Health Insurance Plans for Individuals from

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1 Health Insurance Plans fr Individuals frm Blue Crss f Idah Chse cverage that fits. Frm N (08-14) Plicy Frm Numbers: / / / / / / / / / / / /11

2 INDIVIDUAL AND FAMILY MEDICAL PLANS INDIVIDUAL AND FAMILY MEDICAL PLANS We ffer a variety f health insurance plans with the cverage yu need at a price yu can affrd. Whether yu buy directly frm us r frm Yur Health Idah, yu will find rbust cverage fr yu and yur family frm Blue Crss f Idah. We ffer fur levels f plans based n the amunt f cverage they prvide. These levels, knwn as metal levels, are Brnze, Silver, Gld and Platinum and vary by the mnthly premium cst and the percent f expected csts cvered. The metal level ranking system makes it easy t cmpare plans in the same categry r acrss categries. This allws yu t make apples-t-apples cmparisns amng plans, see yur expected csts mre easily, and get the cverage yu need. It is imprtant t knw that all metal levels have the same essential health benefits, including emergency rm services, maternity and newbrn care, annual dctr visits, and medical screenings. In additin t the infrmatin in this brchure, yu can learn mre abut ur prducts and the metal levels at shppers.bcidah.cm. Blue Crss f Idah Metallic Plans BRONZE SILVER GOLD PLATINUM Chice HSA Saver Cnnect Chice 2000, , & N Deductible Cnnect 2000, 3000, 4000 & N Deductible Chice Cnnect Cnnect Our Cnnect plans are part f ur CnnectedCare netwrk. See ur CnnectedCare Plans fr Individuals brchure fr mre infrmatin abut these plans. (Rev. 03/2015) CHOOSE COVERAGE THAT FITS bcidah.cm 1

3 HOW TO CHOOSE THE RIGHT PLAN Chsing the right cverage depends n knwing yur healthcare needs, what yu want frm yur cverage and what yur budget will allw. Cnsider these questins befre yu chse a plan t help narrw yur ptins: DO I QUALIFY FOR A BREAK ON COSTS BASED ON MY INCOME AND FAMILY SIZE? Take a lk at the Get a Break n Csts n the next page t learn if yu may be eligible fr financial assistance. WHAT SORT OF HEALTH SERVICES AND MEDICATIONS MIGHT MY FAMILY AND I NEED? Think abut yur current and future healthcare needs. Hw ften d yu need t g t the dctr? What is yur family s health histry? D yu have a jb r d activities during which yu might get injured? Des yur child play a sprt in which they might get injured? DOES THE PLAN INCLUDE MY CURRENT DOCTORS? Each plan may include a different set f dctrs and ther health service prviders, which is called being in-netwrk. Lk at the list f dctrs and hspitals in each plan at shppers.bcidah.cm t see if the prviders yu prefer are in the netwrk f the plans yu are cnsidering. WHAT IS THE BEST WAY FOR ME TO BALANCE THE DEDUCTIBLE AND PREMIUM OPTIONS? As a general rule f thumb, yu can chse t pay a higher mnthly premium, s when yu need medical care, yu pay less. Or yu can chse a lwer mnthly premium but when yu need medical care, yu pay mre. Blue Crss f Idah has plans in many premium and deductible ranges, s yu can chse the level f cverage that best meets yur health needs and budget. WHAT OTHER VALUE DOES MY HEALTH INSURANCE COMPANY OFFER MY FAMILY? Nt all insurance cmpanies prvide rich benefit cverage, award-winning custmer service, and easy access t the dctrs yu want. Blue Crss f Idah plans cme with this kind f added value, giving yu mre fr yur mnthly premium. Yu can learn mre abut the ways we are wrking t bring yu the highest quality care at a cst yu can affrd n page HEALTH INSURANCE PLANS frm BLUE CROSS OF IDAHO Individuals

