Medical-Blue Cross of Idaho

Other Benefit Summaries:

MEDICAL-BCI MEDICAL-GH DENTAL DENTAL-WILL. VISION LIFE-ACTIVES LIFE-RETIREES
SUPP LIFE STD LTD EAP

Blue Cross of Idaho Medical Plan July 1, 2008 - July 1, 2009
Information provided is in summary format. Any difference between the summary provided and actual contract will be settled in favor of the contract.
	In-Network	Out-Of-Network*
Provider Network	North Idaho Health Network	Non-Participating Providers
Individual Deductible	$1,000	$2,000
Family Deductible	$2,000	$4,000
Coinsurance	90%	70%
Out-of-Pocket Max	$1,500 per individual	$3,000 per individual
Maximum Benefit	$1,000,000 lifetime
Office Visits	$20 co-pay for PCP $35 co-pay for non-PCP	70% after deductible
Preventive Care**	No Copay Blue Cross will pay up to $500 for specifically listed covered services***	70% after deductible
Outpatient Lab Work	90% after deductible	70% after deductible
Ambulance	90% after deductible	70% after deductible
Hospital Inpatient**	90% after deductible	70% after deductible
Emergency Room	90% after deductible	70% after deductible
Accident Benefit	First $300 at 100%
Chiropractic ($800 Max/Yr)	90% after deductible	50% after deductible
Inpatient Physical Rehabilitation ($150,000 Lifetime Max)	90% after deductible	70% after deductible
Outpatient Physical, Speech & Occupational Therapies (Limited to a combined max of $2,000/Yr)	50% after deductible	50% after deductible
Organ Transplant**	90% after deductible	70% after deductible
Mental Nervous/Drug and Alcohol:
Outpatient** - Limited to 20 visits per member per benefit period	90% after deductible	70% after deductible
Inpatient** - Limited to 8 visits per member per benefit period	90% after deductible	70% after deductible
Prescription Drugs (Par Pharmacies)	Generic copay: $10 Brand copay: $20
RX Dosages	34 day supply or 100-unit doses, whichever is greater
Mail Order	Same as RX co-pay	Not Covered
Contraceptives	Oral: Same co-pay as prescription drugs Diaphragms and IUD's: $25 co-pay Depo Provera: $20 co-pay Norplant: $100 co-pay
Acupuncture**	Not Covered	Not Covered
Naturopathy	Not Covered	Not Covered
Dependent Age Limit	Age 23 or Age 25 if a Full-Time Student
Vision	VSP
Routine Vision Exam	$20 co-pay for PCP	$20 co-pay - 100% up to $20
Glasses or Contacts	$20 co-pay	$20 co-pay - up to restrictive schedule

* Non-participating providers will be reimbursed at 70% of the contracted Participating Provider rate, therefore you may also incur 'balance billing' from the provider. Additionally, you may be required to pay at time of service and file the claim yourself to Blue Cross of Idaho or Group Health.

** Plan Year Limits Apply. See Contract for Limitations.

*** Blue Cross of Idaho's expanded preventive care services to provide first dollar benefits up to $500 for specifically listed in-network covered services. Specifically listed services include, but are not limited to: Annual Physical Exams, Preventive Screening Mammograms, Pap Tests, PSA Tests, Cholesterol Screening, Diabetes Screening, Bone Density, Colorectal Cancer Screenings (Colonoscopy and Sigmoidoscopy) and Diabetes Screening.