2020 Individual ACA Plan Guide

2020 | PLAN GUIDE INDIVIDUAL AND FAMILY HEALTH INSURANCE PLAN GUIDE

Serving all counties in Idaho

Policy No. 18-069-01/20 18-073-01/20 18-102-01/20 18-116-01/20 18-704-01/20 18-724-01-20 18-070-01/20 18-075-01/20 18-107-01/20 18-117-01/20 18-722-01/20 18-770-01/20 18-071-01/20 18-076-01/20 18-108-01/20 18-118-01/20 18-723-01/20 18-788-01/20 Form No. 20-013 (01-20) 18-072-01/20 18-078-01/20 18-109-01/20

BLUE CROSS OF IDAHO

Make the Choice that Works for You.

When it comes to finding the right healthcare coverage, we know you have choices. Understanding how to make the best choice is the first step in choosing the right plan with the coverage you want and the benefits you deserve.

We are here to make it easier for you so you can get on with your life with less worry, less hassle and more financial peace of mind.

There’s a reason why thousands of your friends and neighbors trust Blue Cross of Idaho.

We understand when to step in and help you through the health insurance process. We also know when to get out of the way and let you work with your provider to take control of your health.

We understand the important questions you may have about our plans or health coverage in general. We have the tools you need to make informed decisions and get the most out of your health plan.

We are Idahoans who have been helping Idahoans make the most informed healthcare decisions for over 70 years. And we’d love to serve you.

2 HEALTH PLANS | BLUE CROSS OF IDAHO Ready to find a plan that’s right for you? Let’s The following pages outline specific Blue Cross of Idaho networks and plans. Get If you need help, call your insurance agent or talk to Blue Cross of Idaho sales team today Started at 1-888-GO-CROSS (1-888-462-7677).

Follow these steps to find the best plan to meet your needs and get the coverage you deserve.

HERE’S YOUR CHECKLIST:

Find a plan that fits your lifestyle and budget on pages 2 - 5.

See if you qualify for a tax credit or cost-sharing reduction. If you qualify for a cost-sharing reduction, see pages 6 - 9. If you are a Native American or American Indian, see pages 10 and 11.

Read how your plan will work, review the networks, PCPs and hospitals available where you live, pages 12 - 17.

Buy your plan. Open enrollment is November 1 through December 16, 2019.

BLUE CROSS OF IDAHO | HEALTH PLANS 1 KEY TERMS Affordable Care Coinsurance C Blue Cross of Idaho shares the cost of your AT IC GOLD SILVER BRONZE ASTROPH healthcare covered under your plan. For Act (ACA) Plans example, if we cover 70 percent of a doctor’s charges, you’re responsible for paying the remaining 30 percent. LEARN MORE ABOUT THE METAL LEVELS: BRONZE, Copay A set amount you pay directly to a doctor, SILVER AND GOLD hospital or pharmacy when you need a service. Depending on your plan, you might C AT IC pay a copayG OtoLD see a primary care provider SILVER BRONZE ASTROPH (PCP), have an MRI or visit the ER. If you don’t see a doctor very often, a bronze plan is a great way to save Deductible on your monthly premium. We pay The dollar amount you pay for most about 60 percent of the average healthcare you get before your insurance plan starts to pay. Some plans have one deductible medical costs.* for medical care and a separate deductible for prescriptions.

CA C G S B E TA HI In-Network OLD If you see a doctor once in a while,ILVER a RONZ STROP Care you receive from a primary care provider silver plan is a good option. This is a on your plan’s list of covered doctors or care you receive from a doctor, hospital, clinic “middle-of-the-road” plan where we or pharmacy on your plan’s list of covered pay about 70 percent of the average doctors when you have a referral. medical costs.* You can find a list for your plan network at bcidaho.com/findaprovider.

Out-of-Network If you go to the doctor regularly, Care you receive from a doctor, hospital or a gold plan may be right for clinic who is not on your plan’s list of covered you. You pay a higher monthly doctors or without a referral from your primary care provider. premium, but Blue Cross of Idaho pays about 80 percent of the Even if you have a referral, providers who are not on your plan’s list can also bill you average medical costs.* for whatever insurance doesn’t cover; this is *Payment percentages are based on an average called “balance billing” and is a major reason person’s healthcare expenses over a year. you should use providers in your plan’s network.

Out-of-Pocket Maximum The combined maximum deductible, copay, FIND YOUR PLAN BEFORE THE and coinsurance amount you pay for covered healthcare each year. FOLLOWING BENEFIT GRIDS

The following benefit grids outline common in- and Premium The amount you pay monthly for your health out-of-network services, and are not comprehensive insurance plan. lists of benefits. For more information, please visit bcidaho.com/SBC to review a Summary of Benefits and Coverage. 2 HEALTH PLANS | BLUE CROSS OF IDAHO SUPPORT FROM LOCAL NETWORKS When you choose a Blue Cross of Idaho managed care plan, you must choose a primary care provider (PCP) from your local network. Your PCP will serve as your care coordinator and provide referrals to visit specialists or other healthcare providers.

BRONZE 8150 OR BRONZE 6300 OR BRONZE HSA 6000 OR BRONZE CAREPOINT 8150 BRONZE CAREPOINT 6300 BRONZE HSA CAREPOINT 6000 What You Pay What You Pay What You Pay What You Pay What You Pay What You Pay In Network Out of Network In Network Out of Network In Network Out of Network BENEFITS YOU ARE MOST LIKELY TO NEED Primary Care Visits $40 $40 Urgent Care Visits 60% after 60% after 20% after 60% after deductible deductible deductible deductible Specialist Visits $65 $105 (w/referral)

Preferred Generic $5 after deductible* $5 after deductible* Prescriptions $15 $15 $15 $15 Non-Preferred Generic $10 after deductible $10 after deductible Prescriptions Immunizations $0 $0 $0 $0 $0 $0 Preventive Care Diabetes Education $20 $20 Outpatient Mental 60% after 60% after 60% after Health and Substance deductible deductible 20% after deductible Abuse Visits $40 $40 deductible Applied Behavior Analysis Visits1 OTHER BENEFITS YOU MIGHT NEED $350 $350 $350 $350 $350 Emergency Room Visits after deductible2 after deductible after deductible2 after deductible after deductible2 Imaging $500, then 40% $500, then 60% $250, then 20% $250, then 60% (MRIs, CT scans) after deductible after deductible after deductible after deductible Lab Work and X-rays Surgery (doctors $0 charges, anesthesia and after deductible 60% after other covered charges) deductible 40% after 60% after 20% after 60% after Having a Baby deductible deductible deductible deductible (pregnancy care, delivery and after care) Therapy Visits3 (PT, ST, and OT) WHAT YOU’LL PAY FOR THE CARE YOU RECEIVE EACH YEAR How much you’ll pay each year before we start paying for some services; Medical Deductible deductible is doubled for family policies, no matter how many are covered $8,150 $16,300 $6,300 $16,300 $6,000 $16,300 Prescription Deductible No separate drug deductible No separate drug deductible No separate drug deductible The percent you’ll pay for covered services; we’ll pay the other part Coinsurance 0% 60% 40% 60% 20% 60% The most you’ll pay out of pocket each year for covered care and prescriptions; Out-of-Pocket maximum is doubled for family policies, no matter how many are covered Maximum $8,150 $81,500 $8,150 $81,500 $6,850 $81,500 IF YOU NEED BRAND NAME OR SPECIALTY PRESCRIPTIONS

Preferred Brand $35 after deductible $35 after deductible $35 after deductible Name Prescriptions4 Non-Preferred Brand $50 after deductible $50 after deductible $50 after deductible Name Prescriptions4 Preferred 30% after deductible 30% after deductible 30% after deductible Specialty Drugs Non-Preferred 50% after deductible 50% after deductible 50% after deductible Specialty Drugs

*The Bronze HSA 6000 plan includes an additional list of prescriptions with no copay. The HSA Preventive Drug List can be found online at members.bcidaho.com. See page 5 for footnote descriptions.