4 GET A BREAK ON COSTS GET A BREAK ON COSTS Depending n yur incme and family size, yu may be eligible fr financial assistance with yur mnthly health insurance csts r ut-f-pcket expenses. Cst Sharing Reductin This can lwer yur ut-f-pcket expenses (yur deductible and cinsurance payments) when yu buy thrugh Yur Health Idah. If yur husehld incme is less than 250 percent f the federal pverty level yu may qualify fr the cst sharing reductin if yu dn t have access t insurance thrugh yur emplyer. See ur Cst Sharing Plans fr Individuals brchure fr mre details. Mnthly Premium Tax Credit This new kind f tax credit can save yu mney by lwering yur mnthly premium payments when yu buy thrugh Yur Health Idah. If yur husehld incme is less than 400 percent f the federal pverty level and yu dn t have access t insurance thrugh yur emplyer yu can qualify. QUALIFY FOR FINANCIAL HELP T qualify, yu ll need t enrll in health cverage thrugh Yur Health Idah at yurhealthidah.rg. The exchange is a website where yu can cmpare insurance plans, apply fr financial assistance, and buy a plan that best fits the needs f yu and yur family. THE FEDERAL INCOME GUIDELINES (2014) Family Size and Incme Cst Sharing Reductin 250% f FPL If yu make less than this, yu may qualify fr help paying expenses such as deductible and cinsurance payments. Mnthly Premium Tax Credit 400% f FPL If yu make less than this, yu may qualify fr help paying yur mnthly premiums. 1 $11,670 $29,175 $46,680 2 $15,730 $39,325 $62,920 3 $19,790 $49,475 $79,160 4 $23,850 $59,625 $95,400 5 $27,910 $69,775 $111,640 6 $31,970 $79,925 $127,880 7 $36,030 $90,075 $144,120 8 $40,090 $100,225 $160,360 FREE SUBSIDY CALCULATOR Visit ur subsidy calculatr at shppers. bcidah.cm t get an estimate n hw much mney yu might be able t save. If yu dn t qualify fr a tax credit r cst-sharing reductin, there s n need t visit yurhealthidah.rg. Yu can quickly and easily apply fr insurance cverage directly frm us at shppers.bcidah.cm. * Fr families with mre than 8 peple, add $4,020 fr each additinal persn. CHOOSE COVERAGE THAT FITS bcidah.cm 3

5 Benefit grid utlines cverage fr in-netwrk and ut-f-netwrk services. This is nt a cmprehensive list f benefits. Yu can find a cmprehensive list f services in the member cntract. METAL LEVEL INDIVIDUAL BRONZE HSA SAVER FAMILY BRONZE HSA SAVER Benefit Details In-Netwrk Out-f-Netwrk In-Netwrk Out-f-Netwrk Deductible $5,000 per persn $5,000 per persn $10,000 per family* $10,000 per family* Cinsurance The percentage yu pay f the allwed amunt fr cvered services after meeting yur deductible. Yu pay n cinsurance nce yu ve met yur deductible. Yu pay n cinsurance nce yu ve met yur deductible. Annual Out-f- Pcket Maximum Includes yur deductible, cpayments, cinsurance, and prescriptin deductible. Fr in-netwrk care, the mst a year is $6,350 (individual). Fr cvered care, the mst a year is $8,350 (individual). Fr in-netwrk care, the mst a year is $12,700 (family). Fr cvered care, the mst a year is $16,700 (family). WHAT YOU LL PAY UP TO YOUR ANNUAL OUT-OF-POCKET MAXIMUM Dctr s Office Visit/Urgent Care deductible, yu pay nthing. deductible, yu pay nthing. Emergency Rm Prescriptin Drugs 3 Prescriptin drug csts cunt tward yur ut-f-pcket maximum. Diagnstic X-Ray and Lab Inpatient Hspital Outpatient Rehab 4 Physician, Surgical & Medical Pregnancy Chirpractic Care 5 Diabetes Educatin Outpatient Mental Health & Substance Abuse Preventive Care Immunizatins Yu pay $150 cpayment per visit. deductible, yu pay nly the cpayment. Yu pay $150 cpayment per visit. 2 Yu pay nthing fr cvered generic and brand-name preventive drugs. deductible, yu pay $10 cpayment fr nn-preventive generic drugs and 50% fr nn-preventive brand-name drugs. deductible, yu pay nthing. deductible, yu pay nthing. Yu pay $30 cpayment deductible, yu pay nthing. Yu pay nthing fr listed preventive care. Yu pay $150 cpayment Once yu ve met yur deductible, yu nly the cpayment. Yu pay $150 cpayment per visit. 2 Yu pay nthing fr cvered generic and brand-name preventive drugs. deductible, yu pay $10 cpayment fr nn-preventive generic drugs and 50% fr nn-preventive brand-name drugs. deductible, yu pay nthing. deductible, yu pay nthing. Yu pay $30 cpayment deductible, yu pay nthing. Yu pay nthing fr listed preventive care. Yu pay nthing fr listed immunizatins. 1 Preventive visits are nt included in this ttal. 2 Fr treatment f emergency medical cnditins as defined in the plicy, Blue Crss f Idah will prvide in-netwrk benefits fr cvered services. 3 Prescriptin drug cverage includes a generic substitutin requirement. If yu r yur dctr requests a brand-name prescriptin when a generic equivalent is available, yu are respnsible t pay the difference between the allwed cst f the generic drug and the brand-name drug and any applicable brand-name cpayment. The extra csts d nt cunt tward yur deductible r annual ut-f-pcket maximum. Yur dctr can request an exceptin t this plicy by submitting a prir authrizatin request. 4 HEALTH INSURANCE PLANS frm BLUE CROSS OF IDAHO Individuals

