Gold 1000 Revised 08/2018

Transcription

1 Summary of Benefits Individual Benefit Period* Deductible $1,000 $3,000 Family Benefit Period* Deductible (No member/insured may contribute more than the Individual Deductible amount toward the Family Deductible) Individual Out-of-Pocket Limit (See Contract/Policy for services that do not apply to the limit.) (Includes applicable Deductible, and s) Family Out-of-Pocket Limit (See Contract/Policy for services that do not apply to the limit.) (Includes applicable Deductible, and s) (Applies to only. Other services rendered during an office visit will be subject to deductible and coinsurance.) Advanced Imaging Services (Outpatient services only) (Magnetic Resonance Imaging (MRI), Magnetic Resonance Angiography (MRA), Computed Tomography Scan (CT Scan), Positron Emission Tomography (PET), Nuclear Cardiology) Ambulance Transportation Services Ground Air Ambulatory Surgical Facility (Surgery Center) and Professional Services (See the BCI Web site, for specifically listed facilities.) $2,000 $6,000 You pay 20% of the allowed amount You pay 80% of the allowed amount $5,500 $16,500 $11,000 $33,000 You pay $30 copayment per visit for / You pay $50 copayment per visit for Non-Primary Care Provider procedure, then 10%, after Deductible for services at facilities specifically listed Not applicable procedure, then Breastfeeding Support and Supply Services (Limited to one (1) breast pump purchase per benefit period, per member/insured.) Chiropractic Care (Limited to 18 visits combined per member/insured, per benefit period.) Dental Services Related to Accidental Injury Diabetes Self-Management Education Services (Only for accredited providers approved by BCI.) Diagnostic Services (Including diagnostic mammograms.) Durable Medical Equipment/Orthotic Devices/Prosthetic Appliances For services at facilities not specifically listed,

2 Emergency Services Facility Services ( waived if admitted) (Additional services, such as laboratory, x-ray, and other Diagnostic Services are subject to applicable Deductible, and/or. BCI will provide benefits for treatment of Emergency Medical Conditions. Member/Insured may be balance-billed for these services.) Emergency Services Professional Services (BCI will provide benefits for treatment of Emergency Medical Conditions. Member/Insured may be balance-billed for these services.) Home Health Skilled Nursing Home Intravenous Therapy Hospice Services Hospital Services (Inpatient and outpatient services at a licensed general hospital or ambulatory surgical facility.) Rehabilitation or Habilitation Services Maternity Services (Physician Services including prenatal, delivery, and postnatal care) Outpatient Applied Behavioral Analysis (as part of an approved treatment plan) Mental Health Inpatient (Facility and Professional Services) Mental Health Outpatient Psychotherapy Services Facility and other Professional Services Deductible, then $350 copayment per hospital Outpatient emergency room visit Deductible, then $350 copayment per hospital Outpatient emergency room visit Outpatient Habilitation Therapy Services (Includes physical, speech and occupational therapies. Limited to 20 visits combined per member/insured, per Outpatient Rehabilitation Therapy Services (Includes physical, speech and occupational therapies. Limited to 20 visits combined per member/insured, per Physician Office Visit Post Mastectomy Reconstructive Surgery Prescribed Contraceptive Services (Includes diaphragms, intrauterine devices (IUDs), implantables, injections and tubal ligation.) Skilled Nursing Facility (Limited to 30 days combined per member/insured, per Sleep Study Services ( waived for home sleep studies) / Non-Primary Care Provider Sleep Study, then Sleep Study, then

3 Surgical/Medical (Professional Services) Therapy Services (Including chemotherapy, growth hormone, radiation, renal dialysis.) Transplant Services Preventive Care Benefits (See the BCI Web site, for specifically listed preventive care services.) for services specifically listed For services not specifically listed Immunizations (See the BCI Web site, for specifically listed immunizations.) Treatment for Autism Spectrum Disorder (Services identified as part of the approved treatment plan) for listed immunizations Covered the same as any other illness, depending on the services rendered see appropriate Covered Services section. Visit limits do not apply to Treatment for Autism Spectrum Disorder. *The specified period of time during which charges for covered services must be incurred in order to accumulate toward annual benefit limits, deductible amounts and out-of-pocket limits.

4 Pediatric Vision Care Benefits (VCSV) (For member/insured under the age of 19 only) Service Frequency Limitations For Providers and Services Exam Member/Insured may receive one (1) eye exam per benefit period Member/Insured may receive one (1) pair of spectacle Lenses or Contact Lenses per benefit period Member/Insured may receive one (1) Frame per benefit period Nonparticipating Participating Provider * Provider 50% Lenses Single Vision, lined bifocal, lined trifocal or lenticular lenses Polycarbonate lenses Plastic or glass optional Scratch and UV Frame Includes select frames for participating providers Contact Lenses In lieu of eyeglasses, elective contact lens services and materials are covered with the following limitations: Standard (one pair annually) = 1 contact lens per eye (total 2 lenses) Monthly (six month supply) = 6 lenses per eye (total 12 lenses) Bi-weekly (three month supply) = 6 lenses per eye (total 12 lenses) Dailies (three month supply) = 90 lenses per eye (total 180 lenses) Medically Necessary contact lenses are covered for member/insured who have specific conditions for which contact lenses provide better visual correction. 50% 50% 50% *The Participating Provider is responsible for verifying benefits with the VCSV prior to rendering services. A member/insured must provide the Participating Provider sufficient information to verify eligibility. Failure of the member/insured to provide sufficient information may delay services and may affect benefit payment under the Contract/Policy.

5 Prescription Drug Option (The Formulary will be made available to any Member/Insured on request by contacting our Blue Cross of Idaho Customer Service Department at (208) or (800) ) Each non Specialty Prescription Drug shall not exceed a 90-day supply at one (1) time (one for each 30-day supply, except for Mail Order specific Maintenance Prescription Drugs which require two s for a 90-day supply) (Prescription Drug Services apply to the Out-of-Pocket Limits) RETAIL OR BCI MAIL ORDER PHARMACIES Tier 1 Preferred Generic Prescription Drugs Tier 2 Non-Preferred Generic Prescription Drugs Tier 3 Preferred Brand Name Prescription Drugs WHAT YOU PAY $5 per prescription $10 per prescription $30 per prescription $500 Deductible for Non-Preferred Brand Name Drugs, Preferred Specialty Drugs, Generic Specialty Drugs and Non-Preferred Specialty Drugs Tier 4 Non-Preferred Brand Name Prescription Drugs $50 per prescription, after Deductible Tier 5 Preferred Specialty Prescription Drugs and Generic Specialty Prescription Drugs (30 day supply limit at one time) Tier 6 Non-Preferred Specialty Prescription Drugs (30 day supply limit at one time) ACA Preventive Prescription Drugs Prescribed Contraceptives 30% per prescription, after Deductible 50% per prescription, after Deductible for Preventive Prescription Drugs as specifically listed on the BCI Formulary on the BCI Web site, Deductible does not apply. for Women s Preventive Prescription Drugs and devices as specifically listed on the BCI Formulary on the BCI Web site, Deductible does not apply. The day supply allowed shall not exceed a 90-day supply at one (1) time, as applicable to the specific contraceptive drug or supply. *Certain Prescription Drugs have generic equivalents. If the Member/Insured requests a Brand Name Drug, the Member/Insured is responsible for the difference between the price of the Generic Drug and the Brand Name Drug, regardless of the Preferred or Non-Preferred status.