BLUE CROSS OF IDAHO | HEALTH PLANS 3 SILVER 6000 OR SILVER 5000 OR SILVER 4000 OR SILVER CAREPOINT 6000 SILVER CAREPOINT 5000 SILVER CAREPOINT 4000 What You Pay What You Pay What You Pay What You Pay What You Pay What You Pay In Network Out of Network In Network Out of Network In Network Out of Network BENEFITS YOU ARE MOST LIKELY TO NEED Primary Care Visits $20 $30 $35 Urgent Care Visits 60% after 60% after 60% after deductible deductible deductible Specialist Visits $50 $60 $55 (w/referral)

Preferred Generic $5 $5 $5 $5 $5 $5 Prescriptions Non-Preferred Generic Prescriptions $10 $10 $10 $10 $10 $10 Immunizations $0 $0 $0 $0 $0 $0 Preventive Care Diabetes Education $20 $20 $20 Outpatient Mental Health and Substance 60% after 60% after 60% after Abuse Visits deductible deductible deductible $20 $30 $35 Applied Behavior Analysis Visits1

OTHER BENEFITS YOU MIGHT NEED $350 after $350 after $350 after $350 after $350 after $350 after Emergency Room Visits deductible deductible2 deductible deductible2 deductible deductible2 Imaging $250, then 20% $250, then 60% $250, then 40% $250, then 60% $250, then 40% $250, then 60% (MRIs, CT scans) after deductible after deductible after deductible after deductible after deductible after deductible Lab Work and X-rays Surgery (doctors charges, anesthesia and other covered charges) 20% after 60% after 40% after 60% after 40% after 60% after Having a Baby deductible deductible deductible deductible deductible deductible (pregnancy care, delivery and after care) Therapy Visits3 (PT, ST, and OT) WHAT YOU’LL PAY FOR THE CARE YOU RECEIVE EACH YEAR How much you’ll pay each year before we start paying for some services; deductible is doubled for family policies, Medical Deductible no matter how many are covered $6,000 $16,300 $5,000 $16,300 $4,000 $16,300 Prescription Deductible No separate drug deductible $1,000 per person $1,500 per person The percent you’ll pay for covered services; we’ll pay the other part Coinsurance 20% 60% 40% 60% 40% 60% The most you’ll pay out of pocket each year for covered care and prescriptions; maximum is doubled for family policies, Out-of-Pocket no matter how many are covered Maximum $8,150 $81,500 $8,150 $81,500 $8,150 $81,500 IF YOU NEED BRAND NAME OR SPECIALTY PRESCRIPTIONS Preferred Brand $35 after deductible $35 after deductible $35 after deductible Name Prescriptions4 Non-Preferred Brand $50 after deductible $50 after deductible $50 after deductible Name Prescriptions4 Preferred 30% after deductible 30% after deductible 30% after deductible Specialty Drugs Non-Preferred 50% after deductible 50% after deductible 50% after deductible Specialty Drugs

See page 5 for footnote descriptions.

4 HEALTH PLANS | BLUE CROSS OF IDAHO 1 GOLD 2000 OR CATASTROPHIC 8150 OR Treatment for Autism Spectrum Disorder is covered the same as any GOLD CAREPOINT 2000 CATASTROPHIC CAREPOINT 8150* other condition, depending on the What You Pay What You Pay What You Pay What You Pay services rendered. Visit limits do not apply to Treatments for Autism In Network Out of Network In Network Out of Network Spectrum Disorder and related BENEFITS YOU ARE MOST LIKELY TO NEED diagnoses. Primary Care Visits $30 up to 3 visits, 2 For treatment of emergency $20 60% after then deductible 60% after medical conditions as defined in Urgent Care Visits the policy, Blue Cross will provide deductible deductible Specialist Visits $0 after in-network benefits for covered $50 (w/referral) deductible services. Preferred Generic 3 Includes physical, occupational, and Prescriptions $0 $0 $0 $0 speech therapy services. You have a total of 20 in- and out-of-network Non-Preferred Generic $10 $10 $10 $10 visits for covered rehabilitative Prescriptions therapy services per member per year and a total of 20 in- and out-of- Immunizations $0 $0 network visits for covered habilitative $0 $0 Preventive Care therapy services per member per year. Diabetes Education 4 Prescription drug coverage includes Outpatient Mental 60% after 60% after a generic substitution requirement. If $0 Health and Substance $20 deductible deductible you or your doctor requests a brand- Abuse Visits after deductible name prescription when a generic Applied Behavior equivalent is available, you are 1 responsible for paying the difference Analysis Visits between the allowed cost of the OTHER BENEFITS YOU MIGHT NEED generic drug and the brand-name drug and any applicable brand-name $350 $350 Emergency Room Visits copayment. The extra costs do not after deductible after deductible2 count toward your out-of-pocket Imaging $250, then 20% $250, then 60% maximum. You or your healthcare (MRIs, CT scans) provider can ask Blue Cross to review after deductible after deductible this policy on a case-by-base basis. Lab Work and X-rays *Catastrophic plans are only Surgery (doctors $0 60% available to people under the age charges, anesthesia and after deductible after deductible2 of 30 or to people who qualify for other covered charges) a hardship exemption through the 20% after 60% after Idaho health insurance exchange. Having a Baby deductible deductible Visit yourhealthidaho.org for (pregnancy care, more information on catastrophic delivery and after care) coverage. Therapy Visits3 (PT, ST, and OT) WHAT YOU’LL PAY FOR THE CARE YOU RECEIVE EACH YEAR How much you’ll pay each year before we start paying for some services; Medical Deductible deductible is doubled for family policies, no matter how many are covered $2,000 $16,300 $8,150 $16,300 Prescription Deductible $1,000 per person No separate drug deductible The percent you’ll pay for covered services; we’ll pay the other part Coinsurance 20% 60% 0% 60% The most you’ll pay out of pocket each year for covered care and prescriptions; Out-of-Pocket maximum is doubled for family policies, no matter how many are covered Maximum $5,500 $81,500 $8,150 $81,500 IF YOU NEED BRAND NAME OR SPECIALTY PRESCRIPTIONS Preferred Brand $35 after deductible Name Prescriptions4 Non-Preferred Brand $50 after deductible Name Prescriptions4 $0 Preferred after deductible Specialty Drugs 30% after deductible Non-Preferred Specialty Drugs 50% after deductible

BLUE CROSS OF IDAHO | HEALTH PLANS 5 Cost-Sharing Reductions can help you save even more on your out-of- pocket insurance costs.

In addition to your tax credit, you may qualify for even more savings on your health insurance costs, depending on your income and family size. These savings make your deductibles, coinsurance and copays less expensive.

Use the chart on the next page to see which CSR level you may qualify for.

To take advantage of these savings, make sure you:

• Apply for your health insurance plan through Your Health Idaho. You can find them online at yourhealthidaho.org or call 1-855-944-3246.

• Choose one of the Silver plans listed on the following pages.

Note: Members of Native American tribes qualify for a separate CSR. See pages 10 and 11 for details.

6 HEALTH PLANS | BLUE CROSS OF IDAHO MONTHLY PREMIUM TAX CREDIT Depending on your income, you may qualify for a tax credit, also known as a subsidy. If you qualify, the government will pay part of your monthly premium, which could result in major savings for you. Use the first column in the chart below to see if you qualify. You can also estimate your savings at Idaho’s health insurance marketplace, Your Health Idaho, at yourhealthidaho.org.

COST-SHARING REDUCTION You may also be eligible for cost-sharing reduction (CSR) plans that lower the amount you pay out of your own pocket for deductibles, coinsurance and copays. Use the second column in the chart below to see if you qualify. If you do, turn to pages 8 - 9 to see what your out-of- pocket costs could look like.

IMPORTANT: If you qualify for a tax credit or cost-sharing reduction, you need to purchase your plan at yourhealthidaho.org to take advantage of your savings. However, you can still work with a local insurance agent or a Blue Cross of Idaho sales rep to find the right plan.

The combination of your family size and household income determines whether you’re eligible for a premium tax credit and cost-sharing reduction.