6 BLUE CROSS OF IDAHO HEALTH INSURANCE PLANS Visit bcidah.cm/sbc fr a Summary f Benefits and Cverage. METAL LEVEL BRONZE CHOICE Benefit Details In-Netwrk Out-f-Netwrk Deductible Cinsurance The percentage yu pay f the allwed amunt fr cvered services after meeting yur deductible. Annual Out-f- Pcket Maximum Includes yur deductible, cpayments, cinsurance, and prescriptin deductible. $6,350 per persn r $12,700 per family Yu pay n cinsurance nce yu ve met yur deductible. Fr in-netwrk care, the mst a year is $6,350 (individual) r $12,700 (family). $6,350 per persn r $12,700 per family Fr cvered care, the mst a year is $8,350 (individual) r $16,700 (family). WHAT YOU LL PAY UP TO YOUR ANNUAL OUT-OF-POCKET MAXIMUM Key terms PREMIUM The amunt yu pay each mnth fr yur health insurance plan. DEDUCTIBLE The amunt yu pay each year fr ut-f-pcket expenses befre the health insurer picks up expenses. Yu wn t have t pay any deductible fr sme services. COINSURANCE Yur share f the csts yu pay, calculated as a percentage. Fr example, yu pay 20 percent, insurance pays 80 percent. Dctr s Office Visit/Urgent Care Yu pay $30 cpayment per visit fr the first 4 visits per persn. 1 Fr additinal visits, nce yu ve met yur deductible, yu pay nthing. COPAYMENT A flat fee yu pay fr services such as a dctr visit, emergency rm visit, r prescriptin medicatin. Emergency Rm Prescriptin Drugs 3 Prescriptin drug csts cunt tward yur ut-f-pcket maximum. Diagnstic X-Ray and Lab Inpatient Hspital Outpatient Rehab 4 Physician, Surgical & Medical Pregnancy Chirpractic Care 5 Diabetes Educatin Outpatient Mental Health & Substance Abuse Preventive Care Immunizatins deductible, yu pay nthing. 2 deductible, yu pay nthing. deductible, yu pay nthing. deductible, yu pay nthing. Yu pay $30 cpayment Yu pay $30 cpayment Yu pay nthing fr listed preventive care. Yu pay nthing fr listed immunizatins. NETWORK The grup f physicians, hspitals and ther prviders that an insurer has cntracted with t deliver medical services t its members. OUT-OF-POCKET EXPENSES Mney yu pay fr health-related services in additin t yur mnthly premium. Depending n yur health insurance plan, these may include an annual deductible, cinsurance and cpayments fr dctr s visits and prescriptins. OUT-OF-POCKET MAXIMUM After yur premium payments, the mst in a year yu will pay fr cvered healthcare services frm in-netwrk prviders is $6,350 fr individuals and $12,700 fr families fr mst plans. THE COST OF YOUR CARE When yu use in-netwrk prviders, yur cst f care is lwer because even when yu are paying yur deductible, yu nly pay Blue Crss f Idah s discunted fee. 4 Includes physical, ccupatinal, and speech therapy services. Yu have a cmbined ttal f up t 20 in- and ut-f-netwrk visits fr cvered therapy services per member per year. 5 Yu have up t a cmbined ttal f 18 in- and ut-f-netwrk visits fr cvered chirpractic services per member per year. * Please nte: All family members cntribute tward the family deductible. Claims will nt be paid fr any individual family member until the ttal family deductible has been satisfied. CHOOSE COVERAGE THAT FITS bcidah.cm 5

7 Benefit grid utlines cverage fr in-netwrk and ut-f-netwrk services. This is nt a cmprehensive list f benefits. Yu can find a cmprehensive list f services in the member cntract. METAL LEVEL SILVER CHOICE 4000 SILVER CHOICE 3000 Benefit Details In-Netwrk Out-f-Netwrk In-Netwrk Out-f-Netwrk Deductible Cinsurance The percentage yu pay f the allwed amunt fr cvered services after meeting yur deductible. Annual Out-f- Pcket Maximum Includes yur deductible, cpayments, cinsurance, and prescriptin deductible. Dctr s Office Visit/Urgent Care Emergency Rm $4,000 per persn r $8,000 per family Fr in-netwrk care, the mst a year is $6,350 (individual) r $12,700 (family). Yu pay $10 cpayment per visit fr the first 4 visits per persn. 