up to your deductible
and then 40%.
For treatment of emergency medical conditions as defined in the policy, Blue Cross of Idaho will provide in-network benefits for covered services.
1
6
HEALTH INSURANCE PLANS from BLUE CROSS OF IDAHO – Small Groups
Blue cross of Idaho Health Insurance Plans
Provider networks in southwest and southeast Idaho support the Bronze, Silver, Gold Connect plans
and members must visit doctors or hospitals within a specific service area and receive referrals to see
specialists from a Primary Care Provider (PCP). See Connect description on Page 3.
Metal level
Plans
Deductible
SILVER
Gold
Silver Choice 2000
Silver Point 2000
Silver Connect 2000 *
Gold Choice 2000
Gold Point 2000
Gold Connect 2000*
In-NetworkOut-of-Network
In-NetworkOut-of-Network
Individual - $2,000
Family - $4,000
Individual - $2,000
Family - $4,000
Individual - $2,000
Family - $4,000
Individual - $3,500 Family - $7,000
(Separate $3,500 Individual / $7,000
Family Prescription Out-of-Pocket
Maximum)
Individual - $5,500
Family - $11,000
You pay 20% of the cost of your
care. (Services may be subject to
deductible.)
You pay 40% of the cost of your
care. (Services may be subject to
deductible.)
Individual - $2,000
Family - $4,000
Annual
Out-of-Pocket
Maximum Costs
Coinsurance
Individual - $6,350
Individual - $8,350
Family - $12,700
Family - $16,700
(Separate $6, 350 Individual / $12,700 Family
Prescription Out-of-Pocket Maximum)
You pay 30% of the cost of your
You pay 50% of the cost of your
care. (Services may be subject to
care. (Services may be subject to
deductible.)
deductible.)
Preventive Care
Services
You pay nothing for covered
preventive care services.
W h at Yo u ’ l l Pay up to your a nnua l out - of- pocke t ma x i mum
You pay costs up to your deductible
then 50%.
Silver Choice and Silver Point: You
You pay costs up to your deductible
pay $30 copayment for primary care then 50%.
office visits and a $50 copayment for
specialist office visits. (Silver Connect
members must have referral for nonPCP visits.)
You pay $10 copayment for generic prescriptions. You pay $50 for preferred
brand-name, $65 for non-preferred brand-name, $100 for specialty drugs.
Prescriptions are not subject to deductible, but this plan has a separate
$2, 350 Individual / $12,700 Family Prescription Out-of-Pocket Maximum.
Doctor’s Office
Visit
Prescription Drugs
Immunizations
Inpatient Hospital
Stays
Emergency Room
Visit
Maternity
You pay nothing for covered immunizations.
Outpatient Mental
Health Services
Pediatric Vision
Care (For plan members
under age 19)
Physician, Surgical
& Medical Services
Diabetes Education
Services
Chiropractic Care
You pay costs up to your deductible
and then 40%.
You pay a $10 copayment for generic prescriptions. You pay a $20 copayment
for preferred brand-name, a $35 copayment for non-preferred brand-name,
and a $100 copayment for specialty drugs. Prescriptions are not subject to
deductible, but this plan has a separate $3,500 Individual / $7,000 Family
Prescription Out-of-Pocket Maximum.
You pay nothing for covered immunizations.
You pay costs up to your deductible
and then 20%.
You pay costs up to your deductible
and then 40%.
You pay costs up to your deductible,
30% and $150 copayment.
You pay costs up to your deductible,
50% and $150 copayment. 1
You pay costs up to your deductible,
20% and $150 copayment.
You pay costs up to your deductible,
40% and $150 copayment. 1
You pay costs up to your deductible
then 30%.
You pay costs up to your deductible
then 50%.
You pay costs up to your deductible
and then 20%.
You pay costs up to your deductible
and then 40%.
You pay $30 copayment for
You pay costs up to your deductible
outpatient psychotherapy services
and then 50%.
(not subject to deductible). For facility
and other professional services, you
pay costs up to your deductible and
then 30%.
You pay $20 copayment for
outpatient psychotherapy services
(not subject to deductible). For
facility and other professional
services, you pay costs up to your
deductible and then 20%.
You pay costs up to your deductible
and then 40%.
You pay nothing for one eye exam, one
pair of eyeglasses or contact lenses
and one eyeglasses frame per benefit
period.