MONTHLY PREMIUM TAX CREDIT COST-SHARING REDUCTION Family Size Annual Household Income Annual Household Income 1 $12,490 – $49,960 $12,490 – $31,225

2 $16,910 – $67,640 $16,910 – $42,275

3 $21,330 – $85,320 $21,330 – $53,325

4 $25,750 – $103,000 $25,750 – $64,375

5 $30,170 – $120,680 $30,170 – $75,425

6 $34,590 – $138,360 $34,590 – $86,475

7 $39,010 – $156,040 $39,010 – $97,525

8 $43,430 – $173,720 $43,430 – $108,575

BLUE CROSS OF IDAHO | HEALTH PLANS 7 SILVER 6000 OR SILVER CAREPOINT 6000 CSR LEVEL 73 CSR LEVEL CSR LEVEL CSR LEVEL Family Size Annual Household Income 73 87 94 1 $24,980 - 31,225 WHAT YOU PAY WHAT YOU PAY WHAT YOU PAY IN NETWORK IN NETWORK IN NETWORK 2 $33,820 - 42,275 BENEFITS YOU ARE MOST LIKELY TO NEED Primary Care Visits 3 $42,660 - 53,325 $20 $20 $10 Urgent Care Visits Specialist Visits $50 $50 $20 4 $51,500 - 64,375 (w/referral) Preferred Generic Prescriptions $5 $5 $5 5 $60,340 - 75,425 Non-Preferred Generic $10 $10 $10 Prescriptions 6 $69,180 - 86,475 Immunizations $0 $0 $0 7 $78,020 - 97,525 Preventive Care Diabetes Education $20 $20 $20 8 $86,860 - 108,575 Outpatient Mental Health and Substance Abuse Visits $20 $20 $10 Applied Behavior Analysis Visits1 CSR LEVEL 87 OTHER BENEFITS YOU MIGHT NEED Emergency Room Visits2 $350 after $350 after $350 after deductible deductible deductible Family Size Annual Household Income Imaging $250, then $250, then $250, then 1 $18,735 - 24,980 (MRIs, CT scans) applicable applicable applicable coinsurance coinsurance coinsurance 2 $25,365 - 33,820 after deductible after deductible after deductible Lab Work and X-rays 3 $31,995 - 42,660 Surgery (doctors charges, anesthesia and other covered 4 $3,8625 - 51,500 charges) 20% coinsurance 20% coinsurance 20% coinsurance Having a Baby (pregnancy care, after deductible after deductible after deductible 5 $45,255 - 60,340 delivery and after care) Therapy Visits3 (physical, speech and occupational) 6 $51,885 - 69,180 HOW MUCH YOU’LL PAY FOR THE CARE YOU RECEIVE EACH YEAR 7 $58,515 - 78,020 What you’ll pay each year before we start paying for some services; eductible is doubled for family policies, Medical Deductible no matter how many are covered 8 $65,145 - 86,860 $4,000 $750 $300

Prescription Deductible No separate drug No separate drug No separate drug deductible deductible deductible CSR LEVEL 94 The percent you’ll pay for covered services; Coinsurance we’ll pay the other part Family Size Annual Household Income 20% 20% 20% 1 $12,490 - 18,735 The most you’ll pay out of pocket each year for covered care and prescriptions; maximum is doubled for family 2 $16,910 - 25,365 Out-of-Pocket Maximum policies, no matter how many are covered $6,500 $2,500 $950 3 $21,330 - 31,995 IN CASE YOU NEED BRAND NAME OR SPECIALTY PRESCRIPTIONS Preferred Brand $30 after $30 after $30 after 4 $25,750 - 38,625 Name Prescriptions4 deductible deductible deductible Non-Preferred Brand Name $50 after $50 after $50 after 5 $30,170 - 45,255 Prescriptions4 deductible deductible deductible Preferred 30% after 30% after 30% after 6 $34,590 - 51,885 Specialty Drugs deductible deductible deductible

7 $39,010 - 58,515 Non-Preferred 50% after 50% after 50% after Specialty Drugs deductible deductible deductible 8 $43,430 - 65,145

*Benefit details are for in-network coverage only. Your Health Idaho will determine your actual CSR eligibility. This is not a comprehensive list of benefits. See the plan contract for a full list of benefits and coverage details.

8 HEALTH PLANS | BLUE CROSS OF IDAHO SILVER 5000 OR SILVER 4000 OR SILVER CAREPOINT 5000 SILVER CAREPOINT 4000 CSR LEVEL CSR LEVEL CSR LEVEL CSR LEVEL CSR LEVEL CSR LEVEL 73 87 94 73 87 94 WHAT YOU PAY WHAT YOU PAY WHAT YOU PAY WHAT YOU PAY WHAT YOU PAY WHAT YOU PAY IN NETWORK IN NETWORK IN NETWORK IN-NETWORK IN-NETWORK IN-NETWORK BENEFITS YOU ARE MOST LIKELY TO NEED Primary Care Visits $20 $20 $5 $35 $30 $5 Urgent Care Visits Specialist Visits $50 $50 $10 $55 $50 $10 (w/referral) Preferred Generic Prescriptions $5 $5 $5 $5 $5 $5 Non-Preferred Generic $10 $10 $10 $10 $10 $10 Prescriptions Immunizations $0 $0 $0 $0 $0 $0 Preventive Care Diabetes Education $20 $20 $20 $20 $20 $20 Outpatient Mental Health and Substance Abuse Visits $20 $20 $5 $35 $30 $5 Applied Behavior Analysis Visits1 OTHER BENEFITS YOU MIGHT NEED Emergency Room Visits2 $350 after $350 after $350 after $350 after $350 after $350 after deductible deductible deductible deductible deductible deductible Imaging $250, then $250, then $250, then $250, then $250, then $250, then (MRIs, CT scans) applicable applicable applicable applicable applicable applicable coinsurance coinsurance coinsurance coinsurance coinsurance coinsurance after deductible after deductible after deductible after deductible after deductible after deductible Lab Work and X-Rays Surgery (doctors charges, anesthesia and other covered charges) 30% coinsurance 20% coinsurance 20% coinsurance 30% coinsurance 20% coinsurance 20% coinsurance Having a Baby (pregnancy care, after deductible after deductible after deductible after deductible after deductible after deductible delivery and after care) Therapy Visits3 (physical, speech and occupational) HOW MUCH YOU’LL PAY FOR THE CARE YOU RECEIVE EACH YEAR What you’ll pay each year before we start paying for some services; eductible is doubled for family policies, no matter how many are covered Medical Deductible $4,000 $750 $50 $3,500 $750 $0 Prescription Deductible $1,000 $250 $150 $1,000 $250 $150 The percent you’ll pay for covered services; we’ll pay the other part Coinsurance 30% 20% 20% 30% 20% 20% The most you’ll pay out of pocket each year for covered care and prescriptions; maximum is doubled for family policies, no matter how many are covered Out-of-Pocket Maximum $6,500 $2,000 $950 $6,500 $2,000 $900

IN CASE YOU NEED BRAND NAME OR SPECIALTY PRESCRIPTIONS Preferred Brand $30 after $30 after $30 after $30 after $30 after $30 after Name Prescriptions4 deductible deductible deductible deductible deductible deductible Non-Preferred Brand Name $50 after $50 after $50 after $50 after $50 after $50 after Prescriptions4 deductible deductible deductible deductible deductible deductible Preferred 30% after 30% after 30% after 30% after 30% after 30% after Specialty Drugs deductible deductible deductible deductible deductible deductible Non-Preferred 50% after 50% after 50% after 50% after 50% after 50% after Specialty Drugs deductible deductible deductible deductible deductible deductible

1 Treatment for Autism Spectrum Disorder is covered the same as any other condition, depending on the services rendered. Visit limits do not apply to Treatments for Autism Spectrum Disorder or related diagnoses.2 For treatment of emergency medical conditions as defined in the policy, Blue Cross of Idaho will provide in-network benefits for covered services.3 Includes physical, occupational, and speech therapy services. You have a total of 20 in- and out-of-network visits for covered rehabilitative therapy services per member per year and a total of 20 in- and out-of-network visits for covered habilitative therapy services per member per year. 4 Prescription drug coverage includes a generic substitution requirement. If you or your doctor requests a brand-name prescription when a generic equivalent is available, you are responsible to pay the difference between the allowed cost of the generic drug and the brand-name drug and any applicable brand-name copayment. The extra costs do not count toward your deductible or out-of-pocket maximum. You or your provider can ask Blue Cross of Idaho to review this policy on a case-by-case basis.

BLUE CROSS OF IDAHO | HEALTH PLANS 9 The Affordable Care Act (ACA) offers Native Americans health insurance benefits and greater access to healthcare.

We know your access to Indian Health Services (IHS), tribal clinics and other Urban Indian Health Programs (UIHP) is critical to you. A private health plan with Blue Cross of Idaho does NOT impact your eligibility for these programs. In fact, a private health insurance plan provides you and your family greater access to services IHS or UIHPs may not provide, like emergency room services, maternity and newborn care, annual doctors visits and preventive screenings.

The ACA includes specific provisions dedicated to Native Americans, including financial assistance that may greatly reduce your monthly health insurance TRIBAL Health Insurance costs. You might even qualify for healthcare coverage Plans are only available through Medicare, Medicaid or the Children’s Health through Idaho’s health Insurance Program (CHIP). To find out if you qualify, insurance marketplace, visit Your Health Idaho (yourhealthidaho.org). Your Health Idaho at If you are eligible for a Tribal Health Insurance Plan, yourhealthidaho.org. Visit you may enroll in a plan at any time of year. Research yourhealthidaho.org to the plans, find the coverage that fits your budget and learn more and to sign up your family’s medical needs. Once you have selected a for coverage. plan, you are ready to apply.