1 Fr additinal visits, nce yu ve met yur deductible, yu pay 30% f the cst f yur cvered care. Yu pay $150 cpayment per visit. deductible, yu pay cpayment and 30% f the cst f yur cvered care. $4,000 per persn r $8,000 per family Fr cvered care, the mst a year is $8,350 (individual) r $16,700 (family). $3,000 per persn r $6,000 per family Fr in-netwrk care, the mst a year is $6,350 (individual) r $12,700 (family). WHAT YOU LL PAY UP TO YOUR ANNUAL OUT-OF-POCKET MAXIMUM Yu pay $150 cpayment Once yu ve met yur deductible, yu pay cpayment and 50% f the 2 Yu pay $20 cpayment per visit fr the first 4 visits per persn. 1 Fr additinal visits, nce yu ve met yur deductible, yu pay 30% f the cst f yur cvered care. Yu pay $150 cpayment per visit. deductible, yu pay cpayment and 30% f the cst f yur cvered care. $3,000 per persn r $6,000 per family Fr cvered care, the mst a year is $8,350 (individual) r $16,700 (family). Yu pay $150 cpayment Once yu ve met yur deductible, yu pay cpayment and 50% f the 2 Prescriptin Drugs 3 Prescriptin drug csts cunt tward yur ut-f-pcket maximum. Diagnstic X-Ray and Lab Inpatient Hspital Outpatient Rehab 4 Physician, Surgical & Medical Pregnancy Chirpractic Care 5 Diabetes Educatin Outpatient Mental Health & Substance Abuse Preventive Care Yu pay $10 cpayment fr generic drugs. Once yu ve met a separate $2,350 brand-name and specialty drug deductible, yu pay $30 cpayment fr preferred brand-name, $50 cpayment fr nn-preferred brand-name, and $100 cpayment fr specialty drugs. Yu pay $10 cpayment Yu pay $10 cpayment Yu pay nthing fr listed preventive care. Yu pay $10 cpayment fr generic drugs. Once yu ve met a separate $1,000 brand-name and specialty drug deductible, yu pay $30 cpayment fr preferred brand-name, $50 cpayment fr nn-preferred brand-name, and $100 cpayment fr specialty drugs. Yu pay $20 cpayment Yu pay $20 cpayment Yu pay nthing fr listed preventive care. Immunizatins Yu pay nthing fr listed immunizatins. Yu pay nthing fr listed immunizatins. 1 Preventive visits are nt included in this ttal. 2 Fr treatment f emergency medical cnditins as defined in the plicy, Blue Crss f Idah will prvide in-netwrk benefits fr cvered services. 3 Prescriptin drug cverage includes a generic substitutin requirement. If yu r yur dctr requests a brand-name prescriptin when a generic equivalent is available, yu are respnsible t pay the difference between the allwed cst f the generic drug and the brand-name drug and any applicable brand-name cpayment. The extra csts d nt cunt tward yur deductible r annual ut-f-pcket maximum. Yur dctr can request an exceptin t this plicy by submitting a prir authrizatin request. 6 HEALTH INSURANCE PLANS frm BLUE CROSS OF IDAHO Individuals

8 BLUE CROSS OF IDAHO HEALTH INSURANCE PLANS Visit bcidah.cm/sbc fr a Summary f Benefits and Cverage. METAL LEVEL SILVER CHOICE 2000 SILVER CHOICE NO DEDUCTIBLE Benefit Details In-Netwrk Out-f-Netwrk In-Netwrk Out-f-Netwrk Deductible $2,000 per persn r $4,000 per family $2,000 per persn r $4,000 per family $0 $1,000 per persn r $2,000 per family Cinsurance The percentage yu pay f the allwed amunt fr cvered services after meeting yur deductible. Yu pay 50% f the cst f yur cvered care. deductible, yu pay 75% f the Annual Out-f- Pcket Maximum Includes yur deductible, cpayments, cinsurance, and prescriptin deductible. Fr in-netwrk care, the mst a year is $6,350 (individual) r $12,700 (family). Fr cvered care, the mst a year is $8,350 (individual) r $16,700 (family). Fr in-netwrk care, the mst a year is $6,350 (individual) r $12,700 (family). Fr cvered care, the mst a year is $8,350 (individual) r $16,700 (family). WHAT YOU LL PAY UP TO YOUR ANNUAL OUT-OF-POCKET MAXIMUM Dctr s Office Visit/Urgent Care Yu pay $45 cpayment per visit fr the first 4 visits per persn. 