Page 5 - PPP Guide

Medical Benefits

BCBS of Idaho—Preferred Blue PPO—Effective 12/1/2014
PPO Out-of-Network
Employee Eligibility
Class 1 All other full-time employees working a minimum of 30 hours per week
Class 2 All full-time managers and supervisors working a minimum of 30 hours per week
Eligibility Waiting Period
Class 1 First of month following 60 days
Class 2 First of month following date of hire
Calendar Year Deductible
Individual $2,000
Family $4,000
Out-of-Pocket Maximum
Individual $3,500 $5,000
Family $7,000 $10,000
Physician Ofice Visits
Primary care $30 copay 40% after deductible
Specialist $30 copay 40% after deductible
Urgent care $30 copay 40% after deductible
Wellness/preventive 100% 40% after deductible
Lab Services
Physician ofice 20% after deductible 40% after deductible
Outpatient facility 20% after deductible 40% after deductible
Outpatient hospital 20% after deductible 40% after deductible
X-Ray/Radiology Services
Physician ofice 20% after deductible 40% after deductible
Outpatient facility 20% after deductible 40% after deductible
Outpatient hospital 20% after deductible 40% after deductible
Hospital Services
Inpatient 20% after deductible 40% after deductible
Outpatient 20% after deductible 40% after deductible
Emergency room $100 copay then 20% after deductible $100 copay then 40% after deductible
Mental Health
Inpatient facility 20% after deductible 40% after deductible
Outpatient facility 20% after deductible 40% after deductible
Ofice visits $30 copay 40% after deductible
Substance Abuse
Inpatient facility 20% after deductible 40% after deductible
Outpatient facility 20% after deductible 40% after deductible
Ofice visits $30 copay 40% after deductible
Chiropractic Care
20% after deductible 50% after deductible
Limitations 18 visits combined per insured per beneit period
Prescription
Retail—Supply Limit 30 days
Generic $10 copay $10 copay
Preferred brand $20 copay $20 copay
Non-preferred and specialty $20 copay $20 copay
Mail Order—Supply Limit 90 days 90 days
Generic $10 copay $10 copay
Preferred brand $20 copay $20 copay
Non-preferred and specialty $20 copay $20 copay

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