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Benefits Line: [PHONE REDACTED] City of Blackfoot Employee Health Benefits Manual Effective October 1, 2023 ---PAGE BREAK--- Contact Information III-A lines are open 24/7/365 to serve you! III-A Benefits Line: (208) 938-8199 Translation services: (208) 938-8199 [EMAIL REDACTED] III-A Medical Telehealth (call or text): Dustin Reno, NP (208) 203-0783 Velma Seabolt, NP (208) 271-4460 iii-a.org I PO Box 190477 I Boise, ID 83719 I F: (208) 575-6423 Nicole Tuttle Tami Testa Megan Smith Benefits Manager Benefits Specialist Wellness Manager [EMAIL REDACTED] [EMAIL REDACTED] [EMAIL REDACTED] III-A Benefits Line Scan QR Code and Add to Contacts Scan QR Code & Sign Up for III-A Communications: Benefit changes, updates, wellness challenges, CE/training opportunities, events, drawings, etc. ---PAGE BREAK--- Welcome to the III-A Family! III-A is a self-funded health trust that administers your health benefits. We care deeply about you and your health and are available 24/7. Understanding your benefits: III-A members use the BCI PPO network for medical benefits and ProAct for prescriptions. Your provider will need a copy of BOTH your BCI insurance card and your ProAct prescription card. Your ProAct card is what you will provide to your pharmacy. If you have questions about your prescription benefits, a prior authorization or denial, or the cost of a medication, please call the III-A Benefit Line. List of benefit changes effective October 1, 2023: • Virtual Physical Therapy and Personal Training—Hinge Health & BCI • Breast Ultrasounds - Covered 100% • Dermatological Skin Biopsies & Pertaining Pathology - Covered 100% • Hearing Testing and Exams - Diagnostic and Wellness Exams Covered at Member Copay • Specialty Medication Program • Acupuncture Benefit - Administered Internally Only • Bariatric Surgery Program - Administered Internally Only • Hearing Aid Frequency Every Three Years If you have questions or concerns about your health benefits, a prior authorization, or a bill you receive from a provider, call the III-A Benefit Line at [PHONE REDACTED]. The III-A staff is available 24/7/365 to assist you. Sincerely, Your III-A Team Board of Trustees Dan Hammond, Chairman City of American Falls Ruth Bailes, Vice-Chairman Minidoka Irrigation District Danielle Painter, Secretary City of New Plymouth Gilbert Hofmeister, Power Co. Highway Dist. Chad Shepard, Nampa Police Department Lori Yarbrough, City of Athol Stuart Grimes, City of Fruitland Suzanne McNeel, City of Blackfoot Todd Thomas, City of Preston Traci Malvich, City of McCall Tyler Lewis, Eagle Fire Protection Dist. Pat Riley, NLFD Patty Parkinson, City of St. Anthony About III-A ---PAGE BREAK--- III-A Administered Benefits EMPLOYEE ASSISTANCE PROGRAM (EAP): Members and families receive up to 10 free visits per incident/per year for counseling services with a III-A EAP Provider. This is a household benefit (spouse and/or dependents up to age 26), whether or not covered by III-A. • Go to to access the in-network EAP Provider list. • Choose a provider and schedule your appointment. • Tell them you're using your III-A EAP benefit. **No prior authorization is required.** MEDICAL TELEHEALTH: This is a no-cost program available 24/7/365. Dustin Reno, Nurse Practitioner Phone: (208) 203-0783 Velma Seabolt, Nurse Practitioner Phone: (208) 271-4460 • Call or text provider and leave a message with your name, DOB, and agency. You will receive a call back within two hours. • Do not call the other provider, you will receive a call back. **Telehealth providers may refer members for a higher level of care.** HEARING AIDS: One-time purchase of hearing aid devices, up to $3,000 every three calendar years. Go to iii-a.org for a III-A Claim Form to submit for reimbursement or payment to provider. HEARING PROTECTION DEVICES: Protective hearing devices are covered for all members up to $150 once every five calendar years. Devices MUST be designed to reduce decibel levels and include an NRR rating or list decibel reduction (excludes air pods, Samsung earbuds, etc.). Go to iii-a.org for a III-A Claim Form to submit for reimbursement or payment to provider. ---PAGE