1 Fr additinal visits, nce yu ve met yur deductible, yu pay 30% f the cst f yur cvered care. Yu pay $150 cpayment Once yu ve met yur deductible, yu pay cpayment and 30% f the Yu pay 50% f the cst f yur cvered care. deductible, yu pay 75% f the Emergency Rm Yu pay $150 cpayment Once yu ve met yur deductible, yu pay cpayment and 50% f the 2 Yu pay $150 cpayment per visit and 50% f the cst f yur cvered care. Yu pay $150 cpayment Once yu ve met yur deductible, yu pay cpayment and 75% f the 2 Prescriptin Drugs 3 Prescriptin drug csts cunt tward yur ut-f-pcket maximum. Diagnstic X-Ray and Lab Yu pay $10 cpayment fr generic drugs. Once yu ve met a separate $1,000 brand-name and specialty drug deductible, yu pay $30 cpayment fr preferred brand-name, $50 cpayment fr nn-preferred brand-name, and $100 cpayment fr specialty drugs. Yu pay 50% f the cst f yur cvered prescriptins. Inpatient Hspital Outpatient Rehab 4 Yu pay 50% f the cst f yur cvered care. deductible, yu pay 75% f the Physician, Surgical & Medical Pregnancy Chirpractic Care 5 Yu pay 50% f the cst f yur cvered care. deductible, yu pay 75% f the Diabetes Educatin Yu pay $45 cpayment Yu pay 50% f the cst f yur cvered care. deductible, yu pay 75% f the Outpatient Mental Health & Substance Abuse Yu pay $45 cpayment Yu pay 50% f the cst f yur cvered care. deductible, yu pay 75% f the Preventive Care Yu pay nthing fr listed preventive care. Yu pay nthing fr listed preventive care. deductible, yu pay 75% f the Immunizatins Yu pay nthing fr listed immunizatins. Yu pay nthing fr listed immunizatins. 4 Includes physical, ccupatinal, and speech therapy services. Yu have a cmbined ttal f up t 20 in- and ut-f-netwrk visits fr cvered therapy services per member per year. 5 Yu have up t a cmbined ttal f 18 in- and ut-f-netwrk visits fr cvered chirpractic services per member per year. CHOOSE COVERAGE THAT FITS bcidah.cm 7

9 Visit bcidah.cm/sbc fr a Summary f Benefits and Cverage. METAL LEVEL GOLD CHOICE COVERED CHOICE* Benefit Details In-Netwrk Out-f-Netwrk In-Netwrk Out-f-Netwrk Deductible Cinsurance The percentage yu pay f the allwed amunt fr cvered services after meeting yur deductible. Annual Out-f- Pcket Maximum Includes yur deductible, cpayments, cinsurance, and prescriptin deductible. $1,000 per persn r $2,000 per family deductible, yu pay 15% f the Fr in-netwrk care, the mst any year is $6,350 (individual) r $12,700 (family). $1,000 per persn r $2,000 per family Fr cvered care, the mst any year is $8,350 (individual) r $16,700 (family). $6,600 per persn r $13,200 per family deductible, yu pay nthing. Fr in-netwrk care, the mst any year is $6,600 (individual) r $13,200 (family). WHAT YOU LL PAY UP TO YOUR ANNUAL OUT-OF-POCKET MAXIMUM $6,600 per persn r $13,200 per family Fr cvered care, the mst any year is $8,600 (individual) r $17,200 (family). Dctr s Office Visit/Urgent Care Yu pay $10 cpayment per visit fr the first 4 visits per persn. 1 Fr additinal visits, nce yu ve met yur deductible, yu pay 15% f the cst f yur cvered care. Yu pay $30 cpayment per visit fr the first 3 visits per persn. Fr additinal visits, yu pay csts up t yur deductible. Emergency Rm Prescriptin Drugs 3 Prescriptin drug csts cunt tward yur ut-f-pcket maximum. Diagnstic X-Ray and Lab Inpatient Hspital Outpatient Rehab 4 Physician, Surgical & Medical Pregnancy Chirpractic Care 5 Diabetes Educatin Outpatient Mental Health & Substance Abuse Preventive Care Yu pay $150 cpayment per visit. deductible, yu pay cpayment and 15% f the cst f yur cvered care. Yu pay $150 cpayment per visit. deductible, yu pay cpayment and 50% f the cst f yur cvered care. 2 Yu pay $10 cpayment fr generic drugs. deductible, yu pay $30 cpayment fr preferred brand-name, $50 cpayment fr nn-preferred brand-name, and $100 cpayment fr specialty drugs. deductible, yu pay 15% f the deductible, yu pay 15% f the Yu pay $10 cpayment Yu pay $10 cpayment Yu pay nthing fr listed preventive care. deductible, yu pay 50% f the cst f yur cvered care. deductible, yu pay nthing fr cvered care. deductible, yu pay 30% f the 2 deductible, yu pay nthing fr cvered prescriptins. deductible, yu pay nthing fr cvered care. deductible, yu pay nthing fr cvered care. deductible, yu pay nthing fr cvered care. deductible, yu pay nthing fr cvered care. Yu pay nthing fr listed preventive care. Immunizatins Yu pay nthing fr listed immunizatins. Yu pay nthing fr listed immunizatins. *Cvered Chice is a catastrphic plan and is nly available t peple under the age f 30, r t peple wh qualify fr a hardship exemptin thrugh the exchange. 