Medical-Group Health

Other Benefit Summaries:

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

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Group Health Medical Plan July 1, 2009 - July 1, 2010
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	Group Health Providers	Non-Participating Providers
Individual Deductible	$1,000
Family Deductible	$2,000
Coinsurance	100%	70%
Out-of-Pocket Maximum (plus deductible)	$2,000 per individual/$3,000 per family**
Maximum Benefit	$2,000,000 lifetime
Office Visits	$30 co-pay	$30 co-pay/70%
Preventive Care**	Covered in full�no Copay	$300 Individual/ $600 Family
Outpatient Lab Work	100%	70%
Ambulance	80%	80%
Hospital Inpatient**	100% after deductible	70% after deductible
Emergency Room	$75 co-pay, deductible	$125 co-pay, deductible, 70%
Accident Benefit	Covered as any other illness
Chiropractic	$30 co-pay (see contract for limitations)	$30 co-pay/70% 20 visit limit
Inpatient Physical Rehabilitation - 60 visits/yr	100% after deductible	70% after deductible
Outpatient Physical, Speech & Occupational Therapies - 60 visits/yr	$30 co-pay	$30 co-pay/70%
Organ Transplant**	Outpatient Visits: $30 copay Inpatient: 100% after deductible	Outpatient Visits: $30 copay, 70% Inpatient: 70% after deductible
Mental Nervous/Drug and Alcohol:
Outpatient** - Limited to 20 visits per member per benefit period	$30 co-pay, 100% after deductible	$30 co-pay, 70% after deductible
Inpatient** - Limited to 12 visits per member per benefit period	$30 co-pay, 100% after deductible	$30 co-pay, 70% after deductible
Prescription Drugs (Par Pharmacies)	Generic co-pay: $10 Formulary Brand: $20 Non-Formulary Brand: $40	Generic co-pay: $15 Formulary Brand: $25 Non-Formulary Brand: $45
RX Dosages	30-day supply/90 day mail order supply
Mail Order Prescription Drugs	2 x RX co-pay per 90 day supply	Not Covered
Contraceptives	Oral: Same co-pay as prescription drugs Patch, IUD, Diaphragm or Cervical Cap: Rx co-pay + Office Visit Depo Provera: Office Visit co-pay Norplant: Not covered
Acupuncture**	$30 co-pay	$30 co-pay, 70%
Naturopathy	$30 co-pay	$30 co-pay, 70%
Dependent Age Limit	Age 25, regardless of student status
Vision	Group Health
Routine Vision Exam	$30 co-pay	$30 co-pay, 70%
Glasses or Contacts	$100 allowance every 12 months

* 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. Pre-authorization required.