10 HEALTH PLANS | BLUE CROSS OF IDAHO SUPPORT FROM LOCAL NETWORKS When you choose a Blue Cross of Idaho managed care plan, you must choose a primary care provider (PCP) from your local network to serve as your care coordinator and provide referrals to visit specialists or other healthcare providers. The following benefit grids outline common in-network and out-of-network services, and are not comprehensive lists of benefits. For more information, please visit bcidaho.com/SBC to review a Summary of Benefits and Coverage. The two plans shown below show the differences in benefits between the Bronze 8150 Tribal and the Bronze 8150 Tribal 0 (with a cost-sharing reduction). Tribal plans without a cost-sharing reduction come with the same out-of-pocket costs as Blue Cross of Idaho’s Individual and Family metal level plans found on pages 2 - 5.

1 BRONZE 8150 TRIBAL BRONZE 8150 TRIBAL 0 Treatment for Autism Spectrum Disorder is covered What You Pay What You Pay What You Pay What You Pay the same as any other In Network Out of Network In Network Out of Network condition, depending on the BENEFITS YOU ARE MOST LIKELY TO NEED services rendered. Visit limits Primary Care Visits do not apply to Treatments for $40 Autism Spectrum Disorder or Urgent Care Visits 60% after deductible related diagnoses. Specialist Visits $65 (w/referral) 2 For treatment of emergency Prescriptions medical conditions as defined $15 $15 $0 You may owe the (generic only) in the policy, Blue Cross of difference between $0 Idaho will provide in-network Immunizations what you are billed $0 benefits for covered services. Preventive Care and what we allow. $20 Diabetes Education 3Includes physical, Outpatient Mental Health and 60% after occupational, and speech Substance Abuse Visits deductible $40 therapy services. You have Applied Behavior a total of 20 in- and out-of- Analysis Visits1 network visits for covered OTHER BENEFITS YOU MIGHT NEED rehabilitative therapy services per member per year and Emergency Room Visits $350 a total of 20 in- and out-of- 2 after deductible network visits for covered habilitative therapy services Imaging (MRIs, CT scans) per member per year. You may owe the Lab Work and X-Rays 4 $0 difference between Prescription drug coverage $0 Surgery (doctors charges, after deductible what you are billed includes a generic substitution anesthesia, and other covered 60% after and what we allow. requirement. If you or your charges) deductible doctor requests a brand- Having a Baby name prescription when a (pregnancy care, generic equivalent is available, delivery and after care) you are responsible to pay Therapy Visits3 (PT, ST, and OT) the difference between the HOW MUCH YOU’LL PAY FOR THE CARE YOU RECEIVE EACH YEAR allowed cost of the generic drug and the brand-name drug How much you’ll pay each year before we start paying for some services; deductible and any applicable brand- is doubled for family policies, no matter how many are covered Medical Deductible name copayment. The extra $8,150 $16,300 $0 $0 costs do not count toward Prescription Deductible No separate drug deductible No separate drug deductible your deductible or out-of- pocket maximum. You or your The percent you’ll pay for covered services; we’ll pay the other part provider can ask Blue Cross of Coinsurance 0% 60% 0% 0% Idaho to review this policy on a case-by-case basis. The most you’ll pay out of pocket each year for covered care and prescriptions; Out-of-Pocket Maximum maximum is doubled for family policies, no matter how many are covered $8,150 $81,500 $0 $0 IN CASE YOU NEED BRAND NAME OR SPECIALTY PRESCRIPTIONS

Preferred Brand $30 after deductible Name Prescriptions4 Non-Preferred Brand Name $50 after deductible Prescriptions4 $0 $0 Preferred 30% after deductible Specialty Drugs Non-Preferred 50% after deductible Specialty Drugs

BLUE CROSS OF IDAHO | HEALTH PLANS 11 HOW YOUR PLAN WILL WORK Your PCP will be the one you turn to most when you need care. Choosing one you trust is key to starting your health journey off right.

Choosing A PCP can be a healthcare provider from family and a Primary general practice, primary care, internal medicine, obstetrics and gynecology or pediatrics. Which PCP specialty you should choose depends on Care Provider your health, medical history and needs. Feel free to ask a healthcare professional you know for a recommendation. One of your current medical providers may already be eligible to serve as your PCP.

If you don’t know who to choose, we can help. You can use our online Provider Finder at bcidaho.com/ findaprovider to search for PCPs near you. You also can call our sales team at 1-888-GO-CROSS (1-888-462-7677).

Your PCP will refer you for care he or she cannot Referrals provide, such as care not available in your network, or care you’ll need while away from home. He or Help Save she can help you save money by helping you avoid services you don’t need.

You Money If you need to see a specialist, your first call should be to your PCP. Your PCP may see you in the office first or send you directly to a specialist. While it may seem like a waste of time to see your PCP first, your PCP can help save you time and money by sending you to the right specialist the first time.

MORE PRESCRIPTIONS, LESS MONEY Prescription drug prices can be expensive. Our solution to help you save money is a tiered system with hundreds of drugs in the lowest-cost tier. Ask your doctor if drugs from this tier would work for you.

To search your drug list, visit members.bcidaho.com, select Prescription Drugs, Benefits and Coverage. Choose Formulary Information for the current year.

12 HEALTH PLANS | BLUE CROSS OF IDAHO HOW YOUR PLAN WILL WORK In an Emergency, Network Doesn’t Matter

Your Blue Cross of Idaho plan comes with an important protection. In an emergency, it doesn’t matter what emergency room (ER) you choose. Your plan treats emergencies at all hospitals as if they were in your network.* For care that is urgent but not an emergency, you can take your pick from any nearby urgent care and we will treat the clinic as an in-network provider.

* If you end up at an ER or urgent care clinic that doesn’t belong to one of our local networks, they are allowed to charge you for the difference between what they bill and the amount Blue Cross of Idaho allows for that service. This is called balance billing. Obviously, sometimes you don’t get to pick where the ambulance takes you. But if you can, use your Provider Finder to locate a nearby in-network facility to save you more.

Local Care Where You Are

With your PCP at the center of your care, you’re connected to the local doctors, specialists, clinics, pharmacies and hospitals that are part of your network. These providers are right where you live. You’ll pay less to see them because they’ve agreed to charge lower rates to be part of your network.

If you need healthcare that can’t be found in your home network, your PCP and Blue Cross of Idaho will work together to make sure you get that necessary care at in-network prices.

And because staying healthy means trying to prevent disease and illness, your plan includes no-cost preventive care and preventive drugs, hospital and emergency services and hundreds of experienced providers waiting to serve you. Please visit bcidaho. com/findaprovider to explore your new network.

BLUE CROSS OF IDAHO | HEALTH PLANS 13 Plans Available NORTH IDAHO

Clearwater Provider Network (CPN) The Clearwater Provider Network includes over 230 providers representing 19 healthcare specialties. CPN includes St. Joseph Regional Medical Center, Gritman Medical Center, Clearwater Valley Hospital and St. Mary’s Hospital.

Kootenai Care Network (KCN) The Kootenai Care Network provides a comprehensive range of medical services to patients, and access to over 400 providers practicing medicine in more than 50 specialties. KCN includes Kootenai Health.

Hometown North Provider Network (HNPN) Hometown North Provider Network is an association of local healthcare professionals, facilities and clinics across northern Idaho. The HNPN includes Benewah Community Hospital, Bonner General, Boundary Community, Clearwater Valley, Gritman Medical Center, Kootenai Health, Northern Idaho Advanced Care, Shoshone Medical Center, St. Joseph Regional Medical Center, St. Mary’s Hospital and Syringa Hospital.

Our networks are designed to offer more choices for those who like to travel into neighboring counties. Search for your county in the following chart.

If your county shows a checkmark, that means SLHP* KCN CPN HNPN that you may buy a plan with that network. Adams If your county shows a shaded box that means there are providers in that area where Benewah you may receive in-network services. Bonner Plans in this network are available to buy Boundary

Clearwater Gold plan in that network is also available

Idaho In-network primary care providers and specialists are available Kootenai *More information about the St Luke’s Health Latah Partners (SLHP) network is available on Lewis pages 12 and 13.