1 Preventive visits are nt included in this ttal. 2 Fr treatment f emergency medical cnditins as defined in the plicy, Blue Crss f Idah will prvide in-netwrk benefits fr cvered services. 3 Prescriptin drug cverage includes a generic substitutin requirement. If yu r yur dctr requests a brand-name prescriptin when a generic equivalent is available, yu are respnsible t pay the difference between the allwed cst f the generic drug and the brand-name drug and any applicable brand-name cpayment. The extra csts d nt cunt tward yur deductible r annual ut-f-pcket maximum. Yur dctr can request an exceptin t this plicy by submitting a prir authrizatin request. 4 Includes physical, ccupatinal, and speech therapy services. Yu have a cmbined ttal f up t 20 in- and ut-f-netwrk visits fr cvered therapy services per member per year. 5 Yu have up t a cmbined ttal f 18 in- and ut-f-netwrk visits fr cvered chirpractic services per member per year. 8 HEALTH INSURANCE PLANS frm BLUE CROSS OF IDAHO Individuals

10 D Yu Live in Eastern r Suthwest Idah? BLUE CROSS OF IDAHO HEALTH INSURANCE PLANS BRONZE CONNECT SILVER CONNECT SILVER CONNECT NO DEDUCTIBLE GOLD CONNECT PLATINUM CONNECT COVERED CONNECT* If yu live in these areas f the state, yu have additinal chices thrugh Blue Crss f Idah s CnnectedCare SM Plans. Our CnnectedCare plans, available in every metal level, are full-cverage managed care health insurance plans supprted by select prvider netwrks within eastern and suthwestern Idah. Yu can identify these plans by their Cnnect name. Hw is CnnectedCare cverage different? If yu chse a Cnnect plan, yu must fllw sme additinal requirements t get the full benefit f yur cverage. Prtneuf Quality Alliance serves CnnectedCare members with prviders in Bannck and Bingham cunties. 1. Yu must visit dctrs and hspitals that are part f the CnnectedCare netwrk where yu live. 2. Yu must chse ne dctr as yur primary care prvider (PCP). PCPs prvide care and arrange ther treatments and services when needed. 3. Yur PCP must prvide yu referrals t specialists within yur netwrk fr yur in-netwrk cverage benefits. Want t knw mre? See ur CnnectedCare Plans fr Individuals brchure fr mre infrmatin. Yu can see if a certain prvider r hspital is in the CnnectedCare netwrk at bcidah.cm/findaprvider. Saint Alphnsus Health Alliance serves CnnectedCare members with prviders in Ada, Canyn, Gem, Payette, Washingtn and Malheur cunties. Additinal Plans t Meet Yur Needs Shrt Term PPO Plan If yu need cverage fr a shrt time, ur Shrt Term PPO ffers a limited benefit plan fr temprary cverage. This plan is nly available directly frm Blue Crss f Idah and is nt subject t the rules set frth by the Affrdable Care Act (ACA), including the pre-existing cnditin cverage requirement. Fr infrmatin abut ur Shrt Term PPO plan, please call yur lcal Blue Crss f Idah ffice r insurance agent, r visit bcidah. cm/plans/individual/stb.asp. Dental Insurance Gd ral health is an imprtant part f yur verall health. Our flexible and affrdable dental plans include varying degrees f cverage s yu can select a dental plan that best fits yur health and financial needs. Whatever plan yu re lking fr, we ve gt yu cvered. Yu can chse a plan directly frm Blue Crss f Idah at shppers. bcidah.cm r thrugh the Idah Health Insurance Exchange at yurhealthidah.rg. It s imprtant t knw that dental cverage fr members yunger than 19 is cnsidered ne f 10 essential health benefits (EHBs), which are basic benefits mst health insurance plans will prvide. Blue Crss f Idah ffers dental plans that meet the ACA requirements separate frm ur medical plans. See ur Dental Plans fr Individuals brchure fr mre infrmatin. CHOOSE COVERAGE THAT FITS bcidah.cm 9

