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Add Dependent To Health/Dental

Disability & Life Insurance

Blue Cross of Idaho

ENROLLMENT APPLICATION

Insurance rates

Benefit Highlight Sheet Boundary County School District #101 Effective Date September 1, 2019

Preferred Blueâ Dental PPO Plan for Idaho School Benefit Trust

In-Network

Out-of-Network.

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

Individual Benefit Period Maximum

$1,250

Preventive Services

What you pay

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*

Fluoride Limited to one (1) application per benefit period and limited to Participant’s who are under age twenty-six (26).

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.

X-rays, Bitewings Once per benefit period.

X-rays, Complete Mouth Series or Panoramic x-ray

One (1) time in any five (5) consecutive benefit periods.

Prophylaxis (Cleaning) Once every six (6) months. (Regardless of type)

Basic Services

What you pay

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*

Extractions

Root Canal Therapy

Periodontal Maintenance Once every six (6) months. (Regardless of type)

Scaling and Root planing Once per quadrant of the mouth every three

(3) benefit periods.

Occlusal Guard One appliance every two (2) benefit periods.

Osseous Surgery Once per area of the mouth every three (3) years.

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.

Major Services

Preauthorization required on all major services

What you pay

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*

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.

 

Benefit Highlight Sheet Boundary County School District #101

Effective Date September 1, 2019

Blue Valueâ for Idaho School Benefit Trust

 

In-Network

 

Out-of-Network

Benefit Period* Deductible (Individual/Family)

$1,500/$3,000

$3,000/$6,000

 

Cost Sharing

 

You pay 10% of the allowed amount

 

You pay 30% of the allowed amount

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

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

 

 

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

 

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

 

What you pay

Ambulance Transportation Services

Deductible and Cost Sharing

 

Deductible and Cost Sharing

Breastfeeding Support and Supply Services (Limited to one (1) breast pump purchase per benefit period, per Participant)

No charge

Chiropractic Care (Limited to 18 visits combined per Participant, per benefit period)

Deductible and Cost Sharing

50% Cost Sharing after Deductible

Dental Services Related to Accidental Injury

 

 

 

Deductible and Cost Sharing

Diabetes Self-Management Education Services (Only for accredited providers approved by BCI.)

Non-Primary Care Provider Copayment

 

Diagnostic Services (Including diagnostic mammograms)

No charge up to

$100, then Deductible and Cost

Sharing

Durable Medical Equipment, Orthotic Devices and Prosthetic Appliances

Deductible and Cost Sharing

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

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

Home Health Skilled Nursing

Home Intravenous Therapy

 

 

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

What you pay

Hospice Services

No charge

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Deductible and Cost Sharing

Hospital Services (Inpatient and outpatient services at a licensed general hospital or ambulatory surgical facility.)

Deductible and Cost Sharing

Rehabilitation or Habilitation Services

Maternity Services and/or Involuntary Complications of Pregnancy (Physician Services including prenatal, delivery, and postnatal care.)

Deductible and Cost Sharing

Outpatient Applied Behavioral Analysis (as part of an approved treatment plan)

Primary Care Provider Copayment

Mental HealthInpatient (Facility and Professional Services)

Deductible and Cost Sharing

 

Mental HealthOutpatient

Psychotherapy Services

Primary Care Provider Copayment

Facility and other Professional Services

 

 

Deductible and Cost Sharing

Morbid Obesity ($5,000 combined lifetime benefit limit, per participant)

Outpatient Habilitation Therapy Services (Includes physical, speech and occupational therapies. Limited to 20 visits combined per Participant, per benefit period.)

Outpatient Rehabilitation Therapy Services (Includes physical, speech and occupational therapies. Limited to 20 visits combined per Participant, per benefit period.)

 

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

Prescribed Contraceptive Services (Includes diaphragms, intrauterine devices (IUDs), implantables, injections and tubal ligation.)

No charge

Post-Mastectomy/Lumpectomy Reconstructive Surgery

 

 

Deductible and Cost Sharing

Skilled Nursing Facility (Limited to 30 days combined per Participant, per benefit period.)

Surgical/Medical (Professional Services)

Therapy Services (Including chemotherapy, growth hormone therapy, radiation and renal dialysis.)

Transplant Services

 

 

 

Preventive Care Benefits (See plan for specifically listed services)

No charge for services specifically listed

 

For services not specifically listed

deductible and Cost sharing

Immunizations (See Plan for specifically listed immunizations)

No charge for listed immunizations

 

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.

*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.

Benefit Highlight Sheet Boundary County School District #101

Effective Date September 1, 2019

Prescription Benefits for Idaho School Benefit Trust

 

 

 

 

Retail and Mail Order

(90-day supply with multiple copays)

What you pay

 

Generic

$10 Copayment per prescription – No Deductible required

$250 Deductible per participant on Formulary and Non-Formulary Brand Name Drugs*

Preferred Brand Name

$30 Copayment per prescription after Deductible is met

 

Non-Preferred Brand Name

 

$50 Copayment per prescription after Deductible is met

 

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)

 

 

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.

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.

Benefit Highlight Sheet

Boundary County School District #101

Effective Date September 1, 2019

VISION CARE BENEFITS (VSP) for Idaho School Benefit Trust – Option III

For Covered Providers and Services

What you pay

 

Copayment

Nothing per eye exam and/or $25 per Frame and Lenses or Medically Necessary Contact Lenses.

Service Frequency Limitations

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.

Payment for Services Rendered

 

Participating VSP Doctor

 

BCI pays 100% of Maximum Allowance after Copayment

 

Nonparticipating VSP Doctor

 

Professional Fees

 

Eye Exam

$45

Materials—lenses per pair

 

Single Vision

$48

Bifocals, up to

$65

Trifocals, up to

$90

Frame, up to

$45

Contact Lenses— per pair

 

(evaluation, materials, and fittings only)

$120

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.