HEALTH INSURANCE SOLUTIONS - For groups with 51 or more employees - Blue Cross of Idaho
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HEALTH INSURANCE SOLUTIONS
For groups with 51 or more employees
Policy Form Numbers
18-187 (01/22) 18-183 (01/22)
18-190 (01/22) 18-173 (01/22)
18-180 (01/22) 18-178 (01/22)
Form No. 3-1337 (08-21) bcidaho.com
18-907 (01/22)
1
Health plan options for employers Blue Cross of Idaho is committed to making healthcare easier to use, afford and understand for our members and clients. Our 2022 plan offerings aim to do just that. We’re refining our employer plans and solutions so they better meet the needs of our clients’ employees and their families. We’re also working hard to simplify the healthcare journey for members making their experience easier than ever before. These innovations for 2022 are paired with our core set of network options, value-based contracts with providers, and clinical solutions for members. 2
Group market solutions
Blue Cross of Idaho medical plans offer a combination of provider networks and
benefits that meet the needs of employers. These plans give employers options
to offer cost-effective, quality health benefits to their employees. All plan options
are available in each network.
Standard and high-deductible health plans Ancillary products
• Essential health benefits for preventive • Dental
services and immunizations • Vision
• Pharmacy benefits • Wellness
Network options • Employee Assistance Program (EAP)
• Preferred Provider Organization (PPO) • COBRA
• Coordinated Care Organization (CCO) Digital tools
Funding options • New member app
• Fully insured • Online Enrollment Center
• Self funded • Employer services website
• Balanced funded • Large group reporting and analytics
bcidaho.com
3
Expanded access to care
Tools to empower members while
Vital benefits to members and families: shopping for care:
$0
• NEW: ChoiceLocations – Members looking
for care can find low-cost facilities that are
highlighted in our provider directory.
• $0 copayment for primary care provider
(PCP) and behavioral healthcare visits for
dependent children* • SmartShopper: Members can use our online
tools to shop for the most cost-effective
$0 places for care when they need to have a
medical procedure. Members who shop for
and select low-cost facilities for care may be
• $0 copayment for Coordinated Care eligible for a cash reward.
Organization (CCO) PCP and behavioral
health visits
• ChoiceDocs: Members with plans in the
PPO network can use our online provider
directory to find ChoiceDocs-designated
• MDLIVE: Members of all ages can get providers. By visiting ChoiceDocs providers,
24/7 non-emergency virtual care from members will pay a lower or – depending on
anywhere through our telehealth vendor the plan – even no copayment.
MDLIVE
* Age 17 and younger Talk to your broker to learn more
about these benefits.
4
Blue Cross of Idaho member app
Our member app helps members find care
and keep track of their plan in a clean,
easy-to-use mobile app.
With the app, members can:
• Search for care
• Access and send/fax member ID card from the app
• Track claims for the entire family
• Find FAQs and help resources
• And more!
Find the app in the App Store and Google Play Store.
Text message updates from
Blue Cross of Idaho
Members can stay on top of their health with
educational and informational text messages
from Blue Cross of Idaho.
Members who opt in to get text messages from
Blue Cross of Idaho get:
• Updates on health plan benefits
available for you
• Reminders for when it’s time to get
preventive care
• Helpful tips on how to get and stay healthy
• Updates on COVID-19
Members can sign up for texts from
Blue Cross of Idaho in one of two ways:
• Visit connectbcidaho.com/signup
• Text bluecrossidaho to 73-529
Reply “STOP” to any Blue Cross of Idaho text
message and you will be removed from our
contact list.
bcidaho.com
5
Choice of network options
Blue Cross of Idaho offers competitive and flexible network options for our mid-
size and large group employers. All plan options are available in each network.
PPO CCO
• Network with the greatest access • Managed product for a specific network
to providers of providers
• Network includes: • Member’s PCP coordinates care between
o 100% of acute care hospitals in Idaho other providers
o More than 95% of all physicians in Idaho • Referrals are needed for out-of-network
specialist care
• Suitable for employers whose employees are
based in Idaho
Funding options
Fully Insured
Blue Cross of Idaho takes on the risk for the group’s healthcare costs. The group is charged a premium
that covers administration and claims expenses. This premium is billed and collected before the start
of the month that coverage begins.
Self Funded
The employer takes on much of the risk of the group’s healthcare costs from claims and related
expenses. The employer pays Blue Cross of Idaho a fee to administer benefits and process the claims.
The group is billed for the administrative services on a monthly basis in advance of services given, and
for paid claims on a weekly basis.
The group may also purchase excess loss coverage from Blue Cross of Idaho to guard against large or
unexpected medical costs.
Balanced Funded
The employer and Blue Cross of Idaho split the risk for the group’s healthcare costs. The group pays
set monthly amounts, which cover projected claims and administration costs, including an amount
for reinsurance.
If claims are less than projected, the group may get a refund of claims funding costs. If claims are more
than projected, the reinsurance covers the difference.
6
Coordinated Care Organizations
Our CCO plans place a PCP at the center of a member’s care. These PCPs are
part of a healthcare provider network. They treat members and help them find
specialty care or other services as needed. CCO plan members don’t need a
referral to get care from an in-network specialist, but they do need a referral for
out-of-network specialist care.
SOUTHWEST IDAHO
Saint Alphonsus Health Alliance
• More than 2,700 highly skilled providers, including those
at Saint Alphonsus Health System and many independent
providers across the Treasure Valley
• Seven medical centers, 13 outpatient and surgery facilities
and 43 urgent care clinics
• In-network providers located in Ada, Boise, Canyon, Elmore,
Gem, Owyhee, Payette, Valley and Washington counties
Independent Doctors of Idaho
• More than 650 independent providers, including PCPs and
specialists in orthopedics, gastroenterology, neurosurgery,
urology, neurology, dermatology, general surgery, psychiatry
and more
• 12 hospitals and surgery centers and 32 urgent care centers
• In-network providers located in Ada, Boise, Canyon, Elmore,
Gem, Owyhee, Payette, and Washington counties
SOUTHEAST IDAHO
Patient Quality Alliance
• More than 1,000 highly skilled healthcare providers,
including those at Portneuf Medical Center
• In-network providers located in Bannock, Bear Lake, Bingham,
Caribou, Franklin, Oneida and Power counties
Mountain View Network
• More than 1,300 highly skilled healthcare providers, including
those at Mountain View Hospital, Idaho Falls Community
Hospital and Madison Memorial Hospital
• Dozens of hospitals and surgery centers
• In-network providers located in Bingham, Bonneville,
Butte, Clark, Custer, Fremont, Jefferson, Lemhi, Madison
and Teton counties
bcidaho.com
7
Pharmacy plans
We offer a 3-Tier or 6-Tier formulary to let you pick the best option for
your employees.
