2020 INDIVIDUAL AND FAMILY HEALTH INSURANCE PLAN GUIDE · If you need help, call your insurance agent or talk to Blue Cross of Idaho sales team today at 1-888-GO-CROSS (1-888-462-7677)

Form No. 20-013 (01-20)

18-073-01/20 18-075-01/20 18-076-01/20 18-078-01/20

Policy No. 18-069-01/20 18-070-01/20 18-071-01/20 18-072-01/20

18-102-01/20 18-107-01/20 18-108-01/20 18-109-01/20

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2020 | ACA PLAN GUIDE

INDIVIDUAL AND FAMILY HEALTH INSURANCE PLAN GUIDE

Serving all counties in Idaho

2 HEALTH PLANS | BLUE CROSS OF IDAHO

Make the Choice that Works for You.

When it comes to finding the right healthcare coverage, we know you

have choices. Understanding how to make the best choice is the first step

in choosing the right plan with the coverage you want and the benefits

you deserve.

We are here to make it easier for you so you can get on with your life with

less worry, less hassle and more financial peace of mind.

There’s a reason why thousands of your friends and neighbors trust

Blue Cross of Idaho.

We understand when to step in and help you through the health insurance

process. We also know when to get out of the way and let you work with

your provider to take control of your health.

We understand the important questions you may have about our plans

or health coverage in general. We have the tools you need to make

informed decisions and get the most out of your health plan.

We are Idahoans who have been helping Idahoans make the most informed

healthcare decisions for over 70 years. And we’d love to serve you.

BLUE CROSS OF IDAHO

BLUE CROSS OF IDAHO | HEALTH PLANS 1

Ready to find a plan that’s right for you? The following pages outline specific Blue Cross of Idaho networks and plans. If you need help, call your insurance agent or talk to Blue Cross of Idaho sales team today at 1-888-GO-CROSS (1-888-462-7677).

Follow these steps to find the best plan to meet your needs and get the coverage you deserve.

Let’s Get Started

See if you qualify for a tax credit or cost-sharing reduction. If you qualify for a cost-sharing reduction, see pages 6 - 9. If you are a Native American or American Indian, see pages 10 and 11.

Read how your plan will work, review the networks, PCPs and hospitals available where you live, pages 12 - 17.

Find a plan that fits your lifestyle and budget on pages 2 - 5.

Buy your plan. Open enrollment is November 1 through December 16, 2019.

HERE’S YOUR CHECKLIST:

KEY TERMS CoinsuranceBlue Cross of Idaho shares the cost of your healthcare covered under your plan. For example, if we cover 70 percent of a doctor’s charges, you’re responsible for paying the remaining 30 percent.

CopayA set amount you pay directly to a doctor, hospital or pharmacy when you need a service. Depending on your plan, you might pay a copay to see a primary care provider (PCP), have an MRI or visit the ER.

DeductibleThe dollar amount you pay for most healthcare you get before your insurance plan starts to pay. Some plans have one deductible for medical care and a separate deductible for prescriptions.

In-NetworkCare you receive from a primary care provider on your plan’s list of covered doctors or care you receive from a doctor, hospital, clinic or pharmacy on your plan’s list of covered doctors when you have a referral.

You can find a list for your plan network at bcidaho.com/findaprovider.

Out-of-NetworkCare you receive from a doctor, hospital or clinic who is not on your plan’s list of covered doctors or without a referral from your primary care provider.

Even if you have a referral, providers who are not on your plan’s list can also bill you for whatever insurance doesn’t cover; this is called “balance billing” and is a major reason you should use providers in your plan’s network.

Out-of-Pocket MaximumThe combined maximum deductible, copay, and coinsurance amount you pay for covered healthcare each year.

PremiumThe amount you pay monthly for your health insurance plan.

If you don’t see a doctor very often, a bronze plan is a great way to save on your monthly premium. We pay about 60 percent of the average medical costs.*

FIND YOUR PLAN

LEARN MORE ABOUT THE METAL LEVELS: BRONZE, SILVER AND GOLD

Affordable Care Act (ACA) Plans

If you see a doctor once in a while, a silver plan is a good option. This is a “middle-of-the-road” plan where we pay about 70 percent of the average medical costs.*

If you go to the doctor regularly, a gold plan may be right for you. You pay a higher monthly premium, but Blue Cross of Idaho pays about 80 percent of the average medical costs.*

* Payment percentages are based on an average person’s healthcare expenses over a year.

CAC TAA ATT SA TTSS ROPHICBROONZESILLVVLLLL ERGOOLD




The following benefit grids outline common in- and out-of-network services, and are not comprehensive lists of benefits. For more information, please visit bcidaho.com/SBC to review a Summary of Benefits and Coverage.


SUPPORT FROM LOCAL NETWORKSWhen you choose a Blue Cross of Idaho managed care plan, you must choose a primary care provider (PCP) from your local network. Your PCP will serve as your care coordinator and provide referrals to visit specialists or other healthcare providers.

BRONZE 8150 OR BRONZE CAREPOINT 8150

BRONZE 6300 OR BRONZE CAREPOINT 6300

BRONZE HSA 6000 OR BRONZE HSA CAREPOINT 6000

What You Pay In Network

What You Pay Out of Network





BENEFITS YOU ARE MOST LIKELY TO NEEDPrimary Care Visits

$4060% after deductible


20% after deductible


Urgent Care Visits Specialist Visits

(w/referral) $65 $105

Preferred Generic Prescriptions

$15 $15 $15 $15$5 after deductible* $5 after deductible*

Non-Preferred Generic Prescriptions $10 after deductible $10 after deductible

Immunizations$0

$0$0

$0$0

$0Preventive Care




Diabetes Education $20 $20


Outpatient Mental Health and Substance

Abuse Visits $40 $40Applied Behavior

Analysis Visits1

OTHER BENEFITS YOU MIGHT NEED

Emergency Room Visits

No charge after deductible

$350 after deductible2

$350 after deductible




Imaging (MRIs, CT scans)


$500, then 40% after deductible




Lab Work and X-rays





Surgery (doctors charges, anesthesia and other covered charges)

Having a Baby (pregnancy care,

delivery and after care)Therapy Visits3 (PT, ST,

and OT)WHAT YOU’LL PAY FOR THE CARE YOU RECEIVE EACH YEAR

Medical DeductibleHow much you’ll pay each year before we start paying for some services;

deductible is doubled for family policies, no matter how many are covered

$8,150 $16,300 $6,300 $16,300 $6,000 $16,300

Prescription Deductible No separate drug deductible No separate drug deductible No separate drug deductible

CoinsuranceThe percent you’ll pay for covered services; we’ll pay the other part

0% 60% 40% 60% 20% 60%

Out-of-Pocket Maximum

The most you’ll pay out of pocket each year for covered care and prescriptions; maximum is doubled for family policies, no matter how many are covered

$8,150 $81,500 $8,150 $81,500 $6,850 $81,500

IF YOU NEED BRAND NAME OR SPECIALTY PRESCRIPTIONS Preferred Brand

Name Prescriptions4 $35 $35 after deductible $30 after deductible

Non-Preferred Brand Name Prescriptions4 $50 $50 after deductible $50 after deductible

Preferred Specialty Drugs 30% 30% after deductible 30% after deductible

Non-Preferred Specialty Drugs 50% 50% after deductible 50% after deductible

*The Bronze HSA 6000 plan includes an additional list of prescriptions with no copay. The HSA Preventive Drug List can be found online at members.bcidaho.com. See page 5 for footnote descriptions.