You pay 50% for one eye exam, one
pair of eyeglasses or contact lenses
and one eyeglasses frame per benefit
period.
You pay nothing for one eye exam,
one pair of eyeglasses or contact
lenses and one eyeglasses frame per
benefit period.
You pay 50% for one eye exam, one
pair of eyeglasses or contact lenses
and one eyeglasses frame per benefit
period.
You pay costs up to your deductible
then 30%.
You pay costs up to your deductible
then 50%.
You pay costs up to your deductible
and then 20%.
You pay costs up to your deductible
and then 40%.
You pay $30 copayment per visit.
You pay costs up to your deductible
then 50%.
You pay $20 copayment per visit.
You pay costs up to your deductible
and then 40%.
You pay costs up to your deductible
then 30%.
You pay costs up to your deductible
then 50%.
You pay costs up to your deductible
and then 20%.
You pay costs up to your deductible
and then 40%.
You pay costs up to your deductible
then 50%.
Limited to a combined total of 20 visits
per member, per benefit period
You pay costs up to your deductible
then 30%.
Diagnostic X-Ray
and Lab Services
You pay $20 copayment for primary
care office visits and $40 copayment
for specialist office visits. (Gold
Connect members must have referral
for non-PCP visits.)
You pay costs up to your deductible
then 50%.
You pay costs up to your deductible
then 30%.
Physical Therapy (PT) Occupational
Therapy (OT) Speech Therapy (ST)
You pay costs up to your deductible
and then 40%.
You pay costs up to your deductible
then 30%.
Up to a combined in- and out-of-network total of 18 visits
per member, per benefit period.
Outpatient
Rehabilitation
Services
You pay nothing for covered
preventive care services.
You pay costs up to your deductible
then 50%.
Up to a combined in- and out-of-network total of 18 visits
per member, per benefit period.
You pay costs up to your deductible
and then 20%.
You pay costs up to your deductible
and then 40%.
Limited to a combined total of 20 visits
per member, per benefit period
You pay costs up to your deductible
and then 20%.
You pay costs up to your deductible
and then 40%.
*Our Connect plans are supported by the Saint Alphonsus Health Alliance Network in southwestern Idaho and the Portneuf Quality Alliance Network in eastern Idaho.
When you choose managed care through ConnectedCare networks, you must choose a primary care physician from these networks to serve as your care coordinator. You must obtain a referral
from your PCP to see a specialist.
For treatment of emergency medical conditions as defined in the policy, Blue Cross of Idaho will provide in-network benefits for covered services.
1
Choose coverage that fits – bcidaho.com
7
Provider networks in southwest and southeast Idaho support the Bronze, Silver, Gold Connect plans
and members must visit doctors or hospitals within a specific service area and receive referrals to see
specialists from a Primary Care Provider (PCP). See Connect description on Page 3.
Metal level
Gold
Gold Choice 1000
Gold Point 1000
Gold Connect 1000*
Plans
Gold Choice 500
Gold Point 500
Gold Connect 500*
In-NetworkOut-of-Network
In-NetworkOut-of-Network
Individual - $1,000
Family - $2,000
Individual - $1,000
Family - $2,000
Individual - $500
Family - $1,000
Individual - $500
Family - $1,000
Annual
Out-of-Pocket
Maximum Costs
Coinsurance
Individual - $4,000 Family - $8,000
(Separate $4,000 Individual / $8,000
Family Prescription Out-of-Pocket
Maximum)
Individual - $6,000
Family - $12,000
Individual - $4,000 Family - $8,000
(Separate $4,000 Individual / $8,000
Family Prescription Out-of-Pocket
Maximum)
Individual - $6,000
Family - $12,000
You pay 20% of the cost of your
care. (Services may be subject to
deductible.)
You pay 40% of the cost of your
care. (Services may be subject to
deductible.)
You pay 20% of the cost of your
care. (Services may be subject to
deductible.)
You pay 40% of the cost of your
care. (Services may be subject to
deductible.)
Preventive Care
Services
You pay nothing for covered
preventive care services.
You pay costs up to your deductible
and then 40%.
You pay nothing for covered
preventive care services.
You pay costs up to your deductible
and then 40%.