3-Tier Formulary Tier 2 Non-Preferred Generic Drugs
Tier 1 Generic Drugs and Generic These drugs are equivalent to brand-name
Specialty Drugs drugs in dosage, safety, strength, method of
These drugs are equivalent to brand-name administration, performance characteristics
drugs in dosage, safety, strength, method of and intended use. However, they come with an
administration, performance characteristics and excessive cost compared to other alternatives
intended use. Blue Cross of Idaho has rated them within the same drug class.
as preferred due to their quality and
cost effectiveness. Tier 3 Preferred Brand-Name Drugs
These brand-name drugs have been rated by
Tier 2 Preferred Brand Name Drugs Blue Cross of Idaho as preferred due to their
and Preferred Specialty Drugs quality and cost effectiveness.
These brand-name drugs have been rated by
Blue Cross of Idaho as preferred due to their Tier 4 Non-Preferred Brand-Name Drugs
quality and cost effectiveness. These drugs are clinically effective medications,
but come with an excessive cost compared to
Tier 3 Non-Preferred Brand Name Prescription other alternatives within the same drug class.
Drugs and Non-Preferred Specialty Drugs
These drugs are clinically effective medications, Tier 5 Generic Specialty and
but come with an excessive cost compared to Preferred Specialty Drugs
other alternatives within the same drug class. These medications are used to treat complex
conditions. Blue Cross of Idaho has rated them
6-Tier Formulary as preferred due to their quality and
Tier 1 Preferred Generic Drugs cost effectiveness.
These drugs are equivalent to brand-name
drugs in dosage, safety, strength, method of Tier 6 Non-Preferred Specialty Drugs
administration, performance characteristics and These medications are used to treat complex
intended use. Blue Cross of Idaho has rated conditions, but come with an excessive cost
them as preferred due to their quality and compared to other alternatives within the same
cost effectiveness. drug class.
TIER FOUR OPTIONS DRUG TYPES
$10/$25/$40/$0 Generic and Generic Specialty/Preferred
$15/$30/$45/$0 Brand Name and Preferred Specialty/
3-Tier Rx
$10/$30/$50/$250 Non-Preferred Brand Name Prescription
$10/$30/$50/$500 and Non-Preferred Specialty
Separate prescription
Brand/Specialty deductible
(Rx) out-of-pocket $5/$15 Preferred Generic/
$0
(OOP) options for: Non-Preferred Generic
6-Tier Rx $250
$30/$50 Brand
$1,000 $500
20%/30% Specialty
$750
$2,000
Brand/Specialty deductible
$3,000 $0
$10/$20 Preferred Generic/
Non-Preferred Generic
6-Tier Rx $250
$30/$50 Brand
$500
20%/30% Specialty
$750
$10/$20 Preferred Generic/
Combined Rx and 6-Tier Rx
Brand/Specialty deductible Non-Preferred Generic
medical OOP $0 $30/$50 Brand
20%/30% Specialty
8
In-Network Benefits Highlights
PPO and CCO Plans HSA Plans
$0 copayment for dependent
children’s office visits $0 copayment $0 copayment after deductible
(age 17 and younger)
$30 copayment Deductible/coinsurance
Chiropractic benefit 18 visits 18 visits
Physical/speech/occupational $60 copayment Deductible/coinsurance
therapy 30 visits combined 30 visits combined
$10 copayment Deductible/coinsurance
MDLIVE (telehealth) (medical and behavioral) (medical and behavioral)
$100 copayment plus $100 copayment plus
Emergency room services deductible/coinsurance deductible/coinsurance
$250 or $400 No buy up –
First $DXL buy-up option (if no buy up, deductible/coinsurance) deductible/coinsurance
Option for combined Rx
Yes All HSA plans are combined
and medical OOP
bcidaho.com
9
Physician or other service copayments
ChoiceDocs is the basis for our physician Optional benefits:
copay model in our PPO plans.
FOR MEDIUM-SIZE AND LARGE GROUPS
• ChoiceDocs options include three copay
scenarios: $0-$20-$20-$40; $10-$30-$30- DXL first dollar payment benefits
$50; $20-$40-$40-$60 • Standard is deductible and coinsurance for
• There is a $20 spread between ChoiceDoc both in- and out-of-network services.
providers and standard providers • $250 – First $250 of medical claim is paid
• There is a $20 spread between PCP tiers by Blue Cross of Idaho – in-network only
and specialist tiers • $400 – First $400 of medical claim is paid
Example: $0-$20-$20-$40 option by Blue Cross of Idaho – in-network only
ChoiceDoc PCP: $0 copay Occupational rehabilitation and habilitation
Other in-network PCP: $20 copay therapy copayment
ChoiceDoc specialist: $20 copay • Standard benefit is for a $60 copay for
Other in-network specialist: $40 copay these therapy services
We have split copays for our CCO plans. • Optional buy-up benefit is a $30 copay for
these therapy services
• We have a $0 copay for our CCO network
for PCP visit and four options for specialist FOR LARGE GROUPS
visit copays: $30, $40, $50, $60 Acupuncture: Option for $30 copay for
in-network services. There is a deductible and
For other service type with copay
coinsurance for out-of-network services.
• Allergy injections: $5 copay 24-visit limit.
• Behavioral health outpatient visits:
Match the PCP copay (exception: if the
ChoiceDocs option on a PPO plan is a
$0-20 option for PCP visits, the behavioral
health copay will also be $0)
• Chiropractic services: $30 copay on all
plans for in-network services. Out-of-
network services require deductible and
coinsurance.