SILVER 6000 OR SILVER CAREPOINT 6000














(w/referral) $50 $60 $55

Preferred Generic Prescriptions $5 $5 $5 $5 $5 $5

Non-Preferred Generic Prescriptions $10 $10 $10 $10 $10 $10

Immunizations$0

$0$0

$0$0

$0Preventive Care




Diabetes Education $20 $20 $20Outpatient Mental

Health and Substance Abuse Visits

$20 $30 $35Applied Behavior Analysis Visits1


Emergency Room Visits $350 after deductible













Lab Work and X-rays











Medical DeductibleHow much you’ll pay each year before we start paying for some services; deductible is doubled for family policies,

no matter how many are covered

$6,000 $16,300 $5,000 $16,300 $4,000 $16,300

Prescription Deductible No separate drug deductible $1,000 per person $1,500 per person

Coinsurance The percent you’ll pay for covered services; we’ll pay the other part

20% 60% 40% 60% 40% 60%



$8,150 $81,500 $8,150 $81,500 $8,150 $81,500


Name Prescriptions4 $30 after deductible $30 after deductible $30 after deductible

Non-Preferred Brand Name Prescriptions4 $50 after deductible $50 after deductible $50 after deductible

Preferred Specialty Drugs 30% after deductible 30% after deductible 30% after deductible

Non-Preferred Specialty Drugs 50% after deductible 50% after deductible 50% after deductible

See page 5 for footnote descriptions.

GOLD 2000 OR GOLD CAREPOINT 2000

CATASTROPHIC 8150 OR CATASTROPHIC CAREPOINT 8150*







$30 up to 3 visits, then deductible 60% after

deductibleUrgent Care Visits

Specialist Visits (w/referral) $50

$0 after deductible

Preferred Generic Prescriptions $0 $0

$0 after deductibleNon-Preferred Generic

Prescriptions $10 $10

Immunizations$0

$0$0

$0Preventive Care



Diabetes Education

$20 $0 after deductible

Outpatient Mental Health and Substance

Abuse VisitsApplied Behavior

Analysis Visits1


Emergency Room Visits $350 after deductible


$0 after deductible

60% after deductible2




Lab Work and X-rays







Medical DeductibleHow much you’ll pay each year before we start paying for some services;

deductible is doubled for family policies, no matter how many are covered

$2,000 $16,300 $8,150 $16,300

Prescription Deductible $1,000 per person No separate drug deductible


20% 60% 0% 60%



$5,500 $81,500 $8,150 $81,500


Name Prescriptions4 $30 after deductible

$0 after deductible

Non-Preferred Brand Name Prescriptions4 $50 after deductible

Preferred Specialty Drugs 30% after deductible

Non-Preferred Specialty Drugs 50% after deductible

1 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 and related diagnoses. 2 For treatment of emergency medical conditions as defined in the policy, Blue Cross will provide in-network benefits for covered services. 3 Includes physical, occupational, and speech therapy services. You have a total of 20 in- and out-of-network visits for covered rehabilitative therapy services per member per year and a total of 20 in- and out-of-network visits for covered habilitative therapy services per member per year. 4 Prescription drug coverage includes a generic substitution requirement. If you or your doctor requests a brand-name prescription when a generic equivalent is available, you are responsible for paying the difference between the allowed cost of the generic drug and the brand-name drug and any applicable brand-name copayment. The extra costs do not count toward your out-of-pocket maximum. You or your healthcare provider can ask Blue Cross to review this policy on a case-by-base basis.

*Catastrophic plans are only available to people under the age of 30 or to people who qualify for a hardship exemption through the Idaho health insurance exchange. Visit yourhealthidaho.org for more information on catastrophic coverage.



Note: Members of Native American tribes qualify for a separate CSR. See pages 10 and 11 for details.

Cost-Sharing Reductions can help you save even more on your out-of- pocket insurance costs.

In addition to your tax credit, you may qualify for even more savings on your health insurance costs, depending on your income and family size. These savings make your deductibles, coinsurance and copays less expensive.

Use the chart on the next page to see which CSR level you may qualify for.

To take advantage of these savings, make sure you:

• Apply for your health insurance plan through Your Health Idaho. You can find them online at yourhealthidaho.org or call 1-855-944-3246.

• Choose one of the Silver plans listed on the following pages.


The combination of your family size and household income determines whether you’re eligible for a premium tax credit and cost-sharing reduction.

MONTHLY PREMIUM TAX CREDIT COST-SHARING REDUCTION

Family Size Annual Household Income Annual Household Income1 $12,490 – $49,960 $12,490 – $31,225

2 $16,910 – $67,640 $16,910 – $42,275

3 $21,330 – $85,320 $21,330 – $53,325

4 $25,750 – $103,000 $25,750 – $64,375

5 $30,170 – $120,680 $30,170 – $75,425

6 $34,590 – $138,360 $34,590 – $86,475

7 $39,010 – $156,040 $39,010 – $97,525

8 $43,430 – $173,720 $43,430 – $108,575

MONTHLY PREMIUM TAX CREDITDepending on your income, you may qualify for a tax credit, also known as a subsidy. If you qualify, the government will pay part of your monthly premium, which could result in major savings for you. Use the first column in the chart below to see if you qualify. You can also estimate your savings at Idaho’s health insurance marketplace, Your Health Idaho, at yourhealthidaho.org.

COST-SHARING REDUCTIONYou may also be eligible for cost-sharing reduction (CSR) plans that lower the amount you pay out of your own pocket for deductibles, coinsurance and copays. Use the second column in the chart below to see if you qualify. If you do, turn to pages 8 - 9 to see what your out-of-pocket costs could look like.

IMPORTANT: If you qualify for a tax credit or cost-sharing reduction, you need to purchase your plan at yourhealthidaho.org to take advantage of your savings. However, you can still work with a local insurance agent or a Blue Cross of Idaho sales rep to find the right plan.


*�Benefit�details�are�for�in-network�coverage�only.�Your Health Idaho will determine your actual CSR eligibility. This is not a comprehensive list of benefits. See the plan contract for a full list of benefits and coverage details.