11 WHY BLUE CROSS OF IDAHO? BEST VALUE Our missin is t prvide ur members the best value in health insurance and the tls fr maintaining and imprving their health. Hw d we prvide this value? By ffering insurance ptins, extensive prvider netwrks that let yu get care frm the dctrs yu want, award-winning custmer service and access t the healthcare prgrams yu need t achieve yur best health. And even as healthcare csts cntinue t rise, we wrk t minimize administrative csts, s we can keep yur premiums as lw as pssible. STRONG PROVIDER NETWORKS N insurance cmpany has a mre cmplete netwrk f dctrs and hspitals in the state than we d. We cntract with every hspital in Idah and 96 percent f all Idah physicians and healthcare prviders. If yu re traveling utside f Idah, dctrs and hspitals all ver the United States and in mre than 200 cuntries and territries arund the wrld are in ur BlueCard netwrk. EXCELLENT CUSTOMER SERVICE Blue Crss f Idah takes pride in prviding exceptinal service frm ur custmer service center lcated right here in Idah. We make sure imprtant infrmatin is always at yur fingertips by prviding supprt ver the phne and thrugh ur website at members.bcidah.cm. Our website lets yu view yur health insurance recrds, including yur claims histry and explanatin f benefits statements. S whether yu prefer researching yur questin n ur website r cntacting ne f ur specially trained custmer advcates n the phne, we re here fr yu. Our custmer advcates are available Mnday thrugh Friday frm 7 a.m. 8 p.m. and Saturday frm 8 a.m. nn. (They are clsed Wednesdays frm 8-8:30 a.m. s they can attend a staff meeting.) We als prvide ur members 24-hur access t ur self-service phne system that ffers claims histry, eligibility and deductible infrmatin. HEALTH AND WELLNESS SUPPORT As a member, yu ll have access t ur WellCnnected tls t help yu imprve yur health. Yu can track yur exercise, fd and water intake as well as take a wide range f wellness wrkshps. There s a mbile app t make tracking even mre cnvenient. SEE COSTS AND WAYS TO SAVE With ur new Cst Lkup tl, yu will see the price yu wuld pay at a specific prvider r fr a prescriptin based n where yu live, what insurance plan yu have, and wh is in yur netwrk f dctrs and hspitals. Yu can als sign up fr Ways t Save, which shws yu hw yu can save mney n the services yu already use. 10 HEALTH INSURANCE PLANS frm BLUE CROSS OF IDAHO Individuals

12 WHY BLUE CROSS OF IDAHO? BLUE EXTRAS! We knw that maintaining gd health is imprtant t ur members and that there are many different appraches t achieving gd health. Whether yu fllw a frmal wrkut rutine r rely n evening walks in the neighbrhd, take a daily multi-vitamin r fllw a strict naturpathic medicine, acupuncture and massage therapy prgram, ur Blue Extras 2 prgram can help yu succeed. Blue Extras is a valueadded prgram and nt health insurance. HEALTH MANAGEMENT PROGRAMS We want t help yu succeed in creating and sustaining healthy behavirs. Our health management prgrams fcus n supprting yur gals, giving yu access t the critical infrmatin, tls, and even the caching yu need t live a healthier, happier life. We ffer prgrams fr asthma, cngestive heart failure, depressin, diabetes, and chrnic bstructive pulmnary disease, amng thers. BEHAVIORAL HEALTH MANAGEMENT INTEGRATION Blue Crss f Idah believes gd mental health is a key part f verall health and wellbeing. Our behaviral health team fcuses n imprving the quality f life fr ur members thrugh mental health r substance abuse management, wrks t crdinate verall member care, and seeks t prvide an integrated apprach t yur entire physical and mental health picture. HELPFUL ONLINE TOOLS As a member yu have access t members.bcidah.cm, where yu can find infrmatin n yur cverage and claims, estimate the cst f services, take an nline health risk assessment and find a dctr r hspital all available 24 hurs a day. Additinally, members wh cmplete a persnal health assessment have access t nline health caching prgrams 1 that give them persnalized actin plans, tls and resurces t help them meet their health gals. Blue Extras ffers a variety f value-added services, prgrams and prducts t help ur members achieve their persnal health, wellness and fitness gals. The Blue Extras prgram ffers discunted rates t members fr the fllwing services: Baby health and safety Cmplementary and alternative health Fitness clubs Hearing services Medical alert services Orthdntia services Visin services Blue Extras is available t mst Blue Crss f Idah members and is nt dependent n yur specific benefit plan. Hwever, if yur plan includes cverage fr a service included in the Blue Extras value added prgram, the service prvider will apply the discunt befre submitting the claim fr payment under yur benefit plan. Fr mre infrmatin abut Blue Extras and fr a list f specific clubs and services prviders, visit bcidah.cm. 1 Persnal health caching is a value added prgram and is nt health insurance. 2 Blue Extras is a value added prgram and is nt health insurance. CHOOSE COVERAGE THAT FITS bcidah.cm 11