• Diabetes education: Matches the
PCP copay
• Occupational rehabilitation and
habilitation therapy services: $60 copay
on all plans for in-network services. Out-
of-network services require deductible and
coinsurance.
• Urgent care: Copay is same as PCP visit
10Covered Services
Blue Cross of Idaho health plans offer members a range of covered services to support any preventive,
acute and long-term care needs they may have. Members may be responsible for a portion of the cost
for these services.
• Allergy injections • Mental health – outpatient psychotherapy
• Ambulance transportation services services
• Breastfeeding support and supply services • Facility and other professional services
(limited to one breast pump purchase per • Outpatient cardiac rehabilitation services
benefit period, per insured) (limited to 36 visits per insured, per
• Chiropractic care (limited to 18 visits benefit period)
combined per insured, per benefit period) • Outpatient habilitation therapy services
• Dental services related to accidental injury (Includes physical, speech and occupational
• Diabetes self-management education therapies. Limited to 30 visits combined per
services (only for accredited providers insured, per benefit period.)
approved by Blue Cross of Idaho) • Outpatient rehabilitation therapy services
• Diagnostic services (including (includes physical, speech and occupational
diagnostic mammograms) therapies. Limited to 30 visits combined per
insured, per benefit period.)
• Durable medical equipment, orthotic devices
and prosthetic appliances • Palliative care services
• Emergency services – facility services • Physician office visit
(copayment waived if admitted) • Pediatric physician office visit (for insureds
o Additional services, such as laboratory, younger than 18)
X-ray, and other diagnostic services • Prescribed contraceptive services (includes
are subject to applicable deductible, diaphragms, intrauterine devices [IUDs],
coinsurance and/or copayment implantables, injections and tubal ligation)
o Blue Cross of Idaho will provide in- • Post-mastectomy/lumpectomy
network benefits for treatment of reconstructive surgery
emergency medical conditions. Insured • Pulmonary rehabilitation services
may be balance-billed for these services. • Skilled nursing facility (limited to 30 days
• Emergency services – professional services combined per insured, per benefit period)
o Blue Cross of Idaho will provide • Sleep study services
in-network benefits for treatment of • Surgical/medical professional services
emergency medical conditions. Insured • Therapy services (including chemotherapy,
may be balance-billed for these services. growth hormone therapy, radiation and
• Hearing aids for eligible dependent children renal dialysis)
only (benefits are limited to one device • Transplant services
per ear, every three years, and includes
45 speech therapy visits during the first 12 • Preventive care benefits
months after delivery of the covered device) • Immunizations
• Home health skilled nursing • Telehealth services provided by MDLIVE
• Home intravenous therapy (Non-emergency services provided for
medical consult, psychotherapy treatment,
• Hospice services outpatient medication management and
• Hospital services (inpatient and outpatient psychiatric evaluation/medical service
services at a licensed general hospital or covered services)
ambulatory surgical facility) • Telehealth virtual care services
• Rehabilitation or habilitation services (Providers other than MDLIVE)
• Maternity services and/or involuntary • Treatment for autism spectrum disorder
complications of pregnancy (services identified as part of the approved
• Outpatient applied behavioral analysis (as treatment plan)
part of an approved treatment plan) For more detail on these services, a sample
• Mental health – inpatient (facility and contract with benefit and policy explanations is
professional services) available on our website at bcidaho.com.
bcidaho.com
11Group Plans
Expanded lineup of deductible options
Individual deductible $0 $250 $500 $750 $1,000 $1,500 $2,000
Family deductible $0 $500 $1,000 $1,500 $2,000 $3,000 $4,000
Individual deductible $2,500 $3,000 $4,000 $5,000 $6,000 $7,000 $8,150 $8,500
Family deductible $5,000 $6,000 $8,000 $10,000 $12,000 $14,000 $16,300 $17,000
Deductible/out-of-pocket combinations:
$0-$500/1,000
Individual
$0 $250 $250 $250 $500 $500 $500
amounts
Network Any Any Any Any Any Any Any
Individual
$0 $250 $250 $250 $500 $500 $500
deductible
Family deductible $0 $500 $500 $500 $1,000 $1,000 $1,000
In-network
70% 90%* 90%* 90%* 90%* 90%* 90%*
coinsurance
Out-of-network
50% 70%** 70%** 70%** 70%** 70%** 70%**
coinsurance
Individual in-
network maximum $5,000 $1,750 $3,250 $4,750 $2,000 $3,500 $5,000
OOP
Family in-network
$10,000 $3,500 $6,500 $9,500 $4,000 $7,000 $10,000
maximum OOP
Individual out-of-
network maximum $6,500 $3,250 $5,250 $6,250 $3,500 $5,500 $6,500
OOP
Family out-of-
network maximum $13,000 $6,500 $10,500 $12,500 $7,000 $11,000 $13,000
OOP
* 90%, 80% and 70% coinsurance is available
** Out-of-network coinsurance is always 20% less than the in-network percentage
12Deductible/out-of-pocket combinations:
$750/1,500-$1,000/2,000
Individual amounts $750 $750 $750 $1,000 $1,000 $1,000
Network Any Any Any Any Any Any
Individual deductible $750 $750 $750 $1,000 $1,000 $1,000
Family deductible $1,500 $1,500 $1,500 $2,000 $2,000 $2,000
In-network
90%* 90%* 90%* 90%* 90%* 90%*
coinsurance
Out-of-network
70%** 70%** 70%** 70%** 70%** 70%**
coinsurance
Individual in-network
$2,250 $3,750 $5,250 $2,500 $4,000 $5,500
maximum OOP
Family in-network