CSR LEVEL 73

Family Size Annual Household Income

1 $24,980 - 31,225

2 $33,820 - 42,275

3 $42,660 - 53,325

4 $51,500 - 64,375

5 $60,340 - 75,425

6 $69,180 - 86,475

7 $78,020 - 97,525

8 $86,860 - 108,575

CSR LEVEL 87


1 $18,735 - 24,980

2 $25,365 - 33,820

3 $31,995 - 42,660

4 $3,8625 - 51,500

5 $45,255 - 60,340

6 $51,885 - 69,180

7 $58,515 - 78,020

8 $65,145 - 86,860

CSR LEVEL 94


1 $12,490 - 18,735

2 $16,910 - 25,365

3 $21,330 - 31,995

4 $25,750 - 38,625

5 $30,170 - 45,255

6 $34,590 - 51,885

7 $39,010 - 58,515

8 $43,430 - 65,145


CSR LEVEL 73

CSR LEVEL 87

CSR LEVEL 94

WHAT YOU PAY IN NETWORK




$20 $20 $10Urgent Care Visits

Specialist Visits (w/referral) $50 $50 $20

Preferred Generic Prescriptions $5 $5 $5Non-Preferred Generic

Prescriptions $10 $10 $10

Immunizations$0 $0 $0

Preventive CareDiabetes Education $20 $20 $20

Outpatient Mental Health and Substance Abuse Visits

$20 $20 $10Applied Behavior

Analysis Visits1

OTHER BENEFITS YOU MIGHT NEEDEmergency Room Visits2 $350 after

deductible$350 after deductible



$250, then applicable

coinsurance after deductible





Lab Work and X-rays

20% coinsurance after deductible



Surgery (doctors charges, anesthesia and other covered

charges)

Having a Baby (pregnancy care, delivery and after care)

Therapy Visits3 (physical, speech and occupational)

HOW MUCH YOU’LL PAY FOR THE CARE YOU RECEIVE EACH YEAR

Medical Deductible

What you’ll pay each year before we start paying for some services; eductible is doubled for family policies,


$4,000 $750 $300

Prescription Deductible No separate drug deductible

No separate drug deductible

No separate drug deductible

CoinsuranceThe percent you’ll pay for covered services;

we’ll pay the other part

20% 20% 20%


The most you’ll pay out of pocket each year for covered care and prescriptions; maximum is doubled for family

policies, no matter how many are covered

$6,500 $2,500 $950

IN CASE YOU NEED BRAND NAME OR SPECIALTY PRESCRIPTIONS Preferred Brand

Name Prescriptions4$30 after

deductible$30 after

deductible$30 after

deductible

Non-Preferred Brand Name Prescriptions4




Preferred Specialty Drugs




Non-Preferred Specialty Drugs





1 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 or related diagnoses.2 For treatment of emergency medical conditions as defined in the policy, Blue Cross of Idaho will provide in-network benefits for covered services. 3 Includes physical, occupational, and speech therapy services. You have a total of 20 in- and out-of-network visits for covered rehabilitative therapy services per member per year and a total of 20 in- and out-of-network visits for covered habilitative therapy services per member per year. 4 Prescription drug coverage includes a generic substitution requirement. If you or your doctor requests a brand-name prescription when a generic equivalent is available, you are responsible to pay the difference between the allowed cost of the generic drug and the brand-name drug and any applicable brand-name copayment. The extra costs do not count toward your deductible or out-of-pocket maximum. You or your provider can ask Blue Cross of Idaho to review this policy on a case-by-case basis.



CSR LEVEL 73

CSR LEVEL 87

CSR LEVEL 94

CSR LEVEL 73

CSR LEVEL 87

CSR LEVEL 94




WHAT YOU PAY IN-NETWORK




$20 $20 $5 $35 $30 $5Urgent Care Visits

Specialist Visits (w/referral) $50 $50 $10 $55 $50 $10

Preferred Generic Prescriptions $5 $5 $5 $5 $5 $5

Non-Preferred Generic Prescriptions $10 $10 $10 $10 $10 $10

Immunizations$0 $0 $0 $0 $0 $0

Preventive CareDiabetes Education $20 $20 $20 $20 $20 $20


$20 $20 $5 $35 $30 $5Applied Behavior

Analysis Visits1

OTHER BENEFITS YOU MIGHT NEEDEmergency Room Visits2 $350 after

deductible$350 after deductible


















Lab Work and X-Rays







Surgery (doctors charges, anesthesia and other covered

charges)

Having a Baby (pregnancy care, delivery and after care)

Therapy Visits3 (physical, speech and occupational)


Medical DeductibleWhat you’ll pay each year before we start paying for some services; eductible is doubled for family policies,


$4,000 $750 $50 $3,500 $750 $0

Prescription Deductible $1,000 $250 $150 $1,000 $250 $150


30% 20% 20% 30% 20% 20%

Out-of-Pocket MaximumThe most you’ll pay out of pocket each year for covered care and prescriptions;

maximum is doubled for family policies, no matter how many are covered

$6,500 $2,000 $950 $6,500 $2,000 $900


Name Prescriptions4$30 after

deductible$30 after

deductible$30 after

deductible$30 after

deductible$30 after

deductible$30 after

deductible

Non-Preferred Brand Name Prescriptions4







Preferred Specialty Drugs







Non-Preferred Specialty Drugs








The Affordable Care Act (ACA) offers Native Americans health insurance benefits and greater access to healthcare.

We know your access to Indian Health Services (IHS), tribal clinics and other Urban Indian Health Programs (UIHP) is critical to you. A private health plan with Blue Cross of Idaho does NOT impact your eligibility for these programs. In fact, a private health insurance plan provides you and your family greater access to services IHS or UIHPs may not provide, like emergency room services, maternity and newborn care, annual doctors visits and preventive screenings.

The ACA includes specific provisions dedicated to Native Americans, including financial assistance that may greatly reduce your monthly health insurance costs. You might even qualify for healthcare coverage through Medicare, Medicaid or the Children’s Health Insurance Program (CHIP). To find out if you qualify, visit Your Health Idaho (yourhealthidaho.org).

If you are eligible for a Tribal Health Insurance Plan, you may enroll in a plan at any time of year. Research the plans, find the coverage that fits your budget and your family’s medical needs. Once you have selected a plan, you are ready to apply.

TRIBAL Health Insurance Plans are only available through Idaho’s health insurance marketplace, Your Health Idaho at yourhealthidaho.org. Visit yourhealthidaho.org to learn more and to sign up for coverage.


SUPPORT FROM LOCAL NETWORKSWhen you choose a Blue Cross of Idaho managed care plan, you must choose a primary care provider (PCP) from your local network to serve as your care coordinator and provide referrals to visit specialists or other healthcare providers. The following benefit grids outline common in-network and out-of-network services, and are not comprehensive lists of benefits. For more information, please visit bcidaho.com/SBC to review a Summary of Benefits and Coverage.

The two plans shown below show the differences in benefits between the Bronze 8150 Tribal and the Bronze 8150 Tribal 0 (with a cost-sharing reduction). Tribal plans without a cost-sharing reduction come with the same out-of-pocket costs as Blue Cross of Idaho’s Individual and Family metal level plans found on pages 2 - 5.

