2017 Health Insurance Plans

Transcription

1 Updated and Corrected January 1, 2017 One mission: you 2017 Health Insurance Plans for small groups Form No (01-17) Policy Form Numbers: / / /17

2

3 BLUE CROSS OF IDAHO HEALTH INSURANCE PLANS Welcome to the power of you. As an Idaho employer, you have a tough job balancing the need to manage healthcare costs for your business, while still giving your employees and their families a quality health plan with excellent service and the tools to help them stay healthy. We re here to make your job easier. At Blue Cross of Idaho, we re dedicated to delivering the best value in health insurance to our small business customers. Our goal is to give your employees access to quality care at affordable costs. THIS EMPOWERS YOU TO OFFER YOUR WORKFORCE: Extensive provider networks Integrated claims processing Exceptional customer service Wellness tools and resources Toll-free nurse advice line Online cost comparison tool Because a good health insurance plan doesn t just cover your employees for unexpected medical needs, it actually helps them live life to the fullest, on their terms. And that makes your life easier too. bcidaho.com 1

4 Choosing the right plan The right coverage for your employees and their families depends on their needs and your budget. We offer a variety of small group medical plans, as well as dental, vision, EAP and wellness programs. Please visit the employer groups section at shoppers.bcidaho.com for information on ancillary services. Small group medical plans are organized into bronze, silver and gold levels, depending on the amount of coverage provided. All plans include essential health benefits, such as emergency room services, maternity and newborn care, annual doctor visits, medical screenings and prescription drugs. VARIOUS PROVIDER NETWORKS Different network options are available within each metal level as well. The amount an employee pays for their deductible, coinsurance and copayments will depend on the network paired with the benefit plan you select. The Blue Cross of Idaho s preferred provider organization (PPO), point of service (POS) and coordinated care organization (CCO)* networks offer the best choice of doctors and hospitals in the state. PHARMACY BENEFITS INCLUDED Your employees health plan also includes coverage for generic, brand name and specialty medications. Preventive drugs are covered at 100 percent, while copayments and coinsurance amounts vary for the preferred and non-preferred drugs on our formulary. All plans except HSA Saver plans now use a separate pharmacy benefit deductible. Please see our product tables on the following pages for a general benefit outline of commonly used medical and pharmacy services. NEW AMBULATORY SURGERY BENEFIT Small group plans include a benefit tier to encourage members to use ambulatory surgical facilities and professional services that are not only in-network, but from a list of preferred providers. Please visit bcidaho.com for a list of ambulatory surgical facilities that provide the best coinsurance rate. *NOTE: Our Connect plans use CCO provider networks in eastern and southwestern Idaho. When you choose managed care plans through these networks, your employees must choose a primary care physician (PCP) to serve as their care team. Employees must get referrals from their PCP to see specialists. 2

5 BLUE CROSS OF IDAHO HEALTH INSURANCE PLANS Metal Levels Explained BRONZE If your employees don t see a doctor very often, this is a great way for them to save on their monthly premium. We ll pay 60 percent of their medical costs.* SILVER If they see a doctor once in a while, but not regularly, our middle-of-the-road plan pays 70 percent of your employees medical costs.* GOLD If employees go to the doctor regularly or visit specialists often, they will pay a little higher premium each month. We still pay 80 percent of their medical costs.* Key Terms PREMIUM The monthly bill your employees pay for their health insurance plan. DEDUCTIBLE The amount employees pay each year for out-ofpocket expenses before your insurance company picks up the costs. For some services, employees won t have to pay any deductible. COINSURANCE This is the employees share of the costs for services, calculated as a percentage. For example, member pays 20 percent insurance plan pays 80 percent. COPAYMENT A set amount employees pay directly to a doctor, hospital or pharmacy when they need a service. OUT-OF-POCKET MAXIMUM After their monthly premium payments, the most in a year employees will pay for covered healthcare services from in-network providers. The group of doctors, hospitals and other healthcare providers that have contracted with your insurance company to provide services to your employees and their families at negotiated rates. In-network providers are responsible for seeking prior authorization for certain services. These providers do not have a contract with Blue Cross of Idaho for discounted rates. Employees will pay more for services from out-of-network (OON) providers and they may be liable for the entire medical bill if an OON provider does not request prior authorization for certain services and payment is denied by your insurance company. * Payment percentages are based on an average person s healthcare expenses over a year. bcidaho.com 3