$4,500 $7,500 $10,500 $5,000 $8,000 $11,000
maximum OOP
Individual out-of-
network maximum $3,750 $5,750 $6,750 $4,000 $6,000 $7,000
OOP
Family out-of-
network maximum $7,500 $11,500 $13,500 $8,000 $12,000 $14,000
OOP
Deductible/out-of-pocket combinations:
$1,500/3,000-$2,000/4,000
Individual amounts $1,500 $1,500 $1,500 $2,000 $2,000 $2,000 $2,000
Network Any Any Any Any Any Any Any
Individual deductible $1,500 $1,500 $1,500 $2,000 $2,000 $2,000 $2,000
Family deductible $3,000 $3,000 $3,000 $4,000 $4,000 $4,000 $4,000
In-network
90%* 90%* 90%* 100% 90%* 90%* 90%*
coinsurance
Out-of-network
70%** 70%** 70%** 100% 70%** 70%** 70%**
coinsurance
Individual in-network
$3,000 $4,500 $5,500 $2,000 $3,500 $5,000 $5,500
maximum OOP
Family in-network
$6,000 $9,000 $11,000 $4,000 $7,000 $10,000 $11,000
maximum OOP
Individual out-of-
network maximum $4,500 $6,500 $7,500 $2,000 $5,000 $7,000 $8,000
OOP
Family out-of-
network maximum $9,000 $13,000 $15,000 $4,000 $10,000 $14,000 $16,000
OOP
* 90%, 80% and 70% coinsurance is available
** Out-of-network coinsurance is always 20% less than the in-network percentage
bcidaho.com
13Deductible/out-of-pocket combinations:
$2,500/5,000-$3,000/6,000
Individual amounts $2,500 $2,500 $2,500 $2,500 $3,000 $3,000 $3,000 $3,000
Network Any Any Any Any Any Any Any Any
Individual deductible $2,500 $2,500 $2,500 $2,500 $3,000 $3,000 $3,000 $3,000
Family deductible $5,000 $5,000 $5,000 $5,000 $6,000 $6,000 $6,000 $6,000
In-network
100% 90%* 90%* 90%* 100% 90%* 90%* 90%*
coinsurance
Out-of-network
100% 70%** 70%** 70%** 100% 70%** 70%** 70%**
coinsurance
Individual in-network
$2,500 $4,000 $5,500 $7,000 $3,000 $4,500 $5,500 $7,500
maximum OOP
Family in-network
$5,000 $8,000 $11,000 $14,000 $6,000 $9,000 $11,000 $15,000
maximum OOP
Individual out-of-
network maximum $2,500 $5,500 $7,000 $8,500 $3,000 $6,000 $8,000 $9,000
OOP
Family out-of-
network maximum $5,000 $11,000 $14,000 $17,000 $6,000 $12,000 $16,000 $18,000
OOP
Deductible/out-of-pocket combinations:
$4,000/8,000-$5,000/10,000
Individual amounts $4,000 $4,000 $4,000 $4,000 $5,000 $5,000 $5,000
Network Any Any Any Any Any Any Any
Individual deductible $4,000 $4,000 $4,000 $4,000 $5,000 $5,000 $5,000
Family deductible $8,000 $8,000 $8,000 $8,000 $10,000 $10,000 $10,000
In-network
100% 90%* 90%* 90%* 100% 90%* 90%*
coinsurance
Out-of-network
100% 70%** 70%** 70%** 100% 70%** 70%**
coinsurance
Individual in-network
$4,000 $5,500 $7,000 $8,000 $5,000 $5,500 $7,000
maximum OOP
Family in-network
$8,000 $11,000 $14,000 $16,000 $10,000 $11,000 $14,000
maximum OOP
Individual out-of-
network maximum $4,000 $7,000 $8,500 $9,500 $5,000 $8,000 $9,000
OOP
Family out-of-
network maximum $8,000 $14,000 $17,000 $19,000 $10,000 $16,000 $18,000
OOP
* 90%, 80% and 70% coinsurance is available
** Out-of-network coinsurance is always 20% less than the in-network percentage
14Deductible/out-of-pocket combinations:
$6,000/12,000–$8,500/$17,000
Individual amounts $6,000 $6,000 $6,000 $7,000 $7,000 $8,150 $8,500
Network Any Any Any Any Any Any Any
Individual deductible $6,000 $6,000 $6,000 $7,000 $7,000 $8,150 $8,500
Family deductible $12,000 $12,000 $12,000 $14,000 $14,000 $16,300 $17,000
In-network
100% 90%** 90%** 100% 90%** 100% 100%
coinsurance
Out-of-network
100% 70%*** 70%*** 100% 70%*** 100% 100%
coinsurance
Individual in-network
$6,000 $7,500 $8,000 $7,000 $8,000 $8,150 $8,500
maximum OOP
Family in-network
$12,000 $15,000 $16,000 $14,000 $16,000 $16,300 $17,000
maximum OOP
Individual out-of-
network maximum $6,000 $9,000 $10,000 $7,000 $10,000 $8,150 $8,500
OOP
Family out-of-
network maximum $12,000 $18,000 $20,000 $14,000 $20,000 $16,300 $17,000
OOP
HSA non-embedded plans*
Individual-Only Plans
Individual deductible $1,500 $2,500 $3,500
In-network maximum OOP $5,000 $5,000 $5,000
Out-of-network maximum OOP $5,000 $5,000 $5,000
In-network coinsurance 90%** 90%** 90%**
Out-of-network coinsurance 70%*** 70%*** 70%***
Family Plans
Family deductible $3,000 $5,000 $7,000
Individual in-network maximum OOP $7,000 $7,000 $7,000
Individual out-of-network maximum OOP $7,000 $7,000 $7,000
Family in-network maximum OOP $10,000 $10,000 $10,000
Family out-of-network maximum OOP $10,000 $10,000 $10,000
In-network coinsurance 90%** 90%** 90%**
Out-of-network coinsurance 70%*** 70%*** 70%***
* Blue Cross of Idaho terminology: Umbrella for quoting
** 90%, 80% and 70% coinsurance is available
*** Out-of-network coinsurance is always 20% less than the in-network percentage
bcidaho.com
15HSA embedded plans*
Individual deductible $3,000 $4,000 $4,000 $5,000 $5,000 $6,800
Family deductible $6,000 $8,000 $8,000 $10,000 $10,000 $13,600
In-network
90%** 100% 90%** 100% 90%** 100%
coinsurance
Out-of-network
70%*** 100% 70%*** 100% 70%*** 100%
coinsurance
Individual in-network
$5,000 $4,000 $5,500 $5,000 $6,550 $6,800
maximum OOP
Family in-network
$10,000 $8,000 $11,000 $10,000 $13,100 $13,600
maximum OOP
Individual
out-of-network $5,000 $4,000 $5,500 $5,000 $6,550 $6,800
maximum OOP
Family
out-of-network $10,000 $8,000 $11,000 $10,000 $13,100 $13,600
maximum OOP
* Blue Cross of Idaho terminology: Aggregate for quoting
** 90%, 80% and 70% coinsurance is available
*** Out-of-network coinsurance is always 20% less than the in-network percentage
16Added benefits for all members
All Blue Cross of Idaho members can take advantage of an array of valuable
added benefits to help them get the most out of their healthcare dollars by
shopping for care, accessing care while traveling, getting personal support
during a health challenge, and taking advantage of discounts for the services
they need improve their health and well-being.
