Add Dependent To Health/Dental
Disability & Life Insurance
Blue Cross of Idaho
1-800-627-1188
ENROLLMENT APPLICATION
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Benefit Highlight Sheet Boundary County School District #101 Effective Date September 1, 2019 |
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Preferred Blueâ Dental PPO Plan for Idaho School Benefit Trust |
In-Network |
Out-of-Network. |
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Individual/Family Deductible (Deductible applies to In-Network basic, major services, and all Out-of-network services. The Family Deductible is satisfied after three (3) Participants of the same family have met their Individual Deductible.) |
$25/3 Family Maximum |
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Individual Benefit Period Maximum |
$1,250 |
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Preventive Services |
What you pay |
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Oral Examinations One (1) examination every six (6) months. |
No charge of the allowed amount |
By choosing an Out-of-Network provider 20% of the allowed amount* |
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Fluoride Limited to one (1) application per benefit period and limited to Participant’s who are under age twenty-six (26). |
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Sealants: Limited to permanent posterior unrestored dentition of eligible dependent children under age sixteen (16) and limited to one (1) time per tooth in any three (3) consecutive benefit periods. |
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X-rays, Bitewings Once per benefit period. |
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X-rays, Complete Mouth Series or Panoramic x-ray One (1) time in any five (5) consecutive benefit periods. |
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Prophylaxis (Cleaning) Once every six (6) months. (Regardless of type) |
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Basic Services |
What you pay |
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Filings Restorations involving multiple surfaces will be combined and paid according to the number of surfaces treated; same tooth surface restoration is covered once in two (2) year period. |
20% of the allowed amount |
By choosing an Out-of-Network provider 30% of the allowed amount* |
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Extractions |
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Root Canal Therapy |
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Periodontal Maintenance Once every six (6) months. (Regardless of type) |
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Scaling and Root planing Once per quadrant of the mouth every three (3) benefit periods. |
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Occlusal Guard One appliance every two (2) benefit periods. |
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Osseous Surgery Once per area of the mouth every three (3) years. |
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Space Maintainers Limited to Participant’s who are under age sixteen (16). Benefits limited to deciduous teeth. Includes all adjustments made within six (6) months of installation. |
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Major Services Preauthorization required on all major services |
What you pay |
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Bridges, Inlays, Onlays, Crowns, Veneers, and Full or Partial Dentures Five (5) year replacement. |
50% of the allowed amount |
By choosing an Out-of-Network provider 40% of the allowed amount* |
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Dental Implants Including the implant body, implant abutment and implant crown – benefits may be available up to the Maximum Allowance of a standard complete or partial denture, or bridge. Implant body and abutment-limited to once per tooth per lifetime. Implant crown –five (5) year replacement. |
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Benefit Highlight Sheet Boundary County School District #101 Effective Date September 1, 2019 |
Blue Valueâ for Idaho School Benefit Trust |
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In-Network |
Out-of-Network |
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Benefit Period* Deductible (Individual/Family) |
$1,500/$3,000 |
$3,000/$6,000 |
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Cost Sharing |
You pay 10% of the allowed amount |
You pay 30% of the allowed amount |
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Individual Out-of-Pocket Limit (See Plan for services that do not apply to the limit.) (Includes applicable Deductible, Cost Sharing and Copayments) |
$3,000 |
$6,000 |
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Family Out-of-Pocket Limit (See Plan for services that do not apply to the limit.) (Includes applicable Deductible, Cost Sharing and Copayments) |
$6,000 |
$12,000 |
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Copayment (Applies to In-Network only. Other services rendered during an office visit will be subject to Deductible and Cost Sharing.) |
You pay $20 Copayment per visit for Primary Care Provider (PCP)/ You pay $40 Copayment per visit for Non-Primary Care Provider (non-PCP) |
Not applicable |
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COVERED SERVICES By choosing a non-contracting provider you may be responsible for the difference between what Blue Cross allows and what the non-contracting provider charges. This is called balance-billing. Some services may require prior authorization. |
In-Network |
Out-of-Network |
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What you pay |
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Ambulance Transportation Services |
Deductible and Cost Sharing |
Deductible and Cost Sharing |
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Breastfeeding Support and Supply Services (Limited to one (1) breast pump purchase per benefit period, per Participant) |
No charge |
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Chiropractic Care (Limited to 18 visits combined per Participant, per benefit period) |
Deductible and Cost Sharing |
50% Cost Sharing after Deductible |
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Dental Services Related to Accidental Injury |
Deductible and Cost Sharing |
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Diabetes Self-Management Education Services (Only for accredited providers approved by BCI.) |
Non-Primary Care Provider Copayment |
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Diagnostic Services (Including diagnostic mammograms) |
No charge up to $100, then Deductible and Cost Sharing |
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Durable Medical Equipment, Orthotic Devices and Prosthetic Appliances |
Deductible and Cost Sharing |
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Emergency Services – Facility Services (Copayment waived if admitted) (Additional services, such as laboratory, x-ray, and other Diagnostic Services are subject to applicable Deductible, Cost Sharing and/or Copayment.) (BCI will provide in-network benefits for treatment of Emergency Medical Conditions. Participant may be balance- billed for these services.) |
$100 Copayment for hospital Outpatient emergency room visit, then Deductible and Cost Sharing |
$100 Copayment for hospital Outpatient emergency room visit, then Deductible and Cost Sharing |
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Emergency Services – Professional Services (BCI will provide in-network benefits for treatment of Emergency Medical Conditions. Participant may be balance-billed for these services.) |
Deductible and Cost Sharing |
Deductible and Cost Sharing |
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Home Health Skilled Nursing |
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Home Intravenous Therapy |
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COVERED SERVICES By choosing a non-contracting provider you may be responsible for the difference between what Blue Cross allows and what the non-contracting provider charges. This is called balance-billing. Some services may require prior authorization |