6 Please visit bcidaho.com/sbc for a Summary of Benefits and Coverage. Benefit grids outline common in-network and out-of-network services for small groups. This is not a comprehensive list of benefits. Bronze HSA Saver 6000 (PPO Network) Bronze 5500 ANNUAL COSTS Deductible $6,000 individual $12,000 family $18,000 individual $36,000 family $5,500 individual $11,000 family $16,500 individual $33,000 family Coinsurance 3 Out-of-Pocket Maximum SERVICES Primary Care Provider (PCP) Office Visit (PCP selection required for POS/CCO) Specialist Office Visit (referral needed for CCO) Covered Preventive Care Mental Health/Substance Abuse Outpatient Therapy Emergency Room* (copay waived if admitted to hospital) Lab Services/X-Rays Advanced Imaging Outpatient Therapy Services** (for each outpatient procedure) Inpatient Hospital Services (including for mental health/substance abuse) Skilled Nursing Facility (30 days) (Outpatient Surgery Center) (Outpatient Professional Services) PRESCRIPTION DRUGS $6,550 individual $13,100 family 1 1 $19,650 individual $39,300 family $7,150 individual $14,300 family $50 copay Covered Preventive Preferred Generic Non-Preferred Generic $10 $10 $21,450 individual $42,900 family Preferred Brand $30 $30 after $1,000 pharmacy (Rx) deductible+ Non-Preferred Brand $50 $50 after $1,000 pharmacy (Rx) deductible+ Preferred Specialty after $1,000 pharmacy (Rx) deductible+ Non-Preferred Specialty 3 3 after $1,000 pharmacy (Rx) deductible+ 4 *For treatment of emergency medical conditions as defined in the policy/contract, Blue Cross of Idaho will provide in-network benefits for covered services, even if they are provided out-of-network. **Outpatient rehabilitation and habilitation therapy services are each limited to a combined physical therapy, speech therapy and occupational therapy total of 20 visits per member, per benefit period. ***In-network coinsurance for services from listed preferred facilities. In-network charge for unlisted providers is for 6000 plan or 3 for 5500 plan. +Separate pharmacy (Rx) deductible of $1,000 per person applies.

7 BLUE CROSS OF IDAHO HEALTH INSURANCE PLANS Our managed care Connect plans are supported by the Saint Alphonsus Health Alliance in southwestern Idaho and the Portneuf Quality Alliance Network in eastern Idaho. Silver HSA Saver 4400 (PPO Network) Silver HSA Saver 2750 (PPO Network) ANNUAL COSTS Deductible Coinsurance Out-of-Pocket Maximum SERVICES Primary Care Provider (PCP) Office Visit (PCP selection required for POS/CCO) Specialist Office Visit (referral needed for CCO) Covered Preventive Care Mental Health/Substance Abuse Outpatient Therapy Emergency Room* (copay waived if admitted to hospital) Lab Services/X-Rays Advanced Imaging Outpatient Therapy Services** (for each outpatient procedure) Inpatient Hospital Services (including for mental health/substance abuse) Skilled Nursing Facility (30 days) (Outpatient Surgery Center) (Outpatient Professional Services) PRESCRIPTION DRUGS $4,400 individual $8,800 family $13,200 individual $26,400 family $4,400 individual $8,800 family $13,200 individual $26,400 family $2,750 individual $5,500 family $8,250 individual $16,500 family $5,000 individual $10,000 family 1 1 Covered Preventive Preferred Generic Non-Preferred Generic $10 Preferred Brand $30 Non-Preferred Brand $50 Preferred Specialty Non-Preferred Specialty 3 $15,000 individual $30,000 family *For treatment of emergency medical conditions as defined in the policy/contract, Blue Cross of Idaho will provide in-network benefits for covered services, even if they are provided out-of-network. **Outpatient rehabilitation and habilitation therapy services are each limited to a combined physical therapy, speech therapy and occupational therapy total of 20 visits per member, per benefit period. ***In-network coinsurance for services from listed preferred facilities. In-network charge for unlisted providers is. bcidaho.com 5