Cost Advisor
This cost transparency tool lets you
search for and compare providers,
hospitals and other healthcare
costs side-by-side before you
make appointments.
Blue Extras!sm
Blue Extras! offers discounted services,
programs and products that will help
you with your health, wellness and
fitness goals. These extras are provided
by independent sources that have
agreed to offer discounted rates to you
as a Blue Cross of Idaho member.
Care Management
This program helps employees and
their covered dependents who may
be facing a complex health condition.
Care managers work with members
to help guide them through the maze
of complex decision making that may
come with a serious health situation.
BlueCard®
This program enables members to
receive healthcare services while
traveling or living in another plan’s
service area. Participating providers
and the independent Blue Cross Blue
Shield (BCBS) plans across the country
are linked through a single electronic
network for claims processing and
reimbursement.
Included with all medical plans for all group types
Talk to your broker to learn more about these benefits.
bcidaho.com
17Clinical solutions for added support of members
Fully insured group members get access to a range of clinical solutions to lend
them support no matter where they are on their healthcare journey. Self-funded
employer groups can add any of these solutions to their benefit plan to help
their members manage a chronic condition, prevent Type 2 diabetes, get healthy
or manage their mental health.
Condition Support Weight Management
Care managers offer personal health Wondr Health – formerly known as
support to members with asthma, Naturally Slim – is a clinically proven
diabetes, chronic obstructive weight management and lifestyle
pulmonary disease, coronary artery change program. Not a diet, Wondr
disease, and congestive heart failure. Health helps participants learn how
they eat, not what they eat, so they
Diabetes Prevention Program can improve their physical and mental
This program helps members decrease health while still enjoying the foods
their risk of developing Type 2 they love.
diabetes. Through a 16-week program,
it teaches participants to make lasting Behavioral Health Management
lifestyle changes by eating healthier, Members in need get support from a
doing more physical activity and care manager who ensures members
managing challenges that come up get the highest quality and right site
along the way. of care.
Included with fully insured group plans, available as a Talk to your broker to learn more
buy-up with self-funded group plans
about these benefits.
18Add-on products and services
We offer a range of add-on products and services so employers can offer a full
suite of benefits to their employees to help them manage their physical, mental
and financial health while improving their overall well-being.
Dental plans Well-being packages
Our dental plans have been structured Blue Cross of Idaho launches its new
to optimize healthy outcomes by well-being platform with Sharecare in
increasing access to care, reducing cost March 2022. Employers can select a
for services that treat disease and align well-being package option to get the
covered services to support overall most out of the Sharecare platform
health and utilization of medically while administering a wellness
necessary services. See our Group program. Well-being add-on products
Dental Plans brochure for more details paired with a well-being package give
on plan options. employees access to resources to help
them quit smoking, manage diabetes,
Vision plans improve their mental health and more.
An annual well vision exam supports
overall health and may reveal the first COBRA
indication of several chronic diseases. Group health continuation coverage
Our vision plans offer either free or under the Consolidated Omnibus
low-cost WellVision Exams® with Budget Reconciliation Act (COBRA)
Vision Service Plan (VSP) network allows former employees and their
providers. Members get the most out families to temporarily continue their
of their vision benefit when they see job-based health coverage at near-
a VSP provider for corrective services, group rates. Blue Cross of Idaho offers
eyewear and contact lenses. See COBRA administration services to
your Group Vision Plan brochure for employers with 20 or more employees.
more details.
Nurse Advice Line
Employee Assistance Programs (EAP) This service lets members talk with a
EAP can connect you and your registered nurse 24/7 to help them
family to face-to-face counseling make informed choices about their
professionals, referrals to community health. While not a substitute for
resources and web-based tools to medical attention, members can
help you sort out work, personal or use the Nurse Advice Line to get
family issues. information about medications,
tests and procedures, chronic health
issues and answers to health-related
questions to help them and their
families healthy.
Available to purchase as an add-on product or service
Talk to your broker to learn more about these benefits.
bcidaho.com
19EXCLUSIONS AND LIMITATIONS
In addition to the exclusions and limitations listed elsewhere in this Policy, the following exclusions and limitations apply to the entire Policy, unless
otherwise specified.
I. GENERAL EXCLUSIONS AND LIMITATIONS N. For relaxation or exercise therapies, including but not limited to,
educational, recreational, art, aroma, dance, sex, sleep, electro sleep,
There are no benefits for services, supplies, drugs or other charges that vitamin, chelation, homeopathic, or naturopathic, massage, or music
are: even if prescribed by a Physician.
A. Not Medically Necessary. If services requiring Prior Authorization Q. For telephone consultations, and all computer or Internet
by Blue Cross of Idaho are performed by a Contracting Provider and communications, except as provided by MDLIVE or in connection with
benefits are denied as not Medically Necessary, the cost of said services Telehealth Virtual Care Services.
are not the financial responsibility of the Insured. However, the Insured
could be financially responsible for services found to be not Medically R. For failure to keep a scheduled visit or appointment; for completion
Necessary when provided by a Noncontracting Provider. of a claim form; for interpretation services; or for personal mileage,
transportation, food or lodging expenses or for mileage, transportation,
B. In excess of the Maximum Allowance. food or lodging expenses billed by a Physician or other Professional
Provider.
