March 20, 2010

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Blue Cross of Idaho – Simply Blue – IDAHO

A comparison of the Simply Blue offered by Blue Cross of Idaho is detailed out below for both Network and Non-Network coverage.

  Network Non-Network
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Network See Provider See Provider
Application Simply Blue Application Simply Blue Application
Brochure Simply Blue Brochure Simply Blue Brochure
Copay N/A N/A
Office Visit Simply Blue 50% after deductible
Deductible Individual: $10,000, Family: $20,000 Applies to all options unless otherwise indicated
Coinsurance Simply Blue 50%
Coinsurance Limit Simply Blue Simply Blue
Out-of-Pocket Maximum $10,000 in-network limit, includes deductible (Includes your deductible, but does not include $10,000 pregnancy deductible, prescription deductible or copayments) $15,000 in-network limit, includes deductible (Includes your deductible, but does not include $10,000 pregnancy deductible, prescription deductible or copayments)
Lifetime Maximum $1,000,000 per person $1,000,000 per person
Prescription Drugs Prescription Drugs (No annual maximum dollar amount for generic or brand-name drugs) -
  • Generics: $15 copayment
  • Brand-Name Prescriptions: $30 copayment (Require separate $5,000 deductible)
  • Smoking-Cessation Drugs: Limited to $600 per person, per benefit period (Limited to a 30-day supply at one time)
 Prescription Drugs (No annual maximum dollar amount for generic or brand-name drugs) -
  • Generics: $15 copayment
  • Brand-Name Prescriptions: $30 copayment (Require separate $5,000 deductible)
  • Smoking-Cessation Drugs: Limited to $600 per person, per benefit period (Limited to a 30-day supply at one time)
Emergency Room Simply Blue
  • Emergency Room Facility Services: $100 copayment (Waived if admitted to hospital) after which you deductible and coinsurance apply
  • Ambulance Transportation Services: 50% after deductible
    		•
    Adult Preventative Care Simply Blue Preventive Care Services and Immunizations: 50% after deductible
    Child Preventative Care Simply Blue Preventive Care Services and Immunizations: 50% after deductible
    Lab / X-Ray Simply Blue
  • Diagnostic Laboratory and X-ray Services: 50% after deductible
  • Advanced Imaging Services (Outpatient, MRI, MRA, CT scan and PET procedures; prior authorization required): $250 copayment per procedure, after which your deductible and coinsurance apply
    		•
    Maternity Simply Blue Pregnancy Services (A separate combined in-network and out-of-network $10,000 deductible applies, except in cases of involuntary complications): 50%
    Physical Therapy Simply Blue
  • Therapy Services (Such as chemotherapy, radiation, renal dialysis): 50% after deductible
  • Inpatient Physical Rehabilitation (From contracting provider only): 50% after deductible
  • Outpatient Physical and Speech Therapy Services (Limited to $800 each, per person per benefit period): 50% after deductible
    		•
    Skilled Nursing Simply Blue 50% after deductible (Limited to 30-days per person, per benefit period)
    Home Health Care Simply Blue
  • Hospice Services (Available only with prior approval and within Blue Cross of Idaho guidelines): Not covered
  • Home Intravenous Therapy: Not covered
  • Home Health Skilled Nursing (Only for approved providers, must have prior approval, limited to $5,000 per person, per benefit period): Not covered
    		•
    Mental Health N/A N/A
    Hospital Care Simply Blue
  • Physician, Surgical and Medical Professional Services (Includes office visits): 50% after deductible
  • Hospital and Facility Services: 50% after deductible
    		•
    Optional Benefits Simply Blue Simply Blue