8 Please visit bcidaho.com/sbc for a Summary of Benefits and Coverage. Benefit grids outline common in-network and out-of-network services for small groups. This is not a comprehensive list of benefits. Silver 4000 Plus Silver 4000 ANNUAL COSTS Deductible $4,000 individual $8,000 family $12,000 individual $24,000 family $4,000 individual $8,000 family $12,000 individual $24,000 family Coinsurance 3 Out-of-Pocket Maximum SERVICES Primary Care Provider (PCP) Office Visit (PCP selection required for POS/CCO) Specialist Office Visit (referral needed for CCO) Covered Preventive Care Mental Health/Substance Abuse Outpatient Therapy Emergency Room* (copay waived if admitted to hospital) Lab Services/X-Rays Advanced Imaging Outpatient Therapy Services** (for each outpatient procedure) Inpatient Hospital Services (including for mental health/substance abuse) Skilled Nursing Facility (30 days) (Outpatient Surgery Center) (Outpatient Professional Services) PRESCRIPTION DRUGS $6,000 individual $12,000 family $50 copay 1 1 $18,000 individual $36,000 family $6,000 individual $12,000 family $50 copay Covered Preventive Preferred Generic Non-Preferred Generic $10 $10 $18,000 individual $36,000 family Preferred Brand $30 after $1,000 pharmacy (Rx) deductible+ $30 after $1,000 pharmacy (Rx) deductible+ Non-Preferred Brand $50 after $1,000 pharmacy (Rx) deductible+ $50 after $1,000 pharmacy (Rx) deductible+ Preferred Specialty after $1,000 pharmacy (Rx) deductible+ after $1,000 pharmacy (Rx) deductible+ Non-Preferred Specialty 3 after $1,000 pharmacy (Rx) deductible+ 3 after $1,000 pharmacy (Rx) deductible+ 6 *For treatment of emergency medical conditions as defined in the policy/contract, Blue Cross of Idaho will provide in-network benefits for covered services, even if they are provided out-of-network. **Outpatient rehabilitation and habilitation therapy services are each limited to a combined physical therapy, speech therapy and occupational therapy total of 20 visits per member, per benefit period. ***In-network coinsurance for services from listed preferred facilities. In-network charge for unlisted providers is for 4000 Plus plan or 3 for 4000 plan. +Separate pharmacy (Rx) deductible of $1,000 per person applies.

9 BLUE CROSS OF IDAHO HEALTH INSURANCE PLANS Our managed care Connect plans are supported by the Saint Alphonsus Health Alliance in southwestern Idaho and the Portneuf Quality Alliance Network in eastern Idaho. Silver 3000 Plus Silver 3000 ANNUAL COSTS Deductible $3,000 individual $6,000 family $9,000 individual $18,000 family $3,000 individual $6,000 family $9,000 individual $18,000 family Coinsurance 3 Out-of-Pocket Maximum SERVICES Primary Care Provider (PCP) Office Visit (PCP selection required for POS/CCO) Specialist Office Visit (referral needed for CCO) Covered Preventive Care Mental Health/Substance Abuse Outpatient Therapy Emergency Room* (copay waived if admitted to hospital) Lab Services/X-Rays Advanced Imaging Outpatient Therapy Services** (for each outpatient procedure) Inpatient Hospital Services (including for mental health/substance abuse) Skilled Nursing Facility (30 days) (Outpatient Surgery Center) (Outpatient Professional Services) PRESCRIPTION DRUGS $7,150 individual $14,300 family $50 copay $70 copay $50 copay 1 1 $21,450 individual $42,900 family $7,150 individual $14,300 family $40 copay $60 copay $40 copay Covered Preventive Preferred Generic Non-Preferred Generic $10 $10 $21,450 individual $42,900 family Preferred Brand $30 after $1,000 pharmacy (Rx) deductible+ $30 after $1,000 pharmacy (Rx) deductible+ Non-Preferred Brand $50 after $1,000 pharmacy (Rx) deductible+ $50 after $1,000 pharmacy (Rx) deductible+ Preferred Specialty after $1,000 pharmacy (Rx) deductible+ after $1,000 pharmacy (Rx) deductible+ Non-Preferred Specialty 3 after $1,000 pharmacy (Rx) deductible+ 3 after $1,000 pharmacy (Rx) deductible+ *For treatment of emergency medical conditions as defined in the policy/contract, Blue Cross of Idaho will provide in-network benefits for covered services, even if they are provided out-of-network. **Outpatient rehabilitation and habilitation therapy services are each limited to a combined physical therapy, speech therapy and occupational therapy total of 20 visits per member, per benefit period. ***In-network coinsurance for services from listed preferred facilities. In-network charge for unlisted providers is for 3000 Plus plan or 3 for 3000 plan. +Separate pharmacy (Rx) deductible of $1,000 per person applies. bcidaho.com 7