1Treatment 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 or related diagnoses.

2 For treatment of emergency medical conditions as defined in the policy, Blue Cross of Idaho will provide in-network benefits for covered services.

3Includes physical, occupational, and speech therapy services. You have a total of 20 in- and out-of-network visits for covered rehabilitative therapy services per member per year and a total of 20 in- and out-of-network visits for covered habilitative therapy services per member per year.

4Prescription drug coverage includes a generic substitution requirement. If you or your doctor requests a brand-name prescription when a generic equivalent is available, you are responsible to pay the difference between the allowed cost of the generic drug and the brand-name drug and any applicable brand-name copayment. The extra costs do not count toward your deductible or out-of-pocket maximum. You or your provider can ask Blue Cross of Idaho to review this policy on a case-by-case basis.

BRONZE 8150 TRIBAL BRONZE 8150 TRIBAL 0What You Pay

In NetworkWhat You Pay

Out of NetworkWhat You Pay

In NetworkWhat You Pay

Out of NetworkBENEFITS YOU ARE MOST LIKELY TO NEED

Primary Care Visits$40


You may owe the difference between what you are billed and what we allow.


(w/referral) $65

Prescriptions (generic only) $15 $15 $0

Immunizations$0

$0

Preventive Care


Diabetes Education $20


$40Applied Behavior

Analysis Visits1

OTHER BENEFITS YOU MIGHT NEEDEmergency Room Visits

$0 after deductible


$0

You may owe the difference between what you are billed and what we allow.



Lab Work and X-RaysSurgery (doctors charges,

anesthesia, and other covered charges)


delivery and after care)

Therapy Visits3 (PT, ST, and OT)


Medical DeductibleHow much you’ll pay each year before we start paying for some services; deductible

is doubled for family policies, no matter how many are covered

$8,150 $16,300 $0 $0

Prescription Deductible No separate drug deductible No separate drug deductible


0% 60% 0% 0%

Out-of-Pocket MaximumThe most you’ll pay out of pocket each year for covered care and prescriptions;

maximum is doubled for family policies, no matter how many are covered

$8,150 $81,500 $0 $0


Name Prescriptions4 $35

$0 $0

Non-Preferred Brand Name Prescriptions4 $50

Preferred Specialty Drugs 30%

Non-Preferred Specialty Drugs 50%


HOW YOUR PLAN WILL WORK Your PCP will be the one you turn to most when you need care. Choosing one you trust is key to starting your health journey off right.

A PCP can be a healthcare provider from family and general practice, primary care, internal medicine, obstetrics and gynecology or pediatrics. Which PCP specialty you should choose depends on your health, medical history and needs. Feel free to ask a healthcare professional you know for a recommendation. One of your current medical providers may already be eligible to serve as your PCP.

If you don’t know who to choose, we can help. You can use our online Provider Finder at bcidaho.com/ findaprovider to search for PCPs near you. You also can call our sales team at 1-888-GO-CROSS (1-888-462-7677).

Choosing a Primary Care Provider

Your PCP will refer you for care he or she cannot provide, such as care not available in your network, or care you’ll need while away from home. He or she can help you save money by helping you avoid services you don’t need.

If you need to see a specialist, your first call should be to your PCP. Your PCP may see you in the office first or send you directly to a specialist. While it may seem like a waste of time to see your PCP first, your PCP can help save you time and money by sending you to the right specialist the first time.

Referrals Help Save You Money

MORE PRESCRIPTIONS, LESS MONEY

Prescription drug prices can be expensive. Our solution to help you save money is a tiered system with hundreds of drugs in the lowest-cost tier. Ask your doctor if drugs from this tier would work for you.

To search your drug list, visit members.bcidaho.com, select Prescription�Drugs,�Benefits�and�Coverage. Choose Formulary�Information for the current year.

Your Blue Cross of Idaho plan comes with an important protection. In an emergency, it doesn’t matter what emergency room (ER) you choose. Your plan treats emergencies at all hospitals as if they were in your network.* For care that is urgent but not an emergency, you can take your pick from any nearby urgent care and we will treat the clinic as an in-network provider.

* If you end up at an ER or urgent care clinic that doesn’t belong to one of our local networks, they are allowed to charge you for the difference between what they bill and the amount Blue Cross of Idaho allows for that service. This is called balance billing. Obviously, sometimes you don’t get to pick where the ambulance takes you. But if you can, use your Provider Finder to locate a nearby in-network facility to save you more.

In an Emergency,Network Doesn’t Matter

HOW YOUR PLAN WILL WORK

With your PCP at the center of your care, you’re connected to the local doctors, specialists, clinics, pharmacies and hospitals that are part of your network. These providers are right where you live. You’ll pay less to see them because they’ve agreed to charge lower rates to be part of your network.

If you need healthcare that can’t be found in your home network, your PCP and Blue Cross of Idaho will work together to make sure you get that necessary care at in-network prices.

And because staying healthy means trying to prevent disease and illness, your plan includes no-cost preventive care and preventive drugs, hospital and emergency services and hundreds of experienced providers waiting to serve you. Please visit bcidaho.com/findaprovider to explore your new network.

Local Care Where You Are



P lans Ava i lab le

NORTH IDAHO Clearwater Provider Network (CPN)

The Clearwater Provider Network includes over 230 providers representing 19 healthcare specialties. CPN includes St. Joseph Regional Medical Center, Gritman Medical Center,

Clearwater Valley Hospital and St. Mary’s Hospital.

Kootenai Care Network (KCN)The Kootenai Care Network provides a comprehensive range of medical services

to patients, and access to over 400 providers practicing medicine in more than 50 specialties. KCN includes Kootenai Health.

Hometown North Provider Network (HNPN)Hometown North Provider Network is an association of local healthcare professionals, facilities and clinics across northern Idaho. The HNPN includes Benewah Community Hospital, Bonner General, Boundary Community,

Clearwater Valley, Gritman Medical Center, Kootenai Health, Northern Idaho Advanced Care, Shoshone Medical Center, St. Joseph Regional Medical Center, St. Mary’s Hospital and Syringa Hospital.

If your county shows a checkmark, that means that you may buy a plan with that network.

If your county shows a shaded box that means there are providers in that area where you may receive in-network services.

Plans in this network are available to buy

Gold plan in that network is also available

In-network primary care providers and specialists are available

* More information about the St Luke’s Health Partners (SLHP) network is available on pages 15 and 16.

SLHP* KCN CPN HNPN

Adams

Benewah

Bonner

Boundary

Clearwater

Idaho

Kootenai

Latah

Lewis

Nez Perce

Shoshone

Our networks are designed to offer more choices for those who like to travel into neighboring counties. Search for your county in the following chart.