C. For hospital Inpatient or Outpatient care for extraction of teeth or
other dental procedures, unless necessary to treat an Accidental Injury S. For Inpatient admissions that are primarily for Diagnostic Services
or unless an attending Physician certifies in writing that the Insured has or Therapy Services; or for Inpatient admissions when the Insured
a non dental, life endangering condition which makes hospitalization is ambulatory and/or confined primarily for bed rest, special diet,
necessary to safeguard the Insured’s health and life. behavioral problems, environmental change or for treatment not
requiring continuous bed care.
D. Not prescribed by or upon the direction of a Physician or other
Professional Provider; or which are furnished by any individuals or T. For Inpatient or Outpatient Custodial Care; or for Inpatient or
facilities other than Licensed General Hospitals, Physicians, and other Outpatient services consisting mainly of educational therapy, behavioral
Providers. modification, self care or self help training, except as specified as a
Covered Service in this Policy.
E. Investigational in nature.
U. For any cosmetic foot care, including but not limited to, treatment
F. Provided for any condition, Disease, Illness or Accidental Injury to of corns, calluses, and toenails (except for surgical care of ingrown or
the extent that the Insured is entitled to benefits under occupational Diseased toenails).
coverage, obtained or provided by or through the employer under state
or federal Workers’ Compensation Acts or under Employer Liability V. Related to Dentistry or Dental Treatment, even if related to a medical
Acts or other laws providing compensation for work related injuries or condition; or orthoptics, eyeglasses or contact Lenses, or the vision
conditions. This exclusion applies whether or not the Insured claims examination for prescribing or fitting eyeglasses or contact Lenses,
such benefits or compensation or recovers losses from a third party. unless specified as a Covered Service in this Policy.
G. Provided or paid for by any federal governmental entity or unit W. For hearing aids or examinations for the prescription or fitting of
except when payment under this Policy is expressly required by federal hearing aids, except as specified as a Covered Service in this Policy.
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 X. For any treatment of sexual dysfunction, or sexual inadequacy,
by the existence of coverage under this Policy. including erectile dysfunction and/or impotence, except as related to a
prostatectomy.
H. Provided for any condition, Accidental Injury, Disease or Illness
suffered as a result of any act of war or any war, declared or undeclared. Y. Made by a Licensed General Hospital for the Insured’s failure to
vacate a room on or before the Licensed General Hospital’s established
I. Furnished by a Provider who is related to the Insured by blood or discharge hour.
marriage and who ordinarily dwells in the Insured’s household.
Z. Not directly related to the care and treatment of an actual condition,
J. Received from a dental, vision, or medical department maintained by Illness, Disease or Accidental Injury.
or on behalf of an employer, a mutual benefit association, labor union,
trust or similar person or group. AA. Furnished by a facility that is primarily a nursing home, a
convalescent home, or a rest home.
K. For Surgery intended mainly to improve appearance or for
complications arising from Surgery intended mainly to improve AB. For Acute Care, Rehabilitative care, diagnostic testing except
appearance, except for: as specified as a Covered Service in this Policy; for Mental or Nervous
Conditions and Substance Use Disorder or Addiction services not
1. Reconstructive Surgery necessary to treat an Accidental Injury, recognized by the American Psychiatric and American Psychological
infection or other Disease of the involved part; or Associations.
2. Reconstructive Surgery to correct Congenital Anomalies in an Insured AC. For any of the following:
who is a dependent child.
1. For appliances, splints or restorations necessary to increase vertical
3. Benefits for reconstructive Surgery to correct an Accidental Injury tooth dimensions or restore the occlusion, except as specified as a
are available even though the accident occurred while the Insured was Covered Service in this Policy;
covered under a prior insurer’s coverage.
2. For implants in the jaw; for pain, treatment, or diagnostic testing
L. Rendered prior to the Insured’s Effective Date. or evaluation related to the misalignment or discomfort of the
temporomandibular joint (jaw hinge), including splinting services and
K. For personal hygiene, comfort, beautification (including non-surgical supplies;
services, drugs, and supplies intended to enhance the appearance) even
if prescribed by a Physician. 3. For alveolectomy or alveoloplasty when related to tooth extraction.
L. For exercise or relaxation items or services even if prescribed by a AD. For weight control or treatment of obesity or morbid obesity, even
Physician, including but not limited to, air conditioners, air purifiers, if Medically Necessary, including but not limited to Surgery for obesity,
humidifiers, physical fitness equipment or programs, spas, hot tubs, except as specifically provided by the Weight Management Program
whirlpool baths, waterbeds or swimming pools. listed as a Covered Service in the Policy. For reversals or revisions of
Surgery for obesity, except when required to correct a life-endangering
M. For convenience items including but not limited to Durable condition.
Medical Equipment such as bath equipment, cold therapy units,
duplicate items, home traction devices, or safety equipment. AE. 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.
20AF. For the reversal of sterilization procedures, including but not AV. For vitamins and minerals, unless required through a written
limited to, vasovasostomies or salpingoplasties. prescription and cannot be purchased over the counter.
AG. Treatment for reproductive procedures, including but not AW. For an elective abortion, except to preserve the life of the female
limited to, ovulation induction procedures and pharmaceuticals, upon whom the abortion is performed, unless benefits for an elective
artificial insemination, in vitro fertilization, embryo transfer or similar abortion are specifically provided by a separate Endorsement to this
procedures, or procedures that in any way augment or enhance an Policy.
Insured’s reproductive ability, including but not limited to laboratory
services, radiology services or similar services related to treatment for AX. For alterations or modifications to a home or vehicle.
reproduction procedures.
AY. For special clothing, including shoes (unless permanently attached
AH. For Transplant services and Artificial Organs, except as specified to a brace).
as a Covered Service under this Policy.
AZ. Provided to a person enrolled as an Eligible Dependent, but
AI. For acupuncture, except as specified as a Covered Service in this who no longer qualifies as an Eligible Dependent due to a change in
Policy. eligibility status that occurred after enrollment.