10 Please visit bcidaho.com/sbc for a Summary of Benefits and Coverage. Benefit grids outline common in-network and out-of-network services for small groups. This is not a comprehensive list of benefits. Gold 2000 Plus Gold 2000 ANNUAL COSTS Deductible $2,000 individual $4,000 family $6,000 individual $12,000 family $2,000 individual $4,000 family $6,000 individual $12,000 family Coinsurance 3 Out-of-Pocket Maximum SERVICES Primary Care Provider (PCP) Office Visit (PCP selection required for POS/CCO) Specialist Office Visit (referral needed for CCO) Covered Preventive Care Mental Health/Substance Abuse Outpatient Therapy Emergency Room* (copay waived if admitted to hospital) Lab Services/X-Rays Advanced Imaging Outpatient Therapy Services** (for each outpatient procedure) Inpatient Hospital Services (including for mental health/substance abuse) Skilled Nursing Facility (30 days) (Outpatient Surgery Center) (Outpatient Professional Services) PRESCRIPTION DRUGS $3,000 individual $6,000 family $20 copay $40 copay $20 copay 1 1 $9,000 individual $18,000 family $3,000 individual $6,000 family $20 copay $40 copay $20 copay $9,000 individual $18,000 family Covered Preventive Preferred Generic Non-Preferred Generic $10 $10 Preferred Brand $30 after $1,000 pharmacy (Rx) deductible+ $30 after $1,000 pharmacy (Rx) deductible+ Non-Preferred Brand $50 after $1,000 pharmacy (Rx) deductible+ $50 after $1,000 pharmacy (Rx) deductible+ Preferred Specialty after $1,000 pharmacy (Rx) deductible+ after $1,000 pharmacy (Rx) deductible+ Non-Preferred Specialty 3 after $1,000 pharmacy (Rx) deductible+ 3 after $1,000 pharmacy (Rx) deductible+ 8 *For treatment of emergency medical conditions as defined in the policy/contract, Blue Cross of Idaho will provide in-network benefits for covered services, even if they are provided out-of-network. **Outpatient rehabilitation and habilitation therapy services are each limited to a combined physical therapy, speech therapy and occupational therapy total of 20 visits per member, per benefit period. ***In-network coinsurance for services from listed preferred facilities. In-network charge for unlisted providers is for 2000 Plus plan or 3 for 2000 plan. +Separate pharmacy (Rx) deductible of $1,000 per person applies.

11 BLUE CROSS OF IDAHO HEALTH INSURANCE PLANS Our managed care Connect plans are supported by the Saint Alphonsus Health Alliance in southwestern Idaho and the Portneuf Quality Alliance Network in eastern Idaho. Gold 1500 Plus Gold 1000 Plus Gold 500 $1,500 individual $3,000 family $4,500 individual $9,000 family $1,000 individual $2,000 family $3,000 individual $6,000 family $500 individual $1,000 family $1,500 individual $3,000 family 3 $4,000 individual $8,000 family $12,000 individual $24,000 family $4,000 individual $8,000 family $12,000 individual $24,000 family $5,500 individual $11,000 family $16,500 individual $33,000 family $40 copay $50 copay $50 copay $60 copay $40 copay $10 $10 $10 $30 after $1,000 pharmacy (Rx) deductible+ $30 after $1,000 pharmacy (Rx) deductible+ $30 after $1,000 pharmacy (Rx) deductible+ $50 after $1,000 pharmacy (Rx) deductible+ $50 after $1,000 pharmacy (Rx) deductible+ $50 after $1,000 pharmacy (Rx) deductible+ after $1,000 pharmacy (Rx) deductible+ after $1,000 pharmacy (Rx) deductible+ after $1,000 pharmacy (Rx) deductible+ 3 after $1,000 pharmacy (Rx) deductible+ 3 after $1,000 pharmacy (Rx) deductible+ 3 after $1,000 pharmacy (Rx) deductible+ *For treatment of emergency medical conditions as defined in the policy/contract, Blue Cross of Idaho will provide in-network benefits for covered services, even if they are provided out-of-network. **Outpatient rehabilitation and habilitation therapy services are each limited to a combined physical therapy, speech therapy and occupational therapy total of 20 visits per member, per benefit period. ***In-network coinsurance for services from listed preferred facilities. In-network charge for unlisted providers is for 1500 Plus and 1000 Plus plans or 3 for 500 plan. +Separate pharmacy (Rx) deductible of $1,000 per person applies. bcidaho.com 9