In-Network |
Out-of-Network |
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What you pay |
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Hospice Services |
No charge |
Deductible and Cost Sharing |
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Hospital Services (Inpatient and outpatient services at a licensed general hospital or ambulatory surgical facility.) |
Deductible and Cost Sharing |
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Rehabilitation or Habilitation Services |
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Maternity Services and/or Involuntary Complications of Pregnancy (Physician Services including prenatal, delivery, and postnatal care.) |
Deductible and Cost Sharing |
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Outpatient Applied Behavioral Analysis (as part of an approved treatment plan) |
Primary Care Provider Copayment |
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Mental Health– Inpatient (Facility and Professional Services) |
Deductible and Cost Sharing |
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Mental Health– Outpatient |
Psychotherapy Services |
Primary Care Provider Copayment |
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Facility and other Professional Services |
Deductible and Cost Sharing |
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Morbid Obesity ($5,000 combined lifetime benefit limit, per participant) |
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Outpatient Habilitation Therapy Services (Includes physical, speech and occupational therapies. Limited to 20 visits combined per Participant, per benefit period.) |
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Outpatient Rehabilitation Therapy Services (Includes physical, speech and occupational therapies. Limited to 20 visits combined per Participant, per benefit period.) |
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Physician Office Visit (Other services rendered during a physician office visit will be subject to Deductible and Cost Sharing) |
Primary Care Provider Copayment/ Non-Primary Care Provider Copayment |
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Prescribed Contraceptive Services (Includes diaphragms, intrauterine devices (IUDs), implantables, injections and tubal ligation.) |
No charge |
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Post-Mastectomy/Lumpectomy Reconstructive Surgery |
Deductible and Cost Sharing |
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Skilled Nursing Facility (Limited to 30 days combined per Participant, per benefit period.) |
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Surgical/Medical (Professional Services) |
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Therapy Services (Including chemotherapy, growth hormone therapy, radiation and renal dialysis.) |
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Transplant Services |
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Preventive Care Benefits (See plan for specifically listed services) |
No charge for services specifically listed
For services not specifically listed deductible and Cost sharing |
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Immunizations (See Plan for specifically listed immunizations) |
No charge for listed immunizations |
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Treatment for Autism Spectrum Disorder (Services identified as part of the approved treatment plan) |
Covered the same as any other illness, depending on the services rendered, see appropriate Covered Services section. Visit limits do not apply to Treatments for Autism Spectrum Disorder. |
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*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.
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Benefit Highlight Sheet Boundary County School District #101 Effective Date September 1, 2019 |
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Prescription Benefits for Idaho School Benefit Trust |
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Retail and Mail Order (90-day supply with multiple copays) |
What you pay |
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Generic |
$10 Copayment per prescription – No Deductible required |
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$250 Deductible per participant on Formulary and Non-Formulary Brand Name Drugs* |
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Preferred Brand Name |
$30 Copayment per prescription after Deductible is met |
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Non-Preferred Brand Name |
$50 Copayment per prescription after Deductible is met |
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ACA Preventive Prescription Drugs |
No charge for ACA Preventive Prescription Drugs as specifically listed on the BCI Formulary on the BCI Web site, www.bcidaho.com. (Deductible does not apply) |
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Prescribed Contraceptives |
No charge for Women’s Preventive Prescription Drugs and devices as specifically listed on the BCI Formulary on the BCI Web site, www.bcidaho.com; 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. |
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Out-of-Pocket Limit |
Individual $3000 in Copayments and/or Cost Sharing per Benefit Period for a combination of all Prescription Drug charges incurred.
Family: Combination of $6000 in Copayments and/or Cost Sharing per Benefit Period for a combination of all Prescription Drug charges incurred.
When the Prescription Drug Out-of-Pocket Limit is met, the Prescription Drug Benefits payable will increase to 100% of the Allowed Charge or the Usual Charge for the remainder of the Benefit Period. |
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Benefit Highlight Sheet Boundary County School District #101 Effective Date September 1, 2019 |
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VISION CARE BENEFITS (VSP) for Idaho School Benefit Trust – Option III |
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For Covered Providers and Services |
What you pay |
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Copayment |
Nothing per eye exam and/or $25 per Frame and Lenses or Medically Necessary Contact Lenses. |
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Service Frequency Limitations |
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Elective—includes basic eye exam and an allowance of $130 in place of benefits for Prescribed Lenses and Frames |
You may receive one (1) eye exam and/or one (1) pair of Lenses and/or one (1) Frame or one (1) pair of Medically Necessary Contact Lenses (in lieu of eyeglasses) every twelve (12) months. |
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Payment for Services Rendered |
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Participating VSP Doctor |
BCI pays 100% of Maximum Allowance after Copayment |
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Nonparticipating VSP Doctor |
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Professional Fees |
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Eye Exam |
$45 |
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Materials—lenses per pair |
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Single Vision |
$48 |
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Bifocals, up to |
$65 |
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Trifocals, up to |
$90 |
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Frame, up to |
$45 |
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Contact Lenses— per pair |
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(evaluation, materials, and fittings only) |
$120 |
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Medically Necessary, up to |
$250 |
*The Participating VSP Doctor is responsible for verifying benefits with VSP prior to rendering services. A Participant must provide the VCSV Participating Provider sufficient information to verify eligibility. Failure of the Participant to provide sufficient information may delay services and may affect benefit payment under the plan.