13 DETAILS ABOUT OUR PLANS Blue Crss f Idah s member cntracts cntain all the imprtant details abut ur plan benefits including ut-f-pcket amunts, cvered healthcare services, and specific exclusins and limitatins. Here are sme imprtant details fr yu t review. HOW DO WE PROTECT YOUR PERSONAL INFORMATION? We cnsider all persnal infrmatin we cllect frm yu t be cnfidential. Our privacy practices apply equally t persnal infrmatin abut future, current and frmer members. We allw access t yur infrmatin by ur emplyees and business assciates nly t the extent necessary t cnduct ur business f serving yu. We train ur emplyees n ur written privacy and security plicies and prcedures and ur emplyees are subject t disciplinary actins if they vilate them. We wn t disclse yur persnal infrmatin unless we are allwed r required by law, r if yu (r yur persnal representative) give us permissin. We take steps t secure ur buildings and electrnic systems frm unauthrized access. Fr detailed infrmatin abut ur privacy practices and yur rights, including yur right t see yur persnal health recrd, see the Blue Crss f Idah Ntice f Privacy Practices n ur website at bcidah.cm/abut_us/privacy_plicy.asp. Yu can als cntact ur infrmatin privacy fficer at fr mre infrmatin. ABOUT OUT-OF-POCKET LIMITS Be aware that yur actual csts fr services prvided by an ut-f-netwrk prvider may exceed the utf-pcket limit fr ut-f-netwrk services. Csts fr the fllwing Cvered d nt cunt tward the Out-f-Netwrk Out-f-Pcket Limit: Dental, Visin and Prescriptin Drug. In additin, Out-f-Netwrk Prviders can bill yu fr the difference between the amunt they charge fr cvered services and the amunt Blue Crss f Idah allws fr thse services, and that amunt des nt cunt tward the Out-f- Netwrk Out-f-Pcket Limit. Prir Authrizatin NOTICE: Prir Authrizatin is required t determine if the services listed belw are Medically Necessary and a Cvered Service. If Prir Authrizatin has nt been btained t determine Medical Necessity, services may be subject t denial. Any dispute invlved in Blue Crss f Idah s Medical Necessity decisin must be reslved by use f the Blue Crss f Idah appeal prcess. If Nn-Medically Necessary services are perfrmed by Cntracting Prviders, withut the Prir Authrizatin by Blue Crss f Idah, and benefits are denied, the cst f said services are nt the financial respnsibility f the Insured. The Insured is financially respnsible fr Nn-Medically Necessary services perfrmed by a prvider wh des nt have a prvider cntract with Blue Crss f Idah. Prir Authrizatin is a request by the Insured s Cntracting Prvider t Blue Crss f Idah, r delegated entity, fr authrizatin f an Insured s prpsed treatment. Blue Crss f Idah may review medical recrds, test results and ther surces f infrmatin t ensure that it is a Cvered Service and determine whether the prpsed treatment meets the standard f Medical Necessity as defined in the Plicy. T request Prir Authrizatin, the Cntracting Prvider must ntify Blue Crss f Idah f the Insured s intent t receive services that require Prir Authrizatin. Blue Crss f Idah will respnd t a request fr Prir Authrizatin fr the services listed belw received frm either the Prvider r the Insured within tw (2) business days f the receipt f the medical infrmatin necessary t make a determinatin. Fr additinal infrmatin, please check with yur Prvider, call Custmer Service at the telephne number listed n the back f the Insured s Identificatin Card r check the Blue Crss f Idah Web site at bcidah.cm. 12 HEALTH INSURANCE PLANS frm BLUE CROSS OF IDAHO Individuals

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