AJ. For surgical procedures that alter the refractive character of AAA. Provided outside the United States, which if had been provided in
the eye, including but not limited to, radial keratotomy, myopic the United States, would not be a Covered Service under this Policy.
keratomileusis, Laser-In-Situ Keratomileusis (LASIK), and other surgical
procedures of the refractive keratoplasty type, to cure or reduce AAB. For Outpatient pulmonary and/or cardiac Rehabilitation except as
myopia or astigmatism, even if Medically Necessary, unless specified specified as a Covered Service in this Policy.
as a Covered Service in a Vision Benefits Section of this Policy, if AAC. For complications arising from the acceptance or utilization of
any. Additionally, reversals, revisions, and/or complications of such services, supplies or procedures that are not a Covered Service.
surgical procedures are excluded, except when required to correct an
immediately life endangering condition. AAD. For the use of Hypnosis, as anesthesia or other treatment, except
as specified as a Covered Service.
AK. For Hospice, except as specified as a Covered Service in this
Policy. AAE. For dental implants, appliances (with the exception of sleep apnea
devices), and/or prosthetics, and/or treatment related to Orthodontia,
AL. For pastoral, spiritual, bereavement, or marriage counseling. even when Medically Necessary unless specified as a Covered Service in
AM. For homemaker and housekeeping services or home delivered this Policy.
meals. AAF. For arch supports, orthopedic shoes, and other foot devices,
AN. For the treatment of injuries sustained while committing a felony, except as specified as a Covered Service in this Policy.
voluntarily taking part in a riot, or while engaging in an illegal act or AAG. For surgical removal of excess skin that is the result of weight
occupation, unless such injuries are a result of a medical condition or loss or gain, including but not limited to association with prior weight
domestic violence. reduction (obesity) Surgery.
AO. For treatment or other health care of any Insured in connection AAH. For the purchase of Therapy or Service Dogs/Animals and the cost
with an Illness, Disease, Accidental Injury or other condition which of training/maintaining said animals.
would otherwise entitle the Insured to Covered Services under this
Policy, if and to the extent those benefits are payable to or due the AAI. For procedures including but not limited to breast augmentation,
Insured under any medical payments provision, no fault provision, liposuction, Adam’s apple reduction, rhinoplasty and facial
uninsured motorist provision, underinsured motorist provision, or other reconstruction and other procedures considered cosmetic in nature.
first party or no fault provision of any automobile, homeowner’s, or
other similar policy of insurance, contract, or underwriting plan. AAJ. For the treatment of injuries sustained while operating a motor
vehicle under the influence of alcohol and/or narcotics. For purposes
In the event Blue Cross of Idaho (BCI) for any reason makes payment of this Policy exclusion, “Under the influence” as it relates to alcohol
for or otherwise provides benefits excluded by the above provisions, means having a whole blood alcohol content of .08 or above or a serum
it shall succeed to the rights of payment or reimbursement of the blood alcohol content of .10 or above as measured by a laboratory
compensated Provider, the Insured, and the Insured’s heirs and personal approved by the State Police or a laboratory certified by the Centers for
representative against all insurers, underwriters, self insurers or other Medicare and Medicaid Services. For purposes of this Policy exclusion,
such obligors contractually liable or obliged to the Insured, or his or her “Under the influence” as it relates to narcotics means impairment
estate for such services, supplies, drugs or other charges so provided by of driving ability caused by the use of narcotics not prescribed or
BCI in connection with such Illness, Disease, Accidental Injury or other administered by a Physician.
condition.
AAK. Any newly FDA approved Prescription Drug, biological agent,
AP. For which an Insured would have no legal obligation to pay in or other agent until it has been reviewed and implemented by BCI’s
the absence of coverage under this Policy or any similar coverage; Pharmacy and Therapeutics Committee.
or for which no charge or a different charge is usually made in the
absence of insurance coverage or charges in connection with work for AAL. All services, supplies, devices and treatment that are not FDA
compensation or charges; or for which reimbursement or payment is approved.
contemplated under an agreement with a third party.
AAM. Any services, interventions occurring within the framework of
AQ. For a routine or periodic mental or physical examination that is an educational program or institution; or provided in or by a school/
not connected with the care and treatment of an actual Illness, Disease educational setting; or provided as a replacement for services that are
or Accidental Injury or for an examination required on account of the responsibility of the educational system.
employment; or related to an occupational injury; for a marriage license;
or for insurance, school or camp application; or for sports participation II. PRESCRIPTION DRUG EXCLUSIONS AND LIMITATIONS
physicals; or a screening examination including routine hearing
examinations, except as specified as a Covered Service in this Policy. In addition to any other exclusions and limitations of this Policy, the
following exclusions and limitations apply to Prescription Drug Services.
AR. For immunizations, except as specified as a Covered Service in No benefits are available under this Policy for the following:
this Policy.
A. Drugs used for the termination of early pregnancy, and complications
AS. For breast reduction Surgery or Surgery for gynecomastia. arising therefrom, except when required to correct an immediately life-
endangering condition.
AT. For nutritional supplements.
AU. 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, or except as specified as a Covered Service in this Policy.
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21B. Over-the-counter drugs other than insulin, even if prescribed E. Living expenses for the recipient, donor, or family members, except
by a Physician. Notwithstanding this exclusion, BCI, through the as specifically listed as a Covered Service in this Policy.
determination of the BCI Pharmacy and Therapeutics Committee may
choose to cover certain over-the-counter medications when Prescription F. Costs covered or funded by governmental, foundation or charitable
Drug benefits are provided under this Policy. Such approved over-the- grants or programs; or Physician fees or other charges, if no charge is
counter medications must be identified by BCI in writing and will specify generally made in the absence of insurance coverage.
the procedures for obtaining benefits for such approved over-the-
counter medications. Please note that the fact a particular over-the- G. Any complication to the donor arising from a donor’s Transplant
counter drug or medication is covered does not require BCI to cover or Surgery is not a covered benefit under the Insured Transplant recipient’s
otherwise pay or reimburse the Insured for any other over-the-counter Policy. If the donor is a BCI Insured, eligible to receive benefits for
drug or medication. Covered Services, benefits for medical complications to the donor
arising from Transplant Surgery will be allowed under the donor’s policy.
