|
PPO Medical Plan - Blue
Cross
October 1, 2006 - September
30, 2007
MEDICAL
DENTAL
VISION
LIFE/AD&D
LTD
STD
FLEX
EAP
|
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 |
Non-Participating
Providers |
|
Deductible: |
|
|
Individual |
$500 |
|
Family |
$1000 |
|
Coinsurance |
90% |
70% |
|
Out-of-Pocket Max |
$3,000 per individual** |
$6,000
per individual |
|
Maximum
Benefit |
$1,000,000
lifetime |
|
Office
Visits |
$20
co-pay/100% |
70%
after deductible |
|
Preventive
Care |
$20
co-pay/100% (see
contract for limitations) |
No benefits |
|
Lab
Work |
100% for
first $100, then 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 |
|
Chiropractic/$800
Max Per
Calendar Year |
90% after
deductible |
50%
after deductible |
|
Inpatient Physical Rehabilitation |
90% after
deductible $150,000 Lifetime Max
|
No Coverage
|
|
Outpatient Physical Therapy/$800
Max Per Calendar Year |
90% after
deductible
|
70%
after deductible
|
|
Mental
Nervous and Drug and Alcohol:*** |
|
|
Inpatient |
50% after deductible/
8 days/Yr
|
No Coverage
|
|
Outpatient |
50% after
deductible/
20 Visits/Yr
|
No Coverage
|
|
Prescription Drugs
(Par
Pharmacies)
|
Generic:
$10 copay + 20%
Brand:
$20 copay + 20%
|
|
RX
Dosages |
30
day supply |
|
Mail
Order Prescription
Drugs
|
Generic:
$10 copay
Brand:
$20 copay
|
|
RX
Dosages |
90
day supply or 100-unit doses, whichever is less |
*
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 $500 deductible.
***Pre-authorization required.
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