Nez Perce

Shoshone

14 HEALTH PLANS | BLUE CROSS OF IDAHO Plans Available SOUTHWEST IDAHO

Independent Doctors of Idaho (IDID) Independent Doctors of Idaho is made up of more than 500 providers, including over 160 primary care providers and 375 specialists in orthopedics, gastroenterology, psychiatrics and more. IDID includes access to 11 hospitals and surgery centers and 16 urgent care centers.

Saint Alphonsus Health Alliance (SAHA) Saint Alphonsus Health Alliance includes more than 2,000 highly skilled providers, including those at Saint Alphonsus Medical Center. The Alliance has over 700 primary care providers and 1,280 specialty care providers. The Alliance includes access to 18 hospitals and surgery centers, and more than 30 urgent care centers.

St. Luke’s Health Partners (SLHP) St. Luke’s Health Partners serves southwest Idaho with more than 3,000 providers. SLHP includes 17 hospitals and 34 urgent care centers. SLHP also serves counties in north and central Idaho. See page 15 for north Idaho and next page for central Idaho.

Our networks are designed to offer more choices for those who like to travel into neighboring counties. Search for your county in the following chart.

If your county shows a checkmark, that means that you SLHP* IDID SAHA may buy a plan with that network. Ada If your county shows a shaded box that means there are providers in that area where you may receive Boise in-network services. Canyon Plans in this network are available to buy Elmore

Gem Gold plan in that network is also available

Owyhee In-network primary care providers and specialists are available Payette *St. Luke’s Health Partners (SLHP) network serves Valley additional counties in central Idaho. See page 13. Washington

BLUE CROSS OF IDAHO | HEALTH PLANS 15 Plans Available CENTRAL IDAHO

Hometown East Provider Network (HEPN) Hometown East Provider Network consists of local healthcare professionals, facilities and clinics in central and eastern Idaho. HEPN includes Bear Lake Memorial, Bingham Memorial, Caribou Memorial, Cassia Regional, Eastern Idaho Regional Medical Center, Franklin County Medical Center, Lost Rivers District, Madison Memorial, Minidoka Memorial, Mountain View, Nell J Redfield Memorial, North Canyon Medical Center, Portneuf Medical Center, Power County, Steele Memorial and Teton Valley Health Care hospitals.

Patient Quality Alliance (PQA) Patient Quality Alliance is supported by more than 700 highly skilled providers, including those at Caribou Memorial, Mountain View Hospital, Nell J Redfield Memorial, Portneuf Medical Center and Power County Hospital District.

St. Luke’s Health Partners (SLHP) St. Luke’s Health Partners serves southwest and central Idaho with more than 3,000 providers. SLHP includes 17 hospitals and 34 urgent care centers. SLHP serves additional counties in north and southwest Idaho.

Our networks are designed to offer more choices for those who like to travel into neighboring counties. Search for your county in the following chart.

If your county shows a checkmark, that means that you may buy a HEPN PQA* SLHP** plan with that network. Blaine If your county shows a shaded box that means there are providers in that area where you may receive in-network services. Butte

Camas Plans in this network are available to buy Cassia Gold plan in that network is also available Custer In-network primary care providers and specialists are available Gooding * More information about Patient Quality Alliance (PQA) network is Jerome available on page 14. ** St. Luke’s Health Partners network serves additional Idaho Lemhi counties. See page 12. Lincoln

Minidoka

Twin Falls

16 HEALTH PLANS | BLUE CROSS OF IDAHO Plans Available EASTERN IDAHO

Mountain View Network (MVN) Mountain View Network is supported by over 350 medical professionals, including Mountain View Hospital, Madison Memorial Hospital and Portneuf Medical Center.

Our networks are designed to offer more choices for those who like to travel into neighboring counties. Search for your county in the following chart.

If your county shows a checkmark, that means HEPN* MVN PQA* that you may buy a plan with that network. Bannock If your county shows a shaded box that means there are providers in that area where you may Bear Lake receive in-network services. Bingham

Bonneville Plans in this network are available to buy

Caribou Gold plan in that network is also available

Clark In-network primary care providers and specialists are available Franklin * HEPN and PQA serve additional counties in Fremont central Idaho. See page 13. Jefferson

Madison

Oneida

Power

Teton

BLUE CROSS OF IDAHO | HEALTH PLANS 17 Open Enrollment Sign up for coverage. DECEMBER 16

If open enrollment is over, you can still get healthcare Open Enrollment starts coverage if you experience a qualifying life event like having a baby, getting married, adopting a child, or November 1 and ends losing coverage through your employer. December 16, 2019. Learn more about qualifying life events and how to enroll during a special enrollment period by contacting a local insurance agent or calling our sales team at 1-888-GO-CROSS (1-888-462-7677). If you don’t have a qualifying life event, but still need healthcare coverage, our non-renewable short term plans might be a good choice. See the opposite page for more information on short-term coverage.

If you’re eligible for a tax credit or cost-sharing reduction, you can only purchase your plan at yourhealthidaho.org. See page 6 for more information on short-term coverage.

Purchase a Plan ONLINE Complete the enrollment process at Ready to shoppers.bcidaho.com. Here IN PERSON buy? Visit an enrollment center in Coeur d’Alene, Meridian, Twin Falls, Pocatello or Idaho Falls and are three ask a sales representative to walk you through the ways to process in person. WITH A DIRECT SALES REPRESENTATIVE apply. Call us at 1-888-GO-CROSS (1-888-462-7677).

WITH AN AGENT Find an insurance agent near you at shoppers.bcidaho.com.

18 HEALTH PLANS | BLUE CROSS OF IDAHO A Healthier Smile Dental Coverage Good oral health is a key part of your overall health, so Blue Cross of Idaho offers flexible and affordable dental insurance plans that enhance your medical insurance coverage.

Our Dental Choicesm and Dental Choice Plussm plans feature low deductibles and out-of-pocket maximums, and meet all Affordable Care Act (ACA) requirements. We also offer flexible, affordable dental coverage in three benefit tiers in our Healthy Smilessm Preventive, Plus, and Preferred plans.

Learn more about our dental plans by calling your insurance agent, or the Blue Cross of Idaho sales team at 1-888-GO-CROSS (1-888-462-7677) or visit shoppers.bcidaho.com.

Covering the Gap Short-term Coverage For those that are between plans and need temporary options for medical insurance, Blue Cross of Idaho offers short-term coverage at affordable rates to help bridge the coverage gap.

Learn more about these plans by calling our sales team at 1-888-GO-CROSS (1-888-462-7677) or visiting bcidaho.com/short_term.