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SOUTHWEST IDAHO Independent Doctors of Idaho (IDID)

Independent Doctors of Idaho is made up of more than 500 providers, including over 160 primary care providers and 375 specialists in orthopedics, gastroenterology, psychiatrics

and more. IDID includes access to 11 hospitals and surgery centers and 16 urgent care centers.

Saint Alphonsus Health Alliance (SAHA)Saint Alphonsus Health Alliance includes more than 2,000 highly skilled

providers, including those at Saint Alphonsus Medical Center. The Alliance has over 700 primary care providers and 1,280 specialty care providers. The Alliance includes access to 18 hospitals and surgery centers, and more than 30 urgent care centers.

St. Luke’s Health Partners (SLHP)St. Luke’s Health Partners serves southwest Idaho with more than 3,000 providers. SLHP includes 17 hospitals and 34 urgent care centers. SLHP also serves counties in north and central Idaho. See page 15 for north Idaho and next page for central Idaho.

SLHP* IDID SAHA

Ada

Boise

Canyon

Elmore

Gem

Owyhee

Payette

Valley

Washington

Our networks are designed to offer more choices for those who like to travel into neighboring counties.Our networks are designed to offer more choices for those who like to travel into neighboring counties. Search for your county in the following chart.






* St. Luke’s Health Partners (SLHP) network serves additional counties in central Idaho. See pages 14 and 16.


P lans Ava i lab le

CENTRAL IDAHO Hometown East Provider Network (HEPN)

Hometown East Provider Network consists of local healthcare professionals, facilities and clinics in central and eastern Idaho. HEPN includes Bear Lake Memorial, Bingham Memorial,

Caribou Memorial, Cassia Regional, Eastern Idaho Regional Medical Center, Franklin County Medical Center, Lost Rivers District, Madison Memorial, Minidoka Memorial,

Mountain View, Nell J Redfield Memorial, North Canyon Medical Center, Portneuf Medical Center, Power County, Steele Memorial and Teton Valley Health

Care hospitals.

Patient Quality Alliance (PQA)Patient Quality Alliance is supported by more than 700 highly skilled providers, including those at Caribou Memorial, Mountain View Hospital, Nell J Redfield Memorial, Portneuf Medical Center and Power County Hospital District.

St. Luke’s Health Partners (SLHP)St. Luke’s Health Partners serves southwest and central Idaho with more than 3,000 providers. SLHP includes 17 hospitals and 34 urgent care centers. SLHP serves additional counties in north and southwest Idaho.

HEPN PQA* SLHP**

Blaine

Butte

Camas

Cassia

Custer

Gooding

Jerome

Lemhi

Lincoln

Minidoka

Twin Falls






* More information about Patient Quality Alliance (PQA) network is available on page 17.

* * St. Luke’s Health Partners network serves additional Idaho counties. See page 14 and 15.



Plans Ava i lab le

EASTERN IDAHO






* HEPN and PQA serve additional counties in central Idaho. See page 16.

Hometown East Provider Network (HEPN)Hometown East Provider Network consists of local healthcare professionals, facilities and clinics

in central and eastern Idaho. HEPN includes Bear Lake Memorial, Bingham Memorial, Caribou Memorial, Cassia Regional, Eastern Idaho Regional Medical Center, Franklin County Medical

Center, Lost Rivers District, Madison Memorial, Minidoka Memorial, Mountain View, Nell J Redfield Memorial, North Canyon Medical Center, Portneuf Medical Center, Power

County, Steele Memorial, and Teton Valley Health Care hospitals. HEPN serves additional counties in central Idaho. See page 13.

Mountain View Network (MVN)Mountain View Network is supported by over 350 medical professionals, including Mountain View Hospital, Madison Memorial Hospital and Portneuf Medical Center.

Patient Quality Alliance (PQA)Patient Quality Alliance is supported by more than 700 highly skilled providers,

including those at Caribou Memorial, Mountain View Hospital, Nell J Redfield Memorial, Portneuf Medical Center and Power County Hospital District. PQA serves additional counties in central Idaho.

HEPN* MVN PQA*

Bannock

Bear Lake

Bingham

Bonneville

Caribou

Clark

Franklin

Fremont

Jefferson

Madison

Oneida

Power

Teton



Purchase a Plan ONLINEComplete the enrollment process at shoppers.bcidaho.com.

IN PERSONVisit an enrollment center in Coeur d’Alene, Meridian, Twin Falls, Pocatello or Idaho Falls and ask a sales representative to walk you through the process in person.

WITH A DIRECT SALES REPRESENTATIVECall us at 1-888-GO-CROSS (1-888-462-7677).

WITH AN AGENTFind an insurance agent near you at shoppers.bcidaho.com.

Ready to buy? Here are three ways to apply.

Open Enrollment

Open Enrollment starts November 1 and ends December 16, 2019.

Sign up for coverage.

DECEMBER 16

If open enrollment is over, you can still get healthcare coverage if you experience a qualifying life event like having a baby, getting married, adopting a child, or losing coverage through your employer.

Learn more about qualifying life events and how to enroll during a special enrollment period by contacting a local insurance agent or calling our sales team at 1-888-GO-CROSS (1-888-462-7677). If you don’t have a qualifying life event, but still need healthcare coverage, our non-renewable short term plans might be a good choice. See the opposite page for more information on short-term coverage.

If you’re eligible for a tax credit or cost-sharing reduction, you can only purchase your plan at yourhealthidaho.org. See page 19 for more information on short-term coverage.


A Healthier Smile

Good oral health is a key part of your overall health, so Blue Cross of Idaho offers flexible and affordable dental insurance plans that enhance your medical insurance coverage.

Our Dental Choicesm and Dental Choice Plussm plans feature low deductibles and out-of-pocket maximums, and meet all Affordable Care Act (ACA) requirements. We also offer flexible, affordable dental coverage in three benefit tiers in our Healthy Smilessm Preventive, Plus, and Preferred plans.

Learn more about our dental plans by calling your insurance agent, or the Blue Cross of Idaho sales team at 1-888-GO-CROSS (1-888-462-7677) or visit shoppers.bcidaho.com.

Dental Coverage

Covering the Gap

For those that are between plans and need temporary options for medical insurance, Blue Cross of Idaho offers short-term coverage at affordable rates to help bridge the coverage gap.

Learn more about these plans by calling our sales team at 1-888-GO-CROSS (1-888-462-7677) or visiting bcidaho.com/short_term.

Short-term Coverage


DETAILS ABOUT OUR PLANS

How we protect your personal information• We keep all of your personal information

private and confidential.

• We only allow access to your personal information by our employees and business partners when needed to conduct business for you.

• We only disclose your personal information to conduct business for you, when we are required by law or if you (or your personal representative) give us permission.

• For detailed information about our privacy practices see the Blue Cross of Idaho Notice of Privacy Practices on our website at bcidaho.com/about_us/privacy_policy.asp.