12 Exclusions and Limitations In addition to the exclusions and limitations listed elsewhere in your Policy/Contract, the following exclusions and limitations apply to the entire Policy, unless otherwise specified. Preexisting Condition Waiting Period There is no preexisting condition waiting period for benefits available under these Policies. General Exclusions and Limitations There are no benefits for services, supplies, drugs or other charges that are: Not Medically Necessary. If services requiring Prior Authorization by Blue Cross of Idaho are performed by a Contracting Provider and benefits are denied as not Medically Necessary, the cost of said services are not the financial responsibility of the Insured. However, the Insured could be financially responsible for services found to be not Medically Necessary when provided by a Noncontracting Provider. In excess of the Maximum Allowance. For hospital Inpatient or Outpatient care for extraction of teeth or other dental procedures, unless necessary to treat an Accidental Injury or unless an attending Physician certifies in writing that the Insured has a non-dental, life-endangering condition which makes hospitalization necessary to safeguard the Insured s health and life. Not prescribed by or upon the direction of a Physician or other Professional Provider; or which are furnished by any individuals or facilities other than Licensed General Hospitals, Physicians, and other Providers. Investigational in nature. Provided for any condition, Disease, Illness or Accidental Injury to the extent that the Insured is entitled to benefits under occupational coverage, obtained or provided by or through the employer under state or federal Workers Compensation Acts or under Employer Liability Acts or other laws providing compensation for work-related injuries or conditions. This exclusion applies whether or not the Insured claims such benefits or compensation or recovers losses from a third party. Provided or paid for by any federal governmental entity or unit except when payment under this Policy is expressly required by federal law, or provided or paid for by any state or local governmental entity or unit where its charges therefore would vary, or are or would be affected by the existence of coverage under this Policy. Provided for any condition, Accidental Injury, Disease or Illness suffered as a result of any act of war or any war, declared or undeclared. Furnished by a Provider who is related to the Insured by blood or marriage and who ordinarily dwells in the Insured s household. Received from a dental, vision, or medical department maintained by or on behalf of an employer, a mutual benefit association, labor union, trust or similar person or group. For Surgery intended mainly to improve appearance or for complications arising from Surgery intended mainly to improve appearance, except for: 10 Reconstructive Surgery necessary to treat an Accidental Injury, infection or other Disease of the involved part. Reconstructive Surgery to correct Congenital Anomalies in an Insured who is a dependent child. Benefits for reconstructive Surgery to correct an Accidental Injury are available even though the accident occurred while the Insured was covered under a prior insurer s coverage. Rendered prior to the Insured s Effective Date. For personal hygiene, comfort, beautification (including nonsurgical services, drugs, and supplies intended to enhance the appearance), or convenience items or services even if prescribed by a Physician, including but not limited to, air conditioners, air purifiers, humidifiers, physical fitness equipment or programs, spas, hot tubs, whirlpool baths, waterbeds or swimming pools and therapies, including but not limited to, educational, recreational, art, aroma, dance, sex, sleep, electro sleep, vitamin, chelation, homeopathic, or naturopathic, massage, or music. For telephone consultations, and all computer or Internet communications, except as specified as a Covered Service in this Policy. For failure to keep a scheduled visit or appointment; for completion of a claim form; or for personal mileage, transportation, food or lodging expenses unless specified as a Covered Service in this Policy, or for mileage, transportation, food or lodging expenses billed by a Physician or other Professional Provider. For Inpatient admissions that are primarily for Diagnostic Services or Therapy Services; or for Inpatient admissions when the Insured is ambulatory and/or confined primarily for bed rest, special diet, environmental change or for treatment not requiring continuous bed care. For Inpatient or Outpatient Custodial Care; or for Inpatient or Outpatient services consisting mainly of educational therapy, behavioral modification, self-care or self-help training, except as specified as a Covered Service in this Policy. For any cosmetic foot care, including but not limited to, treatment of corns, calluses, and toenails (except for surgical care of ingrown or diseased toenails). Related to Dentistry or Dental Treatment, even if related to a medical condition; or orthoptics, eyeglasses or contact Lenses, or the vision examination for prescribing or fitting eyeglasses or contact Lenses, unless specified as a Covered Service in this Policy. For hearing aids or examinations for the prescription or fitting of hearing aids. For any treatment of sexual dysfunction, or sexual inadequacy, including erectile dysfunction and/or impotence, even if related to a medical condition. Made by a Licensed General Hospital for the Insured s failure to vacate a room on or before the Licensed General Hospital s established discharge hour. Not directly related to the care and treatment of an actual condition, Illness, Disease or Accidental Injury. Furnished by a facility that is primarily a place for treatment of the aged or that is primarily a nursing home, a convalescent home, or a rest home. For Acute Care, Rehabilitative care, diagnostic testing except as specified as a Covered Service in this Policy; for Mental or Nervous Conditions and Substance Abuse or Addiction services not recognized by the American Psychiatric and American Psychological Associations. For any of the following: For appliances, splints or restorations necessary to increase vertical tooth dimensions or restore the occlusion, except as specified as a Covered Service in this Policy; For orthognathic Surgery, including services and supplies to augment or reduce the upper or lower jaw; For implants in the jaw; for pain, treatment, or diagnostic testing or evaluation related to the misalignment or