BLUE CROSS OF IDAHO | HEALTH PLANS 19 the medical necessity of services, eligibility for DETAILS ABOUT OUR PLANS services, and benefit limitations and exclusions Do not apply to Blue Cross of Idaho after you receive the services. dental or short-term plans. See those How we protect your personal policies for a full list of exclusions and limitations. Policy numbers: 18-079-01/18, information Important Information About 18-080-01/18, 18-081-01/18, 3-073P-10/10, • We keep all of your personal information 3-074P-10/10, 3-075P-10/10, 3-420-10/18, private and confidential. Your Prescription Drug Coverage 3-519-10/18, 3-52-10/18, 3-521-10/18, 18- Your Blue Cross of Idaho health insurance 917-10/18, 18- 918-10/18, 18-919-10/18. • We only allow access to your personal plan comes with a list of drugs approved for information by our employees and business coverage under your pharmacy benefit. This partners when needed to conduct business is also called a “formulary.” This prescription • Not prescribed by or upon the direction of for you. drug list can help you better understand a Physician or other Professional Provider; or which are furnished by any individuals • We only disclose your personal information your coverage and how it works. You can get or facilities other than Licensed General to conduct business for you, when we are a copy of our formulary for any of our plans Hospitals, Physicians, and other Providers. required by law or if you (or your personal at shoppers.bcidaho.com. Select Health & representative) give us permission. Wellness from the top menu, then Pharmacy • Investigational in nature. Management. Then select Prescription Drugs • For detailed information about our privacy from the right navigation menu, then Individual • Provided for any condition, Disease, practices see the Blue Cross of Idaho & Family Medical Prescriptions. (If you don’t Illness or Accidental Injury to the extent Notice of Privacy Practices on our website at have internet access, you can also call Blue that the Member is entitled to benefits bcidaho.com/about_us/privacy_policy.asp. Cross of Idaho’s Customer Service Department under occupational coverage, obtained or at 855-230-6862.) provided by or through the employer under state or federal Workers’ Compensation Prior Authorization In most cases, you are responsible to pay a Acts or under Employer Liability Acts or Some services require prior approval and portion of the cost of each prescription drug other laws providing compensation for work your physician will request our review prior to you have filled. Your cost is determined by the related injuries or conditions. This exclusion receiving services. When you are in the hospital, formulary tier assignment of the drug, and the applies whether or not the Member claims we may also work with the hospital and your benefit your plan assigns to that tier. Members such benefits or compensation or recovers physician to determine when you are ready to can find a copy of Blue Cross of Idaho’s losses from a third party. return home. Some procedures are reviewed pharmaceutical management procedures and after the claim is submitted to Blue Cross of check the pharmacy coverage provided by their • Provided or paid for by any federal Idaho, to evaluate eligibility for coverage. plan by logging in to the members’ website at governmental entity except when payment The appeals process is available to you are members.bcidaho.com. under the Contract is expressly required by all times, if you do not agree with a coverage federal law, or provided or paid for by any decision. You do not need prior authorization in state or local governmental entity where emergency situations. EXCLUSIONS AND its charges therefore would vary, or are LIMITATIONS* or would be affected by the existence of In addition to the exclusions and limitations coverage under the Contract, or for which What if I don’t have prior listed elsewhere in this Plan Guide, the payment has been made under Medicare authorization? following exclusions and limitations apply to the Part A and/or Medicare Part B, or would have been made if a Member had applied We want you to receive the best care at the entire Contract, unless otherwise specified: for such payment except when payment right time and place. We also want to ensure under the Contract is expressly required by you receive the right technology that addresses General Exclusions and federal law. your particular clinical issue. We’re here to Limitations work with you, your doctor and the facility so • Provided for any condition, Accidental you have the best possible health outcome. • There are no benefits for services, supplies, Injury, Disease or Illness suffered as a result If you receive services that are not medically drugs or other charges that are: of any act of war or any war, declared or necessary from one of Blue Cross of Idaho’s • Not Medically Necessary. If services undeclared. contracting providers without getting prior requiring Prior Authorization by Blue Cross authorization and payment for the services is • Furnished by a Provider who is related to of Idaho are performed by a Contracting the Member by blood or marriage and denied, you are not financially responsible. Provider and benefits are denied as not However, if you receive services that are who ordinarily dwells in the Member’s Medically Necessary, the cost of said household. not medically necessary from a provider not services are not the financial responsibility contracting with Blue Cross of Idaho, you of the Member. However, the Member • Received from a dental, vision, or medical may be responsible for the entire cost of the could be financially responsible for services department maintained by or on behalf of services. found to be not Medically Necessary when an employer, a mutual benefit association, provided by a Noncontracting Provider. labor union, trust or similar person or group. Who determines if the service is • In excess of the Maximum Allowance. • For Surgery intended mainly to improve approved? appearance or for complications arising • For hospital Inpatient or Outpatient care from Surgery intended mainly to improve Our team of licensed physicians, registered for extraction of teeth or other dental appearance, except for: nurses, and pharmacy technicians receives procedures, unless necessary to treat an and reviews all prior authorization requests. Accidental Injury or unless an attending o Reconstructive Surgery necessary to treat Typically, they complete this review within Physician certifies in writing that the an Accidental Injury, infection or other two business days, and notify the member Member has a non dental, life endangering Disease of the involved part; or and his or her healthcare provider of their condition which makes hospitalization o Reconstructive Surgery to correct decision. Prior authorization is not a guarantee necessary to safeguard the Member’s health Congenital Anomalies in a Member who of payment or coverage. It is a pre-service and life. approval based on information provided to Blue is a dependent child. Cross of Idaho at the time the request is made. • Rendered prior to the Member’s Effective Blue Cross of Idaho retains the right to review Date.

20 HEALTH PLANS | BLUE CROSS OF IDAHO • For personal hygiene, comfort, or diagnostic testing or evaluation related laboratory services, radiology services or beautification (including non-surgical to the misalignment or discomfort of the similar services related to treatment for services, drugs, and supplies intended to temporomandibular joint (jaw hinge), reproduction procedures. enhance the appearance) even if prescribed including splinting services and supplies; by a Physician. • For Transplant Services and Artificial Organs, • For alveolectomy or alveoloplasty when except as specified as a Covered Service in • For exercise or relaxation items or services related to tooth extraction. the Contract. even if prescribed by a Physician, including but not limited to, air conditioners, air • For hearing aids or examinations for the • For acupuncture. prescription or fitting of hearing aids, purifiers, humidifiers, physical fitness • For surgical procedures that alter the equipment or programs, spas, massage except as specified as a Covered Services in the Contract. refractive character of the eye, including but therapy, hot tubs, whirlpool baths, not limited to, radial keratotomy, myopic waterbeds or swimming pools. • For orthoptics, eyeglasses or contact lenses keratomileusis, Laser-In-Situ Keratomileusis • For convenience items including but not or the vision examination for prescribing (LASIK), and other surgical procedures of limited to Durable Medical Equipment such or fitting eyeglasses or contact lenses, the refractive keratoplasty type, to cure as bath equipment, cold therapy units, unless specified as a Covered Service in the or reduce myopia or astigmatism, even if duplicate items, home traction devices, or Contract. Medically Necessary. Additionally, reversals, safety equipment. revisions, and/or complications of such • For any treatment of sexual dysfunction, surgical procedures are excluded, except • For relaxation or exercise therapies, or sexual inadequacy, including erectile when required to correct an immediately life including but not limited to, educational, dysfunction and/or impotence. endangering condition. recreational, art, aroma, dance, sex, • Made by a Licensed General Hospital for sleep, electro sleep, vitamin, chelation, • For Hospice, except as specified as a the Member’s failure to vacate a room on Covered Service in the Contract. homeopathic or naturopathic, massage, or or before the Licensed General Hospital’s music even if prescribed by a Physician. established discharge hour. • For pastoral, spiritual, bereavement or marriage counseling. • For telephone consultations, and all • Not directly related to the care and computer or Internet communications, treatment of an actual condition, Illness, • For homemaker and housekeeping services except as specified as a Covered Service in Disease or Accidental Injury. or home delivered meals. the Contract. • Furnished by a facility that is primarily a • For the treatment of injuries sustained while • For failure to keep a scheduled visit or nursing home, a convalescent home, or a committing a felony, voluntarily taking part appointment; for completion of a claim rest home. in a riot, or while engaging in an illegal act form; for interpretation services; or for or occupation, unless such injuries are a personal mileage, transportation, food • For Acute Care, Rehabilitative care, result of a medical condition or domestic or lodging expenses, unless specified as diagnostic testing, except as specified as a violence. a Covered Service in the Contract, or for Covered Service in the Contract; for Mental mileage, transportation, food or lodging or Nervous Conditions and Substance • Any services or supplies for which a Member expenses billed by a Physician or other Abuse or Addiction services not recognized would have no legal obligation to pay in the Professional Provider. by the American Psychiatric and American absence of coverage under the Contract or Psychological Association. any similar coverage; or for which no charge • For Inpatient admissions that are primarily or a different charge is usually made in the for Diagnostic Services, Therapy Services, or • For weight loss or weight control. For absence of insurance coverage; or charges Physical Rehabilitation, except as specified reversals or revisions of Surgery for obesity, in connection with work for compensation in the Contract; or for Inpatient admissions except when required to correct an or charges for which reimbursement when the Member is ambulatory and/or immediately life-endangering condition. or payment is contemplated under an confined primarily for bed rest, a special • For an elective abortion, unless it is the agreement with a third party. diet, environmental change or for treatment recommendation of one consulting not requiring continuous bed care. • For a routine or periodic mental or physical Physician that an abortion is necessary examination that is not connected with • For Inpatient or Outpatient Custodial Care; to save the life of the mother, or if the the care and treatment of an actual or for Inpatient or Outpatient services pregnancy is a result of rape as defined by Illness, Disease or Accidental Injury or for consisting mainly of educational therapy, Idaho law, or incest as determined by the an examination required on account of behavioral modification, self care or self court. employment; or related to an occupational help training, except as specified as a • For use of operating, cast, examination, injury; for a marriage license; or for Covered Service in the Contract. or treatment rooms or for equipment insurance, school or camp application; or for • For any cosmetic foot care, including but located in a Contracting or Noncontracting sports participation physical; or a screening not limited to, treatment of corns, calluses Provider’s office or facility, except for examination including routine hearing and toenails (except for surgical care of emergency room facility charges in a examinations, except as specified as a ingrown or Diseased toenails). Licensed General Hospital, unless specified Covered Service in the Contract. as a Covered Service in the Contract. • For any of the following: • For immunizations, except as specified as a • For the reversal of sterilization Covered Service in the Contract. • For appliances, splints or restorations procedures, including but not limited to, • For breast reduction Surgery or Surgery for necessary to increase vertical tooth vasovasostomies or salpingoplasties. dimensions or restore the occlusion, except gynecomastia. as specified as a Covered Service in the • Treatment for reproductive procedures, • For nutritional supplements. Contract; including but not limited to, ovulation induction procedures and pharmaceuticals, • For replacements or nutritional formulas, • For orthognathic Surgery, including services artificial insemination, in vitro fertilization, except when administered enterally due to and supplies to augment or reduce the embryo transfer or similar procedures, impairment in digestion and absorption of upper or lower jaw; or procedures that in any way augment an oral diet and is the sole source of caloric • For implants in the jaw; for pain, treatment, or enhance a Member’s reproductive need or nutrition in a Member. ability, including but not limited to