Prior AuthorizationSome services require prior approval and your physician will request our review prior to receiving services. When you are in the hospital, we may also work with the hospital and your physician to determine when you are ready to return home. Some procedures are reviewed after the claim is submitted to Blue Cross of Idaho, to evaluate eligibility for coverage. The appeals process is available to you are all times, if you do not agree with a coverage decision. You do not need prior authorization in emergency situations.

What if I don’t have prior authorization?We want you to receive the best care at the right time and place. We also want to ensure you receive the right technology that addresses your particular clinical issue. We’re here to work with you, your doctor and the facility so you have the best possible health outcome. If you receive services that are not medically necessary from one of Blue Cross of Idaho’s contracting providers without getting prior authorization and payment for the services is denied, you are not financially responsible. However, if you receive services that are not medically necessary from a provider not contracting with Blue Cross of Idaho, you may be responsible for the entire cost of the services.

Who determines if the service is approved?Our team of licensed physicians, registered nurses, and pharmacy technicians receives and reviews all prior authorization requests. Typically, they complete this review within two business days, and notify the member and his or her healthcare provider of their decision. Prior authorization is not a guarantee of payment or coverage. It is a pre-service approval based on information provided to Blue Cross of Idaho at the time the request is made. Blue Cross of Idaho retains the right to review

the medical necessity of services, eligibility for services, and benefit limitations and exclusions after you receive the services.

Important Information About Your Prescription Drug CoverageYour Blue Cross of Idaho health insurance plan comes with a list of drugs approved for coverage under your pharmacy benefit. This is also called a “formulary.” This prescription drug list can help you better understand your coverage and how it works. You can get a copy of our formulary for any of our plans at shoppers.bcidaho.com. Select Health & Wellness from the top menu, then Pharmacy Management. Then select Prescription Drugs from the right navigation menu, then Individual & Family Medical Prescriptions. (If you don’t have internet access, you can also call Blue Cross of Idaho’s Customer Service Department at 855-230-6862.)

In most cases, you are responsible to pay a portion of the cost of each prescription drug you have filled. Your cost is determined by the formulary tier assignment of the drug, and the benefit your plan assigns to that tier. Members can find a copy of Blue Cross of Idaho’s pharmaceutical management procedures and check the pharmacy coverage provided by their plan by logging in to the members’ website at members.bcidaho.com.

EXCLUSIONS AND LIMITATIONS* In addition to the exclusions and limitations listed elsewhere in this Plan Guide, the following exclusions and limitations apply to the entire Contract, unless otherwise specified:

General Exclusions and Limitations • 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 Member. However, the Member 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 Member has a non dental, life endangering condition which makes hospitalization necessary to safeguard the Member’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 Member 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 Member claims such benefits or compensation or recovers losses from a third party.

• Provided or paid for by any federal governmental entity except when payment under the Contract is expressly required by federal law, or provided or paid for by any state or local governmental entity where its charges therefore would vary, or are or would be affected by the existence of coverage under the Contract, or for which payment has been made under Medicare Part A and/or Medicare Part B, or would have been made if a Member had applied for such payment except when payment under the Contract is expressly required by federal law.

• 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 Member by blood or marriage and who ordinarily dwells in the Member’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.

• For Surgery intended mainly to improve appearance or for complications arising from Surgery intended mainly to improve appearance, except for:

o Reconstructive Surgery necessary to treat an Accidental Injury, infection or other Disease of the involved part; or

o Reconstructive Surgery to correct Congenital Anomalies in a Member who is a dependent child.

• Rendered prior to the Member’s Effective Date.

Do not apply to Blue Cross of Idaho dental or short-term plans. See those policies for a full list of exclusions and limitations. Policy numbers: 18-079-01/18, 18-080-01/18, 18-081-01/18, 3-073P-10/10, 3-074P-10/10, 3-075P-10/10, 3-420-10/18, 3-519-10/18, 3-52-10/18, 3-521-10/18, 18-917-10/18, 18- 918-10/18, 18-919-10/18.


• For personal hygiene, comfort, beautification (including non-surgical services, drugs, and supplies intended to enhance the appearance) even if prescribed by a Physician.

• For exercise or relaxation 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, massage therapy, hot tubs, whirlpool baths, waterbeds or swimming pools.

• For convenience items including but not limited to Durable Medical Equipment such as bath equipment, cold therapy units, duplicate items, home traction devices, or safety equipment.

• 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.

• For telephone consultations, and all computer or Internet communications, except as specified as a Covered Service in the Contract.

• For failure to keep a scheduled visit or appointment; for completion of a claim form; for interpretation services; or for personal mileage, transportation, food or lodging expenses, unless specified as a Covered Service in the Contract, 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, Therapy Services, or Physical Rehabilitation, except as specified in the Contract; or for Inpatient admissions when the Member is ambulatory and/or confined primarily for bed rest, a special diet, 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 the Contract.

• 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).

• 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 the Contract;

• 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 hearing aids or examinations for the prescription or fitting of hearing aids, except as specified as a Covered Services in the Contract.

• For orthoptics, eyeglasses or contact lenses or the vision examination for prescribing or fitting eyeglasses or contact lenses, unless specified as a Covered Service in the Contract.

• For any treatment of sexual dysfunction, or sexual inadequacy, including erectile dysfunction and/or impotence.

• Made by a Licensed General Hospital for the Member’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 nursing home, a convalescent home, or a rest home.

• For Acute Care, Rehabilitative care, diagnostic testing, except as specified as a Covered Service in the Contract; for Mental or Nervous Conditions and Substance Abuse or Addiction services not recognized by the American Psychiatric and American Psychological Association.

• For weight loss or weight control. For reversals or revisions of Surgery for obesity, except when required to correct an immediately life-endangering condition.

• For an elective abortion, unless it is the recommendation of one consulting Physician that an abortion is necessary to save the life of the mother, or if the pregnancy is a result of rape as defined by Idaho law, or incest as determined by the court.

• 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 the Contract.

• For the reversal of sterilization procedures, including but not limited to, vasovasostomies or salpingoplasties.

• Treatment for reproductive 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 a Member’s reproductive ability, including but not limited to

laboratory services, radiology services or similar services related to treatment for reproduction procedures.

• For Transplant Services and Artificial Organs, except as specified as a Covered Service in the Contract.

• 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. Additionally, reversals, revisions, and/or complications of such surgical procedures are excluded, except when required to correct an immediately life endangering condition.

• For Hospice, except as specified as a Covered Service in the Contract.

• For pastoral, spiritual, bereavement or marriage counseling.

• For homemaker and housekeeping services or home delivered meals.

• 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.

• Any services or supplies for which a Member would have no legal obligation to pay in the absence of coverage under the Contract or any similar coverage; or for which no charge or a different charge is usually made in the absence of insurance coverage; or charges in connection with work for compensation or charges for which reimbursement or payment is contemplated under an agreement 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 physical; or a screening examination including routine hearing examinations, except as specified as a Covered Service in the Contract.