You pay $30 copayment for primary
care office visits and $50 copayment
for specialist office visits. (Gold
Connect members must have referral
for non-PCP visits.)
You pay costs up to your deductible
and then 40%.
You pay $30 copayment for primary
care office visits and $50 copayment
for specialist office visits. (Gold
Connect members must have referral
for non-PCP visits.)
You pay costs up to your deductible
and then 40%.
Deductible
W h at Yo u ’ l l Pay up to your a nnua l out - of- pocke t ma x i mum
Doctor’s Office
Visit
You pay $10 copayment for generic prescriptions. You pay $30 copayment
for preferred brand-name, $45 copayment for non-preferred brand-name,
and $100 copayment for specialty drugs. Prescriptions are not subject to
deductible, but this plan has a separate $4,000 Individual / $8,000 Family
Prescription Out-of-Pocket Maximum.
Prescription Drugs
Immunizations
Inpatient Hospital
Stays
Emergency Room
Visit
Maternity
You pay nothing for covered immunizations.
Outpatient Mental
Health Services
Pediatric Vision
Care (For plan members
under age 19)
Physician, Surgical
& Medical Services
Diabetes Education
Services
Chiropractic Care
You pay costs up to your deductible
and then 40%.
You pay costs to your deductible and
then 20%.
You pay costs up to your deductible
and then 40%.
You pay costs up to your deductible,
20% and $150 copayment.
You pay costs up to your deductible,
40% and $150 copayment. 1
You pay costs up to your deductible,
20% and $150 copayment.
You pay costs up to your deductible,
40% and $150 copayment. 1
You pay costs up to your deductible
and then 20%.
You pay costs up to your deductible
and then 40%.
You pay costs up to your deductible
and then 20%.
You pay costs up to your deductible
and then 40%.
You pay $30 copayment for
outpatient psychotherapy services
(not subject to deductible). For
facility and other professional
services, you pay costs up to your
deductible and then 20%.
You pay costs up to your deductible
and then 40%.
You pay $30 copayment for
outpatient psychotherapy services
(not subject to deductible). For
facility and other professional
services, you pay costs up to your
deductible and 20%.
You pay costs up to your deductible
and then 40%.
You pay nothing for one eye exam,
one pair of eyeglasses or contact
lenses and one eyeglasses frame per
benefit period.
You pay 50% for one eye exam, one
pair of eyeglasses or contact lenses
and one eyeglasses frame per benefit
period.
You pay nothing for one eye exam,
one pair of eyeglasses or contact
lenses and one eyeglasses frame per
benefit period.
You pay 50% for one eye exam, one
pair of eyeglasses or contact lenses
and one eyeglasses frame per benefit
period.
You pay costs up to your deductible
and then 20%.
You pay costs up to your deductible
and then 40%.
You pay costs up to your deductible
and then 20%.
You pay costs up to your deductible
and then 40%.
You pay $30 copayment per visit.
You pay costs up to your deductible
and then 40%.
You pay $30 copayment per visit.
You pay costs up to your deductible
and then 40%.
You pay costs up to your deductible
and then 20%.
You pay costs up to your deductible
and then 40%.
You pay costs up to your deductible
and then 20%.
You pay costs up to your deductible
and then 40%.
You pay costs up to your deductible
and then 20%.
You pay costs up to your deductible
and then 40%.
Limited to a combined total of 20 visits
per member, per benefit period
Physical Therapy (PT) Occupational
Therapy (OT) Speech Therapy (ST)
You pay costs up to your deductible
and then 20%.
Diagnostic X-Ray
and Lab Services
You pay nothing for covered immunizations.
You pay costs up to your deductible
and then 20%.
Up to a combined in- and out-of-network total of 18 visits
per member, per benefit period.
Outpatient
Rehabilitation
Services
You pay $10 copayment for generic prescriptions. You pay $30 copayment
for preferred brand-name, $45 copayment for non-preferred brand-name,
and $100 copayment for specialty drugs. Prescriptions are not subject to
deductible, but this plan has a separate $4,000 Individual / $8,000 Family
Prescription Out-of-Pocket Maximum.
You pay costs up to your deductible
and then 40%.
Up to a combined in- and out-of-network total of 18 visits
per member, per benefit period.
You pay costs up to your deductible
and then 20%.
You pay costs up to your deductible
and then 40%.