13 BLUE CROSS OF IDAHO HEALTH INSURANCE PLANS discomfort of the temporomandibular joint (jaw hinge), including splinting services and supplies; For alveolectomy or alveoloplasty when related to tooth extraction. For weight control or treatment of obesity or morbid obesity, even if Medically Necessary, including but not limited to Surgery for obesity. For reversals or revisions of Surgery for obesity, except when required to correct a life-endangering condition. For use of operating, cast, examination, or treatment rooms or for equipment located in a Contracting or Noncontracting Provider s office or facility, except for Emergency room facility charges in a Licensed General Hospital unless specified as a Covered Service in this Policy. For the reversal of sterilization procedures, including but not limited to, vasovasostomies or salpingoplasties. Treatment for infertility and fertilization procedures, including but not limited to, ovulation induction procedures and pharmaceuticals, artificial insemination, in vitro fertilization, embryo transfer or similar procedures, or procedures that in any way augment or enhance an Insured s reproductive ability, including but not limited to laboratory services, radiology services or similar services related to treatment for fertility or fertilization procedures. Any expenses, procedures or services related to Surrogate pregnancy, delivery or donor eggs. For Transplant services and Artificial Organs, except as specified as a Covered Service under this Policy. For acupuncture. For surgical procedures that alter the refractive character of the eye, including but not limited to, radial keratotomy, myopic keratomileusis, Laser-In-Situ Keratomileusis (LASIK), and other surgical procedures of the refractive-keratoplasty type, to cure or reduce myopia or astigmatism, even if Medically Necessary, unless specified as a Covered Service in a Vision Benefits Section of this Policy, if any. Additionally, reversals, revisions, and/or complications of such surgical procedures are excluded, except when required to correct an immediately lifeendangering condition. For Hospice, except as specified as a Covered Service in this Policy. For pastoral, spiritual, bereavement, or marriage counseling. For homemaker and housekeeping services or home-delivered meals. For the treatment of injuries sustained while committing a felony, voluntarily taking part in a riot, or while engaging in an illegal act or occupation, unless such injuries are a result of a medical condition or domestic violence. For treatment or other health care of any Insured in connection with an Illness, Disease, Accidental Injury or other condition which would otherwise entitle the Insured to Covered Services under this Policy, if and to the extent those benefits are payable to or due the Insured under any medical payments provision, no fault provision, uninsured motorist provision, underinsured motorist provision, or other first party or no fault provision of any automobile, homeowner s, or other similar policy of insurance, contract, or underwriting plan. In the event Blue Cross of Idaho (BCI) for any reason makes payment for or otherwise provides benefits excluded by the above provisions, it shall succeed to the rights of payment or reimbursement of the compensated Provider, the Insured, and the Insured s heirs and personal representative against all insurers, underwriters, self-insurers or other such obligors contractually liable or obliged to the Insured, or his or her estate for such services, supplies, drugs or other charges so provided by BCI in connection with such Illness, Disease, Accidental Injury or other condition. Any services or supplies for which an Insured would have no legal obligation to pay in the absence of coverage under this Policy or any similar coverage; or for which no charge or a different charge is usually made in the absence of insurance coverage or for which reimbursement or payment is contemplated under an agreement entered into with a third party. For a routine or periodic mental or physical examination that is not connected with the care and treatment of an actual Illness, Disease or Accidental Injury or for an examination required on account of employment; or related to an occupational injury; for a marriage license; or for insurance, school or camp application; or for sports participation physicals; or a screening examination including routine hearing examinations, except as specified as a Covered Service in this Policy. For immunizations, except as specified as a Covered Service in this Policy. For breast reduction Surgery or Surgery for gynecomastia. For nutritional supplements. For replacements or nutritional formulas except, when administered enterally due to impairment in digestion and absorption of an oral diet and is the sole source of caloric need or nutrition in an Insured. For vitamins and minerals, unless required through a written prescription and cannot be purchased over the counter. For alterations or modifications to a home or vehicle. For special clothing, including shoes (unless permanently attached to a brace). Provided to a person enrolled as an Eligible Dependent, but who no longer qualifies as an Eligible Dependent due to a change in eligibility status that occurred after enrollment. Provided outside the United States, which if had been provided in the United States, would not be a Covered Service under this Policy. For Outpatient pulmonary and/or cardiac Rehabilitation. For complications arising from the acceptance or utilization of noncovered services. For the use of Hypnosis, as anesthesia or other treatment, except as specified as a Covered Service. For dental implants, appliances (with the exception of sleep apnea devices), and/or prosthetics, and/or treatment related to Orthodontia, even when Medically Necessary unless specified as a Covered Service in this Policy. For arch supports, orthopedic shoes, and other foot devices. For wigs. For cranial molding helmets, unless used to protect post cranial vault surgery. For surgical removal of excess skin that is the result of weight loss or gain, including but not limited to association with prior weight reduction (obesity) Surgery. For the purchase of Therapy or Service Dogs/Animals and the cost of training/maintaining said animals. Any services or supplies furnished by a Therapeutic Boarding School, a facility that is primarily a health resort, or sanatorium, Residential Treatment Facility, transitional living center,except as specified as an Outpatient Psychiatric Care Covered Service listed in the Policy. For procedures including but not limited to breast augmentation, liposuction, Adam s apple reduction, rhinoplasty and facial reconstruction unless Medically Necessary and other procedures considered cosmetic in nature. bcidaho.com 11

