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PPO Medical Plan

January 1, 2004 - January 1, 2005

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*

PPO Network

 Blue Cross of Idaho  

Deductible

$250 self-insured

Coinsurance

90%

70%

Out-of-Pocket Max

$1,575 per individual**

$3,225 per individual**

Maximum Benefit

$1,000,000

Office Visits

$20 co-pay/100%

Deductible/70%

Preventive Care

$20 co-pay/100% (see contract for limitations)

No Coverage

Lab Work

Deductible/90% 

Deductible/70%

Ambulance

Deductible/90% 

Deductible/70%

Hospital Inpatient

Deductible/90% 

Deductible/70%

Emergency Room

Deductible/90% 

Deductible/70%
Accident Benefit

First $300 at 100%

Chiropractic

Deductible/90% $800 Max/Yr

Deductible/50% $800 Max/Yr
Inpatient Physical Rehabilitation

Deductible/90% $150,000 Lifetime Max

No Coverage

Outpatient Physical Therapy Deductible/90% $800 Max/Yr Deductible/70% $800 Max/Yr
Organ Transplant*** Deductible/90% Deductible 70%
Mental Nervous and Drug and Alcohol:  
     Inpatient Deductible 50% 8 Days/Yr No Coverage
     Outpatient Deductible 50% 20 Visits/Yr No Coverage

Prescription Drugs   

(Par Pharmacies)

Generic copay:  $5 

Brand copay:  $12

     RX Dosages

34 day supply or 100-unit doses, whichever is greater

* Non-Preferred Providers will be reimbursed at 70% of the contracted Preferred 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.

** The out-of-pocket amount listed does not include your $250 deductible.  

***This plan has restrictions for Organ Transplants.  Refer to contract for specific details.


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