Limited to a combined total of 20 visits
per member, per benefit period
You pay costs up to your deductible
and then 20%.
You pay costs up to your deductible
and then 40%.
*Our Connect plans are supported by the Saint Alphonsus Health Alliance Network in southwestern Idaho and the Portneuf Quality Alliance Network in eastern Idaho.
When you choose managed care through ConnectedCare networks, you must choose a primary care physician from these networks to serve as your care coordinator. You must obtain a referral
from your PCP to see a specialist.
For treatment of emergency medical conditions as defined in the policy, Blue Cross of Idaho will provide in-network benefits for covered services.
1
8
HEALTH INSURANCE PLANS from BLUE CROSS OF IDAHO – Small Groups
Dental Plans
Dental Plans
Oral health is important to your employees
and we offer a variety of dental plans that are
flexible and affordable. Our plans ensure your
employees have the dental coverage they need
at a price you can afford.
Blue Cross of Idaho dental
plans offer:
Our dental coverage will make
you smile
• Benefit design flexibility
Getting your dental coverage through
Blue Cross of Idaho also provides the
convenience of having your medical and
dental coverage through one insurance
company.
• Access to the largest preferred
provider organization (PPO) and
traditional dental provider networks in
Idaho
• Access to the national Dental GRID, a
dental network of participating Blue
Cross Blue Shield plans, with access
to additional networks in states where
there are no participating Blue plan
networks.
• Negotiated provider discounts that
allow your employees to stretch their
benefit dollars and save on dental costs
• One customer service telephone
number for dental and medical benefit
questions
• One ID card
• One billing statement
• One renewal
Orthodontic Values
If you are a Blue Cross of Idaho
member, no matter what your
plan covers, you will receive
a discount of $400 off the
total cost of full orthodontic
treatment plans for eligible
family members. All you have
to do is show the Blue Extras!
provider your Blue Cross
member ID card. The discount
applies to any treatment plan
which is initiated after the
orthodontist’s effective date.
Blue Extras! is a discount
program and not a part of your
insurance coverage.
Choose coverage that fits – bcidaho.com
9
Dental Choice and
Dental Choice Plus
Our Dental Choice and Dental Choice
Plus plans offer benefit designs that
protect your employees’ dental health
and meet all dental requirements of
the Affordable Care Act. This includes
coverage for medically necessary
orthodontia and no benefit period
maximums for people under age 19.
Dental Blue Connect
Dental Blue Connect offers extensive
dental coverage with:
• No deductibles
• No benefit period maximums
• No waiting periods
• No claim forms
Orthodontia, with no age limit, is
available for all eligible members
on all Dental Blue Connect plans.
All necessary dental services are
covered at 100% after applicable
co-payments when performed
by dentists and specialists at
Willamette Dental Group.
10
Essential Dental
Essential Dental is our low cost
dental care option, providing
your employees with benefits for
preventive, diagnostic and basic
dental services. Major dental
services are not covered, which keeps
premiums lower than other dental
plans.
Deductible Dental
Deductible Dental has the flexibility
you need when providing dental
benefits to your employees and their
families.
Blue Cross of Idaho’s contracting
dentists agree to recognize our
maximum allowance as their
maximum fee for eligible services.
Members are responsible for any
coinsurance, deductibles and costs
for noncovered services.
Incentive Dental
With Incentive Dental, your
employees are rewarded for taking
care of their smile! Starting at 70%,
benefit payments increase 10%
each year up to 100% for preventive,
diagnostic and basic dental services,
as long as they visit a dental provider
HEALTH INSURANCE PLANS from BLUE CROSS OF IDAHO – Small Groups
each consecutive year. For each year
that a member does not receive
dental services, the amount payable
will decrease by 10%. Major dental
services are covered at 50% with no
deductible.
Preferred Blue Dental
Preferred Blue Dental plans
maximize consumer choice and
flexibility, while delivering reduced
premiums and lower out-of-pocket
expenses. That’s because Preferred
Blue Dental is a PPO plan that uses
our nationwide network of dentists
and specialists. Preventive, basic, and
major dental services are covered.
Voluntary Dental
Voluntary Dental is a great way to
provide your employees with easy
access to dental care coverage.
As implied by the name, the plan
is entirely voluntary, meaning that
your employees decide whether or
not they want to participate. And,
because the program is voluntary,
there are no employee participation
or employer contribution
requirements.
