Preferred Deductible

The Preferred Deductible health-insurance plan offers four package options. Each of the four package options includes a prescription drug benefit of 50 percent to $20 copayment per prescription maximum, a $300 accidental injury benefit and chiropractic benefits.

Deductible Options
We offer four deductible options: $200 • $300 • $500 • $750

Employees are subject to a calendar year deductible; however, families are not required to satisfy more than a total of two individual aggregate deductibles in a calendar year.

Coinsurance Benefit

• 80% of allowable charges after deductible

Each option pays benefits for participating physician/provider and hospital services at the 80 percent coinsurance level for medical benefits.

Note: Coinsurance is the sharing of health care expenses for covered services between Regence BlueShield of Idaho and its' members. After any applicable deductible requirement is met, Regence BlueShield of Idaho will pay a percentage of the allowable charges for covered services. The member's out-of-pocket maximum is accumulated through his or her share of the coinsurance.

Out-of-Pocket Benefit
When the insured's out-of-pocket maximum (plus deductible) is met, his or her benefit will increase to 100% of allowable charges for the remainder of the calendar year for covered services. Families shall not be obligated to meet more than three out-of-pocket maximums in any calendar year.

Non-Participating Physician/Provider Benefits
Benefits for covered services provided by a non-participating physician/provider will be provided at 80 percent of the allowable charge.

Prescription Drug Benefit
Benefits are provided for retail and mail-order prescription drugs.

• 50 percent copayment to a maximum of $20

Mail-order benefits are included. This allows insureds to order up to a 90-day supply of their maintenance prescription medication each time with convenient postage paid home delivery.

Important Note: The cost of covered prescription drugs dispensed by a non-network pharmacist shall be reimbursed to the insured at 50% after a $25 copayment.

Accidental Injury Benefit
This benefit pays up to $300 of accident-related expenses for covered services. Additional charges are subject to the deductible and policy benefit levels. Chiropractic or prescription drug expenses are not included in this provision. Emergency room charges are subject to a $50 copayment before the accidental injury benefit is payable.

Chiropractic Benefit
Benefits are paid at the coinsurance level, and are limited to a maximum of $500 per person each calendar year after the deductible is satisfied.

Lifetime Maximum Benefit
Benefits are limited to $1,000,000 during an insured's lifetime with an automatic reinstatement of up to $5,000 each calendar year.

Maternity Management Program
Regence BlueShield of Idaho provides a maternity management program designed to promote healthy prenatal care through education and support to expectant mothers. This program is available to any employee or their enrolled dependent who is pregnant. Program members are provided with nutrition, exercise, prenatal care and child-care information to help maintain a healthy pregnancy and to deliver a healthy baby. In addition, the maternity management program provides incentive gifts to enrollees to encourage regular prenatal physician exams.

Employee Assistance Program (EAP)
The Employee Assistance Program through Reliant Behavioral Health, provides additional services to the Regence BlueShield of Idaho health benefit plan. General services include the following (refer to policy for specific benefits):

• Up to four counseling sessions, including an initial evaluation to identify problems;
• A plan of assistance, including referrals to outside agencies, for employees and their eligible dependents who seek assistance through the Employee Assistance Program;
• Twenty-four hour, seven days per week, toll free telephone crisis counseling;
• Critical Incident Stress Debriefing; and
• Management and supervisor consultation.

Out-of-Area Program
The Regence BlueShield of Idaho identification card is an insured's direct link to care anywhere in the country. Just show the identification card to any Blue Cross and/or Blue Shield Plan participating hospital or physician across the USA and receive the same comforts and conveniences as provided locally. The three letter prefix on the identification card indicates to participating physicians or hospitals that the insured is covered under a Regence BlueShield of Idaho health insurance plan.

Claim Form Procedures
Preferred Deductible offers streamlined claim procedures. Claim forms are not required when providers bill Regence BlueShield of Idaho directly. If an insured chooses to submit his or her health care bills, we require a completed itemized statement with patient’s name, date of service or services rendered, charge per service and diagnosis.

Eligibility
An eligible employee is an employee who works at least 30 hours per week on a regular basis. Employees who work 20-29 hours per week on a regular basis may be accepted for coverage by agreement between Regence BlueShield of Idaho and the employer.

A dependent is a legal spouse, an unmarried child under the age of 25 and who is financially dependent upon the parent, or an unmarried child of any age who is medically certified as disabled and dependent upon the parent.

Group Takeover Provisions
Waiting periods will be credited for the employee and his or her dependents who have had continuous coverage under the employee's previous group health care program. The employee and his or her dependents not covered by the previous program may be subject to a nine-month pre-existing waiting period if no other qualifying coverage exists. Credit will also be given for deductible amounts satisfied under the previous group health care program for the current calendar year, providing that continuous coverage is maintained.

Hospital Emergency Room
Hospital emergency room charges are subject to a copayment of up $50 per visit before any benefits are provided. The copayment will be waived if the insured is admitted directly to the hospital.

Waiting Periods for Pre-Existing Conditions
Waiting periods for pre-existing conditions will be credited for employees and their dependents who were enrolled under qualifying coverage. This is contingent upon the qualifying coverage not ending more than 63 days prior to the effective date under this coverage. New enrollees without qualifying previous coverage will be subject to a nine-month waiting period for pre-existing conditions. Benefits for pre-existing conditions may be denied until the member has enrolled for coverage on this policy for a continuous nine months.

This waiting period shall not apply to newborn children who shall be covered from the moment of birth, or to adopted children or children in the process of adoption who have been placed with the enrolled employee.

Pre-existing condition means a physical or mental condition, regardless of the cause of the condition, for which medical advice, diagnosis, care or treatment was recommended or received within a six (6) month period immediately preceding the effective date of coverage. Genetic information shall not be considered a pre-existing condition in the absence of a diagnosis of the condition related to such information.

Policies shall be in force and renewable unless terminated due to the following: termination by the employer without cause with 30 days written notice, nonpayment of premium, fraud or intentional misrepresentation of material fact by the employer, noncompliance of minimum participation requirements set for by Regence BlueShield of Idaho.