• For immunizations, except as specified as a Covered Service in the Contract.

• 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 a Member.


• For vitamins and minerals, unless required through a written prescription and cannot be purchased over the counter.

• For alterations or modifications to a home or vehicle.

• For special clothing, including shoes (unless permanently attached to a brace).

• 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 the Contract.

• For Outpatient pulmonary and/or cardiac Rehabilitation.

• For complications arising from the acceptance or utilization of services, supplies or procedures that are not a Covered Service.

• For the use of Hypnosis, as anesthesia or other treatment, except as specified as a Covered Service.

• 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.

• For Dentistry or Dental Treatment, 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 the Contract.

• For procedures including but not limited to breast augmentation, liposuction, Adam’s apple reduction, rhinoplasty and facial reconstruction and other procedures considered cosmetic in nature.

• Any newly FDA approved Prescription Drug, biological agent, or other agent until it has been reviewed and implemented by Blue Cross of Idaho’s Pharmacy and Therapeutics Committee.

• For the treatment of injuries sustained while operating a motor vehicle under the influence of alcohol and/or narcotics. For purposes of the Contract exclusion, “Under the influence” as it relates to alcohol means having a whole blood alcohol content of .08 or above or a serum blood alcohol content of .10 or above as measured by a laboratory

approved by the State Police or a laboratory certified by the Centers for Medicare and Medicaid Services. For purposes of the Contract exclusion, “Under the influence” as it relates to narcotics means impairment of driving ability caused by the use of narcotics not prescribed or administered by a Physician.

• All services, supplies, devices and treatment that are not FDA approved.

• Any services, interventions occurring within the framework of an educational program or institution; or provided in or by a school/educational setting; or provided as a replacement for services that are the responsibility of the educational system.

Hospice Exclusions and Limitations• In addition to any other exclusions and

limitations of the Contract, the following exclusions and limitations apply to Hospice Services. No benefits are available under the Contract for the following:

• Hospice Services not included in a Hospice Plan of Treatment and not provided or arranged and billed through a Hospice.

• Continuous Skilled Nursing Care except as specifically provided as a part of Continuous Crisis Care or Respite Care.

• Hospice benefits provided during any period of time in which a Member is receiving Home Health Skilled Nursing Care benefits.

Pediatric Vison Care Exclusions and Limitations• In addition to any other exclusions and

limitations of the Contract, the following exclusions and limitations apply to Pediatric Vision Care Benefits Section. No benefits are available for professional services or materials connected with:

• Orthoptics or other vision training and any associated supplemental testing; Plano Lenses; or two (2) pair of eyeglasses in place of bifocals.

• Replacement of Lenses, Frames or Contact Lenses furnished hereunder that are lost or broken (Lenses, Frames or Contact Lenses are only replaced at the normal intervals when Covered Services are otherwise available).

• Medical or surgical treatment of the eye(s).

• Any eye examination or any corrective eyewear required by an employer as a condition of employment.

• Low vision aids.

Prescription Drug Exclusions and Limitations• In addition to any other exclusions and

limitations of the Contract, the following exclusions and limitations apply to Prescription Drug Services. No benefits are available under the Contract for the following:

• Drugs used for the termination of early pregnancy, and complications arising therefrom, except when required to correct an immediately life-endangering condition.

• Over-the-counter drugs other than insulin, even if prescribed by a Physician. Notwithstanding this exclusion, Blue Cross of Idaho, through the determination of the Blue Cross of Idaho Pharmacy and Therapeutics Committee may choose to cover certain over-the-counter medications when Prescription Drug benefits are provided under the Contract. Such approved over-the-counter medications must be identified by Blue Cross of Idaho in writing and will specify the procedures for obtaining benefits for such approved over-the-counter medications. Please note that the fact a particular over-the-counter drug or medication is covered does not require Blue Cross of Idaho to cover or otherwise pay or reimburse the Member for any other over-the-counter drug or medication.

• Charges for the administration or injection of any drug, except for vaccinations listed on the Prescription Drug Formulary.

• Therapeutic devices or appliances, including hypodermic needles, syringes, support garments, and other non-medicinal substances except for Diabetic Supplies, regardless of intended use.

• Drugs labeled “Caution—Limited by Federal Law to Investigational Use,” or experimental drugs, even though a charge is made to the Member.

• Immunization agents, except for vaccinations listed on the Prescription Drug Formulary, biological sera, blood or blood plasma. Benefits may be available under the Medical Benefits Section of the Contract.

• Medication that is to be taken by or administered to a Member, in whole or in part, while the Member is an Inpatient in a Licensed General Hospital, rest home, sanatorium, Skilled Nursing Facility, extended care facility, convalescent hospital, nursing home, or similar institution which operates or allows to operate on its premises, a facility for dispensing pharmaceuticals.

• Any prescription refilled in excess of the number specified by the Physician, or any refill dispensed after one (1) year from the Physician’s original order.

• Any Prescription Drug, biological or other agent which is:


o Prescribed primarily to aid or assist the Member in weight loss, including all anorectics, whether amphetamine or nonamphetamine.

o Prescribed primarily to retard the rate of hair loss or to aid in the replacement of lost hair.

o Prescribed primarily to increase fertility, including but not limited to, drugs which induce or enhance ovulation.

o Prescribed primarily for personal hygiene, comfort, beautification, or for the purpose of improving appearance.

o Prescribed primarily to increase growth, including but not limited to, growth hormone.

o Provided by or under the direction of a Home Intravenous Therapy Company, Home Health Agency or other Provider approved by Blue Cross of Idaho. Benefits are available for this Therapy Service under the Medical Benefits Section of the Contract only.

• Lost, stolen, broken or destroyed Prescription Drugs except in the case of loss due directly to a natural disaster.

Transplant Exclusions and Limitations• In addition to any other exclusions and

limitations of the Contract, the following exclusions and limitations apply to Transplant or Autotransplant Services. No benefits are available under the Contract for the following:

• Transplants of brain tissue or brain membrane, islet tissue, 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.

• Any eligible expenses of a donor related to donating or transplanting an organ or tissue unless the recipient is a Member who is eligible to receive benefits for Transplant Services.

• The cost of a human organ or tissue that is sold rather than donated to the recipient.

• Transportation costs including but not limited to, Ambulance Transportation Service or air service for the donor, or to transport a donated organ or tissue.

• Living expenses for the recipient, donor, or family members, except as specifically listed as a Covered Service in the Contract.

• 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.

• Costs related to the search for a suitable donor.

• No benefits are available for services, expenses, or other obligations of or for a deceased donor (even if the donor is a Member).

• Out-of-Area Care - Outside the state of Idaho Provider Reimbursement

• A Contracting Provider rendering Covered Services shall not make an additional charge to a Member for amounts in excess of Blue Cross of Idaho’s payment except for Deductibles, Coinsurance, Copayments, and noncovered services.