?
Tools for Maintaining
and Improving Health
By choosing Blue Cross of Idaho, you can not only
choose from a variety of benefit plans, but you
give your employees access to a variety of support
tools, including:
, a collection of health and
• WellConnectedsm
well-being services to help members make
positive lifestyle changes and informed
decisions about their healthcare.
• Blue Extras!sm offers a variety of discounted
of non-covered health services to assist
employees in achieving personal health,
wellness and fitness goals.
• PHM helps members with chronic diseases,
such as diabetes, asthma, and congestive heart
failure or learn about their condition and better
manage their own care.
• Case management helps employees with
complex care conditions use services in the
most cost effective and appropriate manner.
Integrated behavioral health case management
and pharmacy case management also help control
costs while ensuring your employees are receiving
appropriate, quality healthcare.
Wellness is not only good for your employees,
it’s good for your business. Healthier employees
tend to be more productive, with lower rates of
disability and absenteeism.
Research shows that a significant portion of total
healthcare costs are due to modifiable behaviors,
so over the long run, a healthier workplace can
help contain healthcare costs.
Choose coverage that fits – bcidaho.com
11
ACA Effects on
Small Business
The Affordable Care Act began changing
the healthcare delivery and health insurance
landscape in 2010. However, beginning in
2014, employers face the difficult task of
determining whether it makes better financial
sense to offer coverage to employees or to
leave it to employees to purchase individual or
family coverage on the public exchange.
To help employers quantify the cost
impacts of these options, Blue Cross
of Idaho has purchased a software tool
from Milliman, a consulting firm with
considerable experience in the healthcare
marketplace. With employee and business
information, we can create a strategic
impact report specific to a small business
like yours. This resource helps our existing
group accounts see how healthcare reform
affects both your employees and your
bottom line – now and in the future.
To receive an assessment of the ACA’s
impact on your organization, contact your
Blue Cross of Idaho broker or account
representative.
Highlights will include information on:
• Projected tax risks
• Premium and cost sharing estimates for
employer-based plans vs. the Exchange
• Anticipated tax credits for employers
with fewer than 25 employees
• Estimated impact on rates for
employers with fewer than 50
employees
• Estimates of ACA eligibility and
affordability for employees
• Estimates on employee compensation
needed to replace the value of the
health plan
• Employer pre and post-tax cost of
terminating coverage.
12
HEALTH INSURANCE PLANS from BLUE CROSS OF IDAHO – Small Groups
Affordable Care act at a Glance
ACA at a Glance
The new healthcare law, passed in 2010 and upheld by
the Supreme Court 2012, brings many changes to health
insurance purchased by individuals and families or by
small and large businesses. The Affordable Care Act
changes how we purchase and pay for insurance, and
brings new plan options and even financial assistance to
those who qualify. Here’s a snapshot of the major changes:
• You can’t be denied coverage because of a pre-existing
health condition.
• Insurance companies can’t drop your coverage if you
get sick.
• All health plans must cover a standard set of “essential
health benefits,” including emergency services,
hospitalization, maternity and newborn care, mental
health and substance abuse services.
• Essential health benefits carry no annual or lifetime
dollar maximums.
• Parents can keep their kids on their plans until those
dependents are 26 years old.
• All Idahoans, with few exceptions, are required to have
health insurance or pay a tax penalty.
• Monthly premium tax credits and/or cost sharing
subsidies may be available to offset out-of-pocket
costs for those who qualify.
• The Idaho Health Insurance Exchange is an online
marketplace where both individuals and small
businesses can compare and purchase plans.
Blue Cross of Idaho is your health insurance partner.
We’re committed to helping you understand the complex
health insurance and healthcare delivery systems so you
can find the best coverage for your company and your
employees. We know you have options when you look for
health insurance, but trust that you’ll find that Blue Cross
of Idaho offers the best value in health coverage, along
with many useful tools to help your employees – and your
business – stay healthy.
• Preventive care, such as annual doctor visits or regular
health screenings, is now covered with no out-ofpocket costs through your insurance plan.
• The annual out-of-pocket maximum
(after premiums) for in-network
healthcare services is $6,350 for
individuals and $12,700 for families.
Did You Know?