14 Prescription Drug Exclusions and Limitations In addition to any other exclusions and limitations of this Policy, the following exclusions and limitations apply to this section and throughout the entire Policy, unless otherwise specified. No benefits are provided for the following: Specially Negotiated for religious exempt groups only Contraceptives, oral or other, whether medication or device, and regardless of intended use except for contraceptives that are clearly Medically Necessary for the treatment of a medical condition which requires the use of hormone therapy. Drugs used for the termination of early pregnancy, and complications arising therefrom, except when required to correct an immediately life-endangering condition. Over-the-counter drugs other than insulin, even if prescribed by a Physician. Notwithstanding this exclusion, Blue Cross of Idaho, through the determination of the Blue Cross Pharmacy and Therapeutics Committee may choose to cover certain over-the-counter medications when Prescription Drug benefits are provided under this Policy. Such approved over-the-counter medications must be identified by Blue Cross in writing and will specify the procedures for obtaining benefits for such approved over-the-counter medications. Please note that the fact a particular over-the-counter drug or medication is covered does not require Blue Cross to cover or otherwise pay or reimburse the Insured for any other over-the-counter drug or medication. Charges for the administration or injection of any drug, except for vaccinations listed on the Prescription Drug Formulary. Therapeutic devices or appliances, including hypodermic needles, syringes, support garments, and other non-medicinal substances except Diabetic Supplies, regardless of intended use. Drugs labeled Caution Limited by Federal Law to Investigational Use, or experimental drugs, even though a charge is made to the Insured. Immunization agents, except for vaccinations listed on the Prescription Drug Formulary, biological sera, blood or blood plasma. Benefits may be available under the Major Medical Benefits Section of this Policy. Medication that is to be taken by or administered to an Insured, in whole or in part, while the Insured is an Inpatient in a Licensed General Hospital, rest home, sanatorium, Skilled Nursing Facility, extended care facility, convalescent hospital, nursing home, or similar institution which operates or allows to operate on its premises, a facility for dispensing pharmaceuticals. Any prescription refilled in excess of the number specified by the Physician, or any refill dispensed after one (1) year from the Physician s original order. Any newly FDA approved Prescription Drug, biological agent, or other agent until it has been reviewed and approved by BCI s Pharmacy and Therapeutics Committee. Any Prescription Drug, biological or other agent, which is: Prescribed primarily to aid or assist the Insured in weight loss, including all anorectics, whether amphetamine or nonamphetamine. Prescribed primarily to retard the rate of hair loss or to aid in the replacement of lost hair. Prescribed primarily to increase fertility, including but not limited to, drugs which induce or enhance ovulation. Prescribed primarily for personal hygiene, comfort, beautification, or for the purpose of improving appearance. Prescribed primarily to increase growth, including but not limited to, growth hormone. Provided by or under the direction of a Home Intravenous Therapy Company, Home Health Agency or other Provider approved by BCI. Benefits are available for this Therapy Service under the Major Medical Benefits Section of this Policy only as preauthorized and approved when Medically Necessary. Lost, stolen, broken or destroyed medications, except in the case of loss due directly to a natural disaster. 12