BLUE CROSS OF IDAHO | HEALTH PLANS 21 • For vitamins and minerals, unless required approved by the State Police or a laboratory Prescription Drug Exclusions and through a written prescription and cannot certified by the Centers for Medicare and be purchased over the counter. Medicaid Services. For purposes of the Limitations Contract exclusion, “Under the influence” • In addition to any other exclusions and • For alterations or modifications to a home as it relates to narcotics means impairment or vehicle. limitations of the Contract, the following of driving ability caused by the use of exclusions and limitations apply to • For special clothing, including shoes (unless narcotics not prescribed or administered by Prescription Drug Services. No benefits permanently attached to a brace). a Physician. are available under the Contract for the following: • Provided to a person enrolled as an Eligible • All services, supplies, devices and treatment Dependent, but who no longer qualifies that are not FDA approved. • Drugs used for the termination of early as an Eligible Dependent due to a change • Any services, interventions occurring pregnancy, and complications arising in eligibility status that occurred after within the framework of an educational therefrom, except when required to correct enrollment. program or institution; or provided in or by an immediately life-endangering condition. • Provided outside the United States, which a school/educational setting; or provided • Over-the-counter drugs other than if had been provided in the United States, as a replacement for services that are the insulin, even if prescribed by a Physician. would not be a Covered Service under the responsibility of the educational system. Notwithstanding this exclusion, Blue Cross Contract. of Idaho, through the determination of Hospice Exclusions and the Blue Cross of Idaho Pharmacy and • For Outpatient pulmonary and/or cardiac Therapeutics Committee may choose to Rehabilitation. Limitations cover certain over-the-counter medications • For complications arising from the • In addition to any other exclusions and when Prescription Drug benefits are acceptance or utilization of services, limitations of the Contract, the following provided under the Contract. Such supplies or procedures that are not a exclusions and limitations apply to Hospice approved over-the-counter medications Covered Service. Services. No benefits are available under must be identified by Blue Cross of Idaho in the Contract for the following: writing and will specify the procedures for • For the use of Hypnosis, as anesthesia or • Hospice Services not included in a Hospice obtaining benefits for such approved over- other treatment, except as specified as a the-counter medications. Please note that Covered Service. Plan of Treatment and not provided or arranged and billed through a Hospice. the fact a particular over-the-counter drug • For arch supports, orthopedic shoes, and or medication is covered does not require other foot devices. • Continuous Skilled Nursing Care except as Blue Cross of Idaho to cover or otherwise specifically provided as a part of Continuous pay or reimburse the Member for any other • For wigs. Crisis Care or Respite Care. over-the-counter drug or medication. • For cranial molding helmets, unless used to • Hospice benefits provided during any • Charges for the administration or injection protect post cranial vault surgery. period of time in which a Member is of any drug, except for vaccinations listed receiving Home Health Skilled Nursing Care on the Prescription Drug Formulary. • For surgical removal of excess skin that is benefits. the result of weight loss or gain, including • Therapeutic devices or appliances, including but not limited to association with prior Pediatric Vison Care Exclusions hypodermic needles, syringes, support weight reduction (obesity) surgery. garments, and other non-medicinal and Limitations substances except for Diabetic Supplies, • For the purchase of Therapy or Service regardless of intended use. Dogs/Animals and the cost of training/ • In addition to any other exclusions and maintaining said animals. limitations of the Contract, the following • Drugs labeled “Caution—Limited by Federal exclusions and limitations apply to Pediatric Law to Investigational Use,” or experimental • For Dentistry or Dental Treatment, dental Vision Care Benefits Section. No benefits drugs, even though a charge is made to the implants, appliances (with the exception of are available for professional services or Member. sleep apnea devices), and/or prosthetics, materials connected with: and/or treatment related to Orthodontia, • Immunization agents, except for even when Medically Necessary, unless • Orthoptics or other vision training and any vaccinations listed on the Prescription specified as a Covered Service in the associated supplemental testing; Plano Drug Formulary, biological sera, blood or Contract. Lenses; or two (2) pair of eyeglasses in place blood plasma. Benefits may be available of bifocals. under the Medical Benefits Section of the • For procedures including but not limited Contract. to breast augmentation, liposuction, • Replacement of Lenses, Frames or Contact Adam’s apple reduction, rhinoplasty and Lenses furnished hereunder that are lost or • Medication that is to be taken by or facial reconstruction and other procedures broken (Lenses, Frames or Contact Lenses administered to a Member, in whole or in considered cosmetic in nature. are only replaced at the normal intervals part, while the Member is an Inpatient in when Covered Services are otherwise a Licensed General Hospital, rest home, • Any newly FDA approved Prescription Drug, available). sanatorium, Skilled Nursing Facility, biological agent, or other agent until it has extended care facility, convalescent been reviewed and implemented by Blue • Medical or surgical treatment of the eye(s). hospital, nursing home, or similar institution Cross of Idaho’s Pharmacy and Therapeutics • Any eye examination or any corrective which operates or allows to operate on Committee. eyewear required by an employer as a its premises, a facility for dispensing • For the treatment of injuries sustained condition of employment. pharmaceuticals. while operating a motor vehicle under the • Low vision aids. • Any prescription refilled in excess of the influence of alcohol and/or narcotics. For number specified by the Physician, or any purposes of the Contract exclusion, “Under refill dispensed after one (1) year from the the influence” as it relates to alcohol means Physician’s original order. having a whole blood alcohol content of .08 or above or a serum blood alcohol content • Any Prescription Drug, biological or other of .10 or above as measured by a laboratory agent which is:

22 HEALTH PLANS | BLUE CROSS OF IDAHO o Prescribed primarily to aid or assist the • No benefits are available for services, provided by a Provider not contracting with Member in weight loss, including all expenses, or other obligations of or for the local Blue Cross/Blue Shield plan. anorectics, whether amphetamine or a deceased donor (even if the donor is a nonamphetamine. Member). Network Gap Exception o Prescribed primarily to retard the rate of • Out-of-Area Care - Outside the state of • To receive Covered Services at the hair loss or to aid in the replacement of Idaho Provider Reimbursement In-Network benefit level from a lost hair. Noncontracting Provider, your Primary • A Contracting Provider rendering Covered Care Provider (PCP) may request a referral o Prescribed primarily to increase fertility, Services shall not make an additional charge from Blue Cross of Idaho when there is no including but not limited to, drugs which to a Member for amounts in excess of Provider within your Contract’s Provider induce or enhance ovulation. Blue Cross of Idaho’s payment except for Network capable of providing the services. Deductibles, Coinsurance, Copayments, and Blue Cross of Idaho will respond to a referral o Prescribed primarily for personal hygiene, noncovered services. comfort, beautification, or for the request received from either the PCP or the purpose of improving appearance. • For Covered Services furnished outside the Member within fourteen (14) business days state of Idaho by a Provider who has an of the receipt of the medical information o Prescribed primarily to increase growth, agreement for claims payment with the Blue necessary to make a determination. Blue including but not limited to, growth Cross and/or Blue Shield plan in the area Cross of Idaho’s referral determination will hormone. where the Covered Services were rendered, be sent to both the Member and PCP. Blue o Provided by or under the direction of a Blue Cross of Idaho shall pay the local Blue Cross of Idaho will evaluate referral requests Home Intravenous Therapy Company, Cross and/or Blue Shield plan’s contractual that are outside of the Contract’s Provider Home Health Agency or other Provider charge or the actual charge, whichever Network to determine if the services may approved by Blue Cross of Idaho. is less, minus the Member’s Copayment, be performed by an In-Network Provider. If Benefits are available for this Therapy Deductible, and/or Coinsurance, as Blue Cross of Idaho determines that there is Service under the Medical Benefits applicable. no In-Network Provider capable of providing Section of the Contract only. the service, Blue Cross of Idaho will evaluate • For Covered Services furnished outside the the referred Provider in accordance with • Lost, stolen, broken or destroyed state of Idaho by a Provider who does not quality and efficiency standards listed on Prescription Drugs except in the case of loss have an agreement for claims payments the Referrals page of the Blue Cross of due directly to a natural disaster. with the Blue Cross and/or Blue Shield plan Idaho Web site at: bcidaho.com/benefits- in the area where the Covered Services and-coverage/referrals. If the referral to the Transplant Exclusions and were rendered, Blue Cross of Idaho shall Noncontracting Provider meets this criteria, pay the Maximum Allowance minus the Blue Cross of Idaho will allow the network Limitations Member’s Copayment, Deductible, and/or gap exception and In-Network benefits will • In addition to any other exclusions and Coinsurance, as applicable. The Member be applied to the services. limitations of the Contract, the following may be responsible for charges that exceed exclusions and limitations apply to the Maximum Allowance. Emergency Services Transplant or Autotransplant Services. No benefits are available under the Contract for Referral Procedures • For all Emergency Services, Covered the following: Services provided by a Noncontracting • To receive Covered Services at the In- Provider or Provider not contracting with • Transplants of brain tissue or brain Network benefit level, a referral is required the local Blue Cross/Blue Shield plan are membrane, islet tissue, intestine, pituitary for Covered Services not provided by the eligible for In Network Services without a and adrenal glands, hair Transplants, or Member’s Primary Care Provider (PCP). referral from your PCP. any other Transplant not specifically named It is the PCP’s responsibility to evaluate as a Covered Service in this section; or for conditions or request for referral and • Members may self-refer for Emergency Artificial Organs including but not limited make referrals based on his or her medical Services. to, artificial hearts or pancreases. judgment. If the PCP refers a Member to another Provider, the PCP will provide the • Any eligible expenses of a donor related Member with a referral. If a referral is not to donating or transplanting an organ or completed for services provided by a Non- tissue unless the recipient is a Member who PCP, the benefits may be paid at the Out-of- is eligible to receive benefits for Transplant Network benefit level. Services. • Members may self-refer to Contracting • The cost of a human organ or tissue that is Providers who are obstetricians and sold rather than donated to the recipient. gynecologists for Covered Services for • Transportation costs including but not maternity care, annual visits and follow-up limited to, Ambulance Transportation gynecological care for conditions diagnosed Service or air service for the donor, or to during maternity care or annual visits. transport a donated organ or tissue. • Non-emergency Covered Services provided • Living expenses for the recipient, donor, or by a Provider not contracting with the local family members, except as specifically listed Blue Cross/Blue Shield plan and without as a Covered Service in the Contract. referral from your PCP are eligible for Out of Network benefits. • Costs covered or funded by governmental, foundation or charitable grants or programs; • For non-emergency services, the Member is or Physician fees or other charges, if no responsible for the Copayment, Deductible, charge is generally made in the absence of and/or Coinsurance, as applicable, and insurance coverage. may be responsible for any charges that exceed the Maximum Allowance when a • Costs related to the search for a suitable referral is not obtained by the Member or donor. not accepted by the Provider for services

BLUE CROSS OF IDAHO | HEALTH PLANS 23 DISCRIMINATION IS AGAINST THE LAW Blue Cross of Idaho and Blue Cross of Idaho Care Plus, services or discriminated in another way on the basis of Inc, (collectively referred to as Blue Cross of Idaho) race, color, national origin, age, disability or sex, you can complies with applicable Federal civil rights laws and file a grievance with Blue Cross of Idaho’s Grievances does not discriminate on the basis of race, color, national 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 ext. 3838 Blue Cross of Idaho: Fax: 208-331-7493 • Provides free aids and services to people with Email: [email protected] disabilities to communicate effectively with us, such as: TTY: 1-800-377-1363 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 Rights Complaint Portal, available at https://ocrportal. o Qualified interpreters 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: 1-800-377-1363), or call the customer service (TTY). Complaint forms are available at phone number on the back of your card. If you believe http://www.hhs.gov/ocr/office/file/index.html. that Blue Cross of Idaho has failed to provide these 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: 1-800-377-1363). Arabic: Nepali: ध्यान दिनुहोस्: तपार्इंले नेपाली बोल्नुहुन्छ भने तपार्इंको مملحوظة: إذا كنت تتحدث العربية اذكر اللغة، فإن خدمات المساعدة اللغوية निम्ति भाषा सहायता सेवाहरू निःशुल्क रूपमा उपलब्ध छ । फोन गर्नुहोस् 1-800-627-1188 (टिटिवाइ: 1-800-377- تتوافر لك بالمجان. اتصل برقم 1188-627-800-1 )رقم هاتف الصم । (1363 والبكم:1-800-377-1363).

Bantu: Romanian: ICITONDERWA: Nimba uvuga Ikirundi, uzohabwa ATENȚIE: Dacă vorbiți limba română, vă stau la serivisi zo gufasha mu ndimi, ku buntu. Woterefona dispoziție servicii de asistență lingvistică, gratuit. 1-800-627-1188 (TTY: 1-800-377-1363). Sunați la 1-800-627-1188 (TTY: 1-800-377-1363). Chinese: Russian: 注意：如果您使用繁體中文，您可以免費獲得語言援 ВНИМАНИЕ: Если вы говорите на русском языке, то 助服務。請致電 1-800-627-1188（TTY：1-800-377- 1363）。 вам доступны бесплатные услуги перевода. Звоните Farsi: 1-800-627-1188 (телетайп: 1-800-377-1363). :Serbo-Croatian توجه: اگر به زبان فارسی گفتگو می کنيد، تسهيالت زبانی بصورت رايگان ,OBAVJEŠTENJE: Ako govorite srpsko-hrvatski برای شما فراهم می باشد. با1-800-627-1188 .TTY: 1-800-377-1363( usluge jezičke pomoći dostupne su vam besplatno( تماس بگيريد. French: Nazovite 1-800-627-1188 (TTY- Telefon za osobe sa ATTENTION: Si vous parlez français, des services oštećenim govorom ili sluhom: 1-800-377-1363). d’aide linguistique vous sont proposés gratuitement. Spanish: Appelez le 1-800-627-1188 (ATS : 1-800-377-1363). ATENCIÓN: si habla español, tiene a su disposición German: servicios gratuitos de asistencia lingüística. Llame al ACHTUNG: Wenn Sie Deutsch sprechen, stehen 1-800-627-1188 (TTY: 1-800-377-1363). Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-627-1188 (TTY: 1-800- Tagalog: 377-1363). PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika Japanese: nang walang bayad. Tumawag sa 1-800-627-1188 注意事項：日本語を話される場合、無料の言語支援 (TTY: 1-800-377-1363). をご利用いただけます。1-800-627-1188（TTY:1-800- 377-1363）まで、お電話にてご連絡ください。 Vietnamese: Korean: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 ngữ miễn phí dành cho bạn. Gọi số 1-800-627-1188 무료로 이용하실 수 있습니다. 1-800-627-1188 (TTY: (TTY: 1-800-377-1363). 1-800-377-1363)번으로 전화해 주십시오. Form No. 3-1187 (08-19)

3000 East Pine Avenue | Meridian, Idaho | 83642-5995

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. © 2019 by Blue Cross of Idaho, an independent licensee of the Blue Cross and Blue Shield Association. ATTENTION: If you speak Arabic, Chinese, French, German, Korean, Japanese, Persian (Farsi), Romanian, Russian, Serbo- Croatian, Spanish, Sudanic Fulfulde, Tagalog, Ukrainian, or Blue Cross of Idaho Vietnamese, language assistance services, free of charge, are available to you. Call 1-800-627-1188 (TTY: 1-800-377-1363). Sales 1-888-462-7677 (TTY: 1-800-377-1363) Chinese 注意：如果您使用繁體中文，您可以免費獲得語言援助服 Customer Service 1-855-230-6862 務。請致電 1-800-627-1188 (TTY:1-800-377-1363)。 ATENCIÓN: si habla español, tiene a su disposición servicios Visit bcidaho.com gratuitos de asistencia lingüística. Llame al 1-800-627-1188 (TTY: 1-800-377-1363).