The Affordable Care Act
changes how we purchase
and pay for insurance,
and brings new plan options
and even financial assistance
to those who qualify.
Choose coverage that fits – bcidaho.com
13
Exclusions & Limitations
In addition to the exclusions and limitations
listed elsewhere in this booklet, the following
exclusions and limitations apply to the entire
Policy, unless otherwise specified:
There are no benefits for services,
supplies, drugs, or other charges
that are:
• Not Medically Necessary. If services requiring Prior
Authorization by Blue Cross of Idaho are performed
by a Contracting Provider and benefits are denied as
not Medically Necessary, the cost of said services
are not the financial responsibility of the Insured.
However, the Insured could be financially responsible
for services found to be not Medically Necessary
when provided by a Noncontracting Provider.
• In excess of the Maximum Allowance.
• For hospital Inpatient or Outpatient care for
extraction of teeth or other dental procedures,
unless necessary to treat an Accidental Injury or
unless an attending Physician certifies in writing
that the Insured has a non-dental, life-endangering
condition which makes hospitalization necessary to
safeguard the Insured’s health and life.
• Not prescribed by or upon the direction of a
Physician or other Professional Provider; or which
are furnished by any individuals or facilities other
than Licensed General Hospitals, Physicians, and
other Providers.
• Investigational in nature.
• Provided for any condition, Disease, Illness or
Accidental Injury to the extent that the Insured is
entitled to benefits under occupational coverage,
obtained or provided by or through the employer
under state or federal Workers’ Compensation
Acts or under Employer Liability Acts or other laws
providing compensation for work-related injuries
or conditions. This exclusion applies whether or not
the Insured claims such benefits or compensation or
recovers losses from a third party.
• Provided or paid for by any federal governmental
entity or unit except 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 where its charges therefore would vary, or are
or would be affected by the existence of coverage
under this Policy.
• Provided for any condition, Accidental Injury,
Disease or Illness suffered as a result of any act of
war or any war, declared or undeclared.
• Furnished by a Provider who is related to the Insured
by blood or marriage and who ordinarily dwells in the
Insured’s household.
• Received from a dental, vision, or medical
department maintained by or on behalf of an
employer, a mutual benefit association, labor union,
trust or similar person or group.
14
HEALTH INSURANCE PLANS from BLUE CROSS OF IDAHO – Small Groups
• For Surgery intended mainly to improve appearance
or for complications arising from Surgery intended
mainly to improve appearance, except for:
• Reconstructive Surgery necessary to treat an
Accidental Injury, infection or other Disease of
the involved part; or
• Reconstructive Surgery to correct Congenital
Anomalies in an Insured who is a dependent child.
• Benefits for reconstructive Surgery to correct an
Accidental Injury are available even though the
accident occurred while the Insured was covered
under a prior insurer’s coverage, if there is no
lapse of more than sixty-three (63) days between
the prior coverage and coverage under this Policy.
• Rendered prior to the Insured’s Effective Date.
• For personal hygiene, comfort, beautification
(including non-surgical services, drugs, and supplies
intended to enhance the appearance), or convenience
items or services even if prescribed by a Physician,
including but not limited to, air conditioners, air
purifiers, humidifiers, physical fitness equipment or
programs, spas, hot tubs, whirlpool baths, waterbeds
or swimming pools and therapies, including but not
limited to, educational, recreational, art, aroma,
dance, sex, sleep, electro sleep, vitamin, chelation,
homeopathic, or naturopathic, massage, or music.
• For telephone consultations, and all computer or
Internet communications.
• For failure to keep a scheduled visit or appointment;
for completion of a claim form; or for personal
mileage, transportation, food or lodging expenses
or for mileage, transportation, food or lodging
expenses billed by a Physician or other Professional
Provider.
• For Inpatient admissions that are primarily for
Diagnostic Services or Therapy Services; or for
Inpatient admissions when the Insured is ambulatory
and/or confined primarily for bed rest, special diet,
behavioral problems, environmental change or for
treatment not requiring continuous bed care.
• For Inpatient or Outpatient Custodial Care; or for
Inpatient or Outpatient services consisting mainly
of educational therapy, behavioral modification,
self-care or self-help training, except as specified as
a Covered Service in this Policy.
• For any cosmetic foot care, including but not limited
to, treatment of corns, calluses, and toenails (except
for surgical care of ingrown or Diseased toenails).
• Related to Dentistry or Dental Treatment, even
if related to a medical condition; or orthoptics,
eyeglasses or contact Lenses, or the vision
examination for prescribing or fitting eyeglasses
or contact Lenses, unless specified as a Covered
Service in this Policy.
Exclusions and limitations
• For hearing aids or examinations for the
prescription or fitting of hearing aids.
• For any treatment of either gender leading
to or in connection with transsexual Surgery,
gender transformation, sexual dysfunction,
or sexual inadequacy, including erectile
dysfunction and/or impotence, even if related
to a medical condition.
• Made by a Licensed General Hospital for the
Insured’s failure to vacate a room on or before
the Licensed General Hospital’s established
discharge hour.
• Not directly related to the care and treatment
of an actual condition, Illness, Disease or
Accidental Injury.
• Furnished by a facility that is primarily a place
for treatment of the aged or that is primarily
a nursing home, a convalescent home, or a
rest home.
• For Acute Care, Rehabilitative care,
diagnostic testing except as specified as a
Covered Service in this Policy; for Mental or
Nervous Conditions and Substance Abuse
or Addiction services not recognized by
the American Psychiatric and American
Psychological Associations.
• For any of the following:
• For appliances, splints or restorations
necessary to increase vertical tooth
dimensions or restore the occlusion,
except as specified as a Covered Service
in this Policy;
• For orthognathic Surgery, including
services and supplies to augment or
reduce the upper or lower jaw;
• For implants in the jaw; for pain,
treatment, or diagnostic testing or
evaluation related to the misalignment
or discomfort of the temporomandibular
joint (jaw hinge), including splinting
services and supplies;
• For alveolectomy or alveoloplasty when
related to tooth extraction.
• For weight control or treatment of obesity or
morbid obesity, even if Medically Necessary,
including but not limited to Surgery for
obesity. For reversals or revisions of Surgery
for obesity, except when required to correct a
life-endangering condition.
• For use of operating, cast, examination, or
treatment rooms or for equipment located in
a Contracting or Noncontracting Provider’s
office or facility, except for Emergency room
facility charges in a Licensed General Hospital
unless specified as a Covered Service in this
Policy.
• For the reversal of sterilization procedures,
including but not limited to, vasovasostomies
or salpingoplasties.
• Treatment for infertility and fertilization
procedures, including but not limited
to, ovulation induction procedures and
pharmaceuticals, artificial insemination, in
vitro fertilization, embryo transfer or similar
procedures, or procedures that in any way
augment or enhance an Insured’s reproductive
ability, including but not limited to laboratory
services, radiology services or similar
services related to treatment for fertility or
fertilization procedures.
• For Transplant services and Artificial Organs,
except as specified as a Covered Service
under this Policy.
• For acupuncture.
• For surgical procedures that alter the
refractive character of the eye, including but
not limited to, radial keratotomy, myopic
keratomileusis, Laser-In-Situ Keratomileusis
(LASIK), and other surgical procedures of
the refractive-keratoplasty type, to cure
or reduce myopia or astigmatism, even if
Medically Necessary, unless specified as a
Covered Service in a Vision Benefits Section
of this Policy, if any. Additionally, reversals,
revisions, and/or complications of such
surgical procedures are excluded, except
when required to correct an immediately lifeendangering condition.
examination including routine hearing
examinations, except as specified as a
Covered Service in this Policy.
• For immunizations, except as specified as a
Covered Service in this Policy.
• For breast reduction Surgery or Surgery for
gynecomastia.
• For nutritional supplements.
• For replacements or nutritional formulas
except, when administered enterally due to
impairment in digestion and absorption of an
oral diet and is the sole source of caloric need
or nutrition in an Insured.
• For vitamins and minerals, unless required
through a written prescription and cannot be
purchased over the counter.
• For pastoral, spiritual, bereavement, or
marriage counseling.
• For an elective abortion, except to preserve
the life of the female upon whom the abortion
is performed, unless benefits for an elective
abortion are specifically provided by a
separate Endorsement to this Policy.
• For homemaker and housekeeping services or
home-delivered meals.
• For alterations or modifications to a home or
vehicle.
• For the treatment of injuries sustained while
committing a felony, voluntarily taking part
in a riot, or while engaging in an illegal act or
occupation, unless such injuries are a result of
a medical condition or domestic violence.
• For special clothing, including shoes (unless
permanently attached to a brace).
• For Hospice, except as specified as a Covered
Service in this Policy.
• For treatment or other health care of any
Insured in connection with an Illness, Disease,
Accidental Injury or other condition which
would otherwise entitle the Insured to
Covered Services under this Policy, if and to
the extent those benefits are payable to or
due the Insured under any medical payments
provision, no fault provision, uninsured
motorist provision, underinsured motorist
provision, or other first party or no fault
provision of any automobile, homeowner’s, or
other similar policy of insurance, contract, or
underwriting plan.
I n the event Blue Cross of Idaho (BCI) for
any reason makes payment for or otherwise
provides benefits excluded by the above
provisions, it shall succeed to the rights
of payment or reimbursement of the
compensated Provider, the Insured, and the
Insured’s heirs and personal representative
against all insurers, underwriters, selfinsurers or other such obligors contractually
liable or obliged to the Insured, or his or
her estate for such services, supplies,
drugs or other charges so provided by BCI
in connection with such Illness, Disease,
Accidental Injury or other condition.
• Any services or supplies for which an Insured
would have no legal obligation to pay in the
absence of coverage under this Policy or
any similar coverage; or for which no charge
or a different charge is usually made in the
absence of insurance coverage or for which
reimbursement or payment is contemplated
under an agreement entered into with a third
party.
• For a routine or periodic mental or physical
examination that is not connected with
the care and treatment of an actual
Illness, Disease or Accidental Injury or for
an examination required on account of
employment; or related to an occupational
injury; for a marriage license; or for insurance,
school or camp application; or for sports
participation physicals; or a screening
• Provided to a person enrolled as an Eligible
Dependent, but who no longer qualifies
as an Eligible Dependent due to a change
in eligibility status that occurred after
enrollment.
• Provided outside the United States, which if
had been provided in the United States, would
not be a Covered Service under this Policy.
• Furnished by a Provider or caregiver that is
not listed as a Covered Provider, including but
not limited to, naturopaths and homeopaths.
• For Outpatient pulmonary and/or cardiac
Rehabilitation.
• For complications arising from the
acceptance or utilization of noncovered
services.
• For the use of Hypnosis, as anesthesia or
other treatment, except as specified as a
Covered Service.
• For dental implants, appliances (with the
exception of sleep apnea devices), and/or
prosthetics, and/or treatment related to
Orthodontia, even when Medically Necessary
unless specified as a Covered Service in this
Policy.
• For arch supports, orthopedic shoes, and
other foot devices.
• For wigs.
• For cranial molding helmets, unless used to
protect post cranial vault surgery.
• 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 (obesity) Surgery.
• For the purchase of Therapy or Service Dogs/
Animals and the cost of training/maintaining
said animals.
Choose coverage that fits – bcidaho.com
15
P.O. Box 7408 · Boise, ID · 83707
1 888 GO CROSS (1 888-462-7677)
bcidaho.com
Meridian
Street Address
3000 East Pine Avenue
Meridian, ID 83642-5995
Mailing Address
P.O. Box 7408
Boise, ID 83707
208-387-6683
800-365-2345
Claims Inquiries
(208) 331-7347 | (800) 627-1188
Coeur d’Alene
1450 Northwest Boulevard, Suite 106
Coeur d’Alene, ID 83814
208-666-1495
Lewiston
Street Address
1010 17th Street
Lewiston, ID 83501
Street Address
1910 Channing Way
Idaho Falls, ID 83404
Mailing Address
P.O. Box 2287
Idaho Falls, ID 83403
208-522-8813
P.O. Box 1468
Lewiston, ID 83501
208-746-0531
Pocatello
Street Address
275 South 5th Avenue
Suite 150
Pocatello, ID 83201
Mailing Address
P.O. Box 2578
Pocatello, ID 83206
208-232-6206
Twin Falls
Street Address
Idaho Falls
Mailing Address
1431 North Fillmore Street
Suite 200
Twin Falls, ID 83301
Mailing Address
P.O. Box 5025
Twin Falls, ID 83303-5025
208-733-7258
© 2014 Blue Cross of Idaho is an Independent Licensee of the Blue Cross and Blue Shield Association.