• For Covered Services furnished outside the state of Idaho by a Provider who has an agreement for claims payment with the Blue Cross and/or Blue Shield plan in the area where the Covered Services were rendered, Blue Cross of Idaho shall pay the local Blue Cross and/or Blue Shield plan’s contractual charge or the actual charge, whichever is less, minus the Member’s Copayment, Deductible, and/or Coinsurance, as applicable.

• For Covered Services furnished outside the state of Idaho by a Provider who does not have an agreement for claims payments with the Blue Cross and/or Blue Shield plan in the area where the Covered Services were rendered, Blue Cross of Idaho shall pay the Maximum Allowance minus the Member’s Copayment, Deductible, and/or Coinsurance, as applicable. The Member may be responsible for charges that exceed the Maximum Allowance.

Referral Procedures• To receive Covered Services at the In-

Network benefit level, a referral is required for Covered Services not provided by the Member’s Primary Care Provider (PCP). It is the PCP’s responsibility to evaluate conditions or request for referral and make referrals based on his or her medical judgment. If the PCP refers a Member to another Provider, the PCP will provide the Member with a referral. If a referral is not completed for services provided by a Non-PCP, the benefits may be paid at the Out-of-Network benefit level.

• Members may self-refer to Contracting Providers who are obstetricians and gynecologists for Covered Services for maternity care, annual visits and follow-up gynecological care for conditions diagnosed during maternity care or annual visits.

• Non-emergency Covered Services provided by a Provider not contracting with the local Blue Cross/Blue Shield plan and without referral from your PCP are eligible for Out of Network benefits.

• For non-emergency services, the Member is responsible for the Copayment, Deductible, and/or Coinsurance, as applicable, and may be responsible for any charges that exceed the Maximum Allowance when a referral is not obtained by the Member or not accepted by the Provider for services

provided by a Provider not contracting with the local Blue Cross/Blue Shield plan.

Network Gap Exception• To receive Covered Services at the

In-Network benefit level from a Noncontracting Provider, your Primary Care Provider (PCP) may request a referral from Blue Cross of Idaho when there is no Provider within your Contract’s Provider Network capable of providing the services. Blue Cross of Idaho will respond to a referral request received from either the PCP or the Member within fourteen (14) business days of the receipt of the medical information necessary to make a determination. Blue Cross of Idaho’s referral determination will be sent to both the Member and PCP. Blue Cross of Idaho will evaluate referral requests that are outside of the Contract’s Provider Network to determine if the services may be performed by an In-Network Provider. If Blue Cross of Idaho determines that there is no In-Network Provider capable of providing the service, Blue Cross of Idaho will evaluate the referred Provider in accordance with quality and efficiency standards listed on the Referrals page of the Blue Cross of Idaho Web site at: bcidaho.com/benefits-and-coverage/referrals. If the referral to the Noncontracting Provider meets this criteria, Blue Cross of Idaho will allow the network gap exception and In-Network benefits will be applied to the services.

Emergency Services• For all Emergency Services, Covered

Services provided by a Noncontracting Provider or Provider not contracting with the local Blue Cross/Blue Shield plan are eligible for In Network Services without a referral from your PCP.

• Members may self-refer for Emergency Services.

Blue Cross of Idaho and Blue Cross of Idaho Care Plus, Inc., (collectively referred to as Blue Cross of Idaho) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Blue Cross of Idaho does not exclude people or treat them differently because of race, color, national origin, age, disability or sex.Blue Cross of Idaho: • Provides free aids and services to people with

disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats)

• Provides free language services to people whose primary language is not English, such as:

o Qualified interpreters o Information written in other languages

If you need these services, contact Blue Cross of Idaho Customer Service Department. Call 1-800-627-1188 (TTY: 1-800-377-1363), or call the customer service phone number on the back of your card. If you believe that Blue Cross of Idaho has failed to provide these

services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with Blue Cross of Idaho’s Grievances and Appeals Department at:Manager, Grievances and Appeals 3000 E. Pine Ave., Meridian, ID 83642 Telephone: 1-800-274-4018 Fax: 208-331-7493 Email: grievances&[email protected] TTY: 1-800-377-1363You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, our Grievances and Appeals team is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TTY). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

ATTENTION: If you speak Arabic, Bantu, Chinese, Farsi, French, German, Japanese, Korean, Nepali, Romanian, Russian, Serbo-Croatian, Spanish, Tagalog, or Vietnamese, language assistance services, free of charge, are available to you. Call 1-800-627-1188 (TTY: 1-800-377-1363).

Form No. 3-1187 (02-20)

DISCRIMINATION IS AGAINST THE LAW

Arabic: مملحوظة: إذا كنت تتحدث العربية اذكر اللغة، فإن خدمات المساعدة اللغوية

تتوافر لك بالمجان. اتصل برقم 1188-627-800-1 )رقم هاتف الصم والبكم:1-800-377-1363).

Bantu: ICITONDERWA: Nimba uvuga Ikirundi, uzohabwa serivisi zo gufasha mu ndimi, ku buntu. Woterefona 1-800-627-1188 (TTY: 1-800-377-1363).Chinese:注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-627-1188（TTY：1-800-377-1363）。 Farsi:توجه: اگر به زبان فارسی گفتگو می کنيد، تسهيالت زبانی بصورت رايگان

برای شما فراهم می باشد. با1-800-627-1188)TTY: 1-800-377-1363( تماس بگيريد.

French: ATTENTION: Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Appelez le 1-800-627-1188 (ATS : 1-800-377-1363).German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-627-1188 (TTY: 1-800-377-1363).Japanese:注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-800-627-1188（TTY:1-800-377-1363）まで、お電話にてご連絡ください。

Korean: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-627-1188 (TTY: 1-800-377-1363)번으로 전화해 주십시오.

Nepali: ध्यान दिनुहोस्: तपार्इंले नेपाली बोल्नुहुन्छ भने तपार्इंको निम्ति भाषा सहायता सेवाहरू निःशुल्क रूपमा उपलब्ध छ । फोन गर्नुहोस ्1-800-627-1188 (टिटिवाइ: 1-800-377-1363) ।Romanian: ATENȚIE: Dacă vorbiți limba română, vă stau la dispoziție servicii de asistență lingvistică, gratuit. Sunați la 1-800-627-1188 (TTY: 1-800-377-1363).Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-627-1188 (телетайп: 1-800-377-1363).Serbo-Croatian:OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite 1-800-627-1188 (TTY- Telefon za osobe sa oštećenim govorom ili sluhom: 1-800-377-1363).Spanish:ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-627-1188 (TTY: 1-800-377-1363).Tagalog:PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-627-1188 (TTY: 1-800-377-1363).Vietnamese:CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-627-1188 (TTY: 1-800-377-1363).

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2020 INDIVIDUAL AND FAMILY HEALTH INSURANCE PLAN GUIDE · If you need help, call your insurance agent or talk to Blue Cross of Idaho sales team today at 1-888-GO-CROSS (1-888-462-7677)