C. Charges for the administration or injection of any drug, except for
vaccinations listed on the Prescription Drug Formulary. H. Costs related to the search for a suitable donor.
D. Therapeutic devices or appliances, including hypodermic needles, I. No benefits are available for services, expenses, or other obligations
syringes, support garments, and other non-medicinal substances except of or for a deceased donor (even if the donor is an Insured).
Diabetic Supplies, regardless of intended use. IV. HOSPICE EXCLUSIONS AND LIMITATIONS
E. Drugs labeled “Caution—Limited by Federal Law to Investigational In addition to any other exclusions and limitations of this Policy, the
Use,” or experimental drugs, even though a charge is made to the following exclusions and limitations apply to Hospice Services. No
Insured. benefits are available under this Policy for the following:
F. Immunization agents, except for vaccinations listed on the A. Hospice Services not included in a Hospice Plan of Treatment and not
Prescription Drug Formulary, biological sera, blood or blood plasma. provided or arranged and billed through a Hospice.
Benefits may be available under the Major Medical Benefits Section of
this Policy. B. Continuous Skilled Nursing Care except as specifically provided as a
part of Respite Care or Continuous Crisis Care.
G. 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 C. Hospice benefits provided during any period of time in which an
Hospital, rest home, sanatorium, Skilled Nursing Facility, extended care Insured is receiving Home Health Skilled Nursing Care benefits.
facility, convalescent hospital, nursing home, or similar institution which
operates or allows to operate on its premises, a facility for dispensing V. PREEXISTING CONDITION WAITING PERIOD
pharmaceuticals.
There is no preexisting condition waiting period for benefits available
H. Any prescription refilled in excess of the number specified by the under this Policy.
Physician, or any refill dispensed after one (1) year from the Physician’s
original order. AM. All services, supplies, devices and treatment that are not FDA
approved.
I. Any Prescription Drug, biological or other agent, which is:
AAN. Any services, interventions occurring within the framework of
a) Prescribed primarily to aid or assist the Insured in weight loss, an educational program or institution; or provided in or by a school/
including all anorectics, whether amphetamine or nonamphetamine. educational setting; or provided as a replacement for services that are
the responsibility of the educational system.
b) Prescribed primarily to retard the rate of hair loss or to aid in the
replacement of lost hair.
c) Prescribed primarily to increase fertility, including but not limited to,
drugs which induce or enhance ovulation.
d) Prescribed primarily for personal hygiene, comfort, beautification, or
for the purpose of improving appearance.
e) Prescribed primarily to increase growth, including but not limited to,
growth hormone.
f) 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.
J. Lost, stolen, broken or destroyed Prescription Drugs except in the
case of loss due directly to a natural disaster.
III.Transplant Exclusions and Limitations
In addition to any other exclusions and limitations of this Policy,
the following exclusions and limitations apply to Transplant or
Autotransplant services. No benefits are available under this Policy for
the following:
A. Transplants of brain tissue or brain membrane, intestine, pituitary and
adrenal glands, hair Transplants, or any other Transplant not specifically
named as a Covered Service in this section; or for Artificial Organs
including but not limited to, artificial hearts or pancreases.
B. Any eligible expenses of a donor related to donating or transplanting
an organ or tissue unless the recipient is an Insured who is eligible to
receive benefits for Transplant services.
C. The cost of a human organ or tissue that is sold rather than donated
to the recipient.
D. Transportation costs including but not limited to, Ambulance
Transportation Service or air service for the donor, or to transport a
donated organ or tissue.
22DISCRIMINATION IS AGAINST THE LAW
Blue Cross of Idaho and Blue Cross of Idaho Care Plus, discriminated in another way on the basis
Inc., (collectively referred to as Blue Cross of Idaho) of race, color, national origin, age, disability or sex,
complies with applicable Federal civil rights laws and you can file a grievance with Blue Cross of Idaho’s
does not discriminate on the basis of race, color, national Grievances and Appeals Department at:
origin, age, disability or sex. Blue Cross of Idaho does Manager, Grievances and Appeals
not exclude people or treat them differently because of 3000 E. Pine Ave., Meridian, ID 83642
race, color, national origin, age, disability or sex. Telephone: 1-800-274-4018
Blue Cross of Idaho: Fax: 208-331-7493
• Provides free aids and services to people with Email: grievances&appeals@bcidaho.com
disabilities to communicate effectively with us, such as: TTY: 711
o Qualified sign language interpreters You can file a grievance in person or by mail, fax,
o Written information in other formats (large or email. If you need help filing a grievance, our
print, audio, accessible electronic formats, other Grievances and Appeals team is available to help you.
formats) You can also file a civil rights complaint with the U.S.
• Provides free language services to people whose Department of Health and Human Services, Office for
primary language is not English, such as: Civil Rights electronically through the Office for Civil
o Qualified interpreters Rights Complaint Portal, available at https://ocrportal.
hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
o Information written in other languages
U.S. Department of Health and Human Services, 200
If you need these services, contact Blue Cross of Idaho Independence Avenue SW., Room 509F, HHH Building,
Customer Service Department. Call 1-800-627-1188 Washington, DC 20201, 1-800-368-1019, 800-537-7697
(TTY: 711), or call the customer service phone number (TTY). Complaint forms are available at
on the back of your card. If you believe that Blue http://www.hhs.gov/ocr/office/file/index.html.
Cross of Idaho has failed to provide these services or
ATTENTION: If you speak Arabic, Bantu, Chinese, Farsi, French, German, Japanese, Korean, Nepali, Romanian,
Russian, Serbo-Croatian, Spanish, Tagalog, or Vietnamese, language assistance services, free of charge, are
available to you. Call 1-800-627-1188 (TTY: 711).
Form No. 3-1187 (09-20)There when you need us,
never when you don’t.
Sales 888-462-7677 | Customer Service 855-230-6862
3000 East Pine Avenue | Meridian, Idaho | 83642-5995
PO Box 7408 | Boise, Idaho | 83707-1408
1-800-365-2345 | TTY 711
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