15 BLUE CROSS OF IDAHO HEALTH INSURANCE PLANS Nondiscrimination Statement: Discrimination is Against the Law Blue Cross of Idaho complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Blue Cross of Idaho does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. Blue Cross of Idaho: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, contact Blue Cross of Idaho s Customer Service Department. Call (TTY: ), or call the customer service phone number on the back of your card. If you believe that Blue Cross of Idaho has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with Blue Cross of Idaho s Grievances and Appeals Department at: Manager, Grievances and Appeals 3000 East Pine Avenue, Meridian, Idaho Telephone: (800) ext.3838, Fax: (208) grievances&appeals@bcidaho.com TTY: You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, our Grievances and Appeals team is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, , (TTY). Complaint forms are available at index.html. Reference: ATTENTION: If you speak Arabic, Chinese, French, German, Korean, Japanese, Persian (Farsi), Romanian, Russian, Serbo-Croatian, Spanish, Sudanic Fulfulde, Tagalog, Ukrainian, or Vietnamese, language assistance services, free of charge, are available to you. Call (TTY: ). Arabic ملظوحة: إ اذ كنت تتحدث اذكر اللغة فا ن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم (رقم اھتف الصم ولابكم: ). Chinese 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: ) French ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS : ). German ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: ). Japanese 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます (TTY: ) まで お電話にてご連絡ください Korean 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: ) 번으로전화해주십시오. Persian-Farsi توجھ: گار بھ ا بزن فارسی گفتگو می دینک تسھیلات ینابز وص برت اگ ی ارن بریا شما فرا مھ می دش ا ب. با ( (TTY: تماس بگیردی. Romanian ATENȚIE: Dacă vorbiți limba română, vă stau la dispoziție servicii de asistență lingvistică, gratuit. Sunați la (TTY: ). Russian ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: ). Serbo-Croation OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite (TTY- Telefon za osobe sa oštećenim govorom ili sluhom: ). Spanish ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: ). Sudanic Fulfulde MAANDO: To a waawi [Adamawa], e woodi ballooji-ma to ekkitaaki wolde caahu. Noddu (TTY: ). Tagalog PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: ). Ukrainian УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером (телетайп: ). Vietnamese CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: ) by Blue Cross of Idaho, an independent licensee of the Blue Cross and Blue Shield Association bcidaho.com Form No (10-16) 13

16 One mission: you Meridian 3000 E. Pine Ave. Meridian, ID Lewiston Pocatello 275 S. 5 th Ave. Pocatello, ID Twin Falls 1503 Blue Lakes Blvd. N. Twin Falls, ID Idaho Falls 1910 Channing Way Idaho Falls, ID Coeur d Alene 1450 NW Blvd., Suite 106 Coeur d Alene, ID Blue Cross of Idaho Sales Customer Service Claims Inquiries bcidaho.com 2016 by Blue Cross of Idaho, an independent licensee of the Blue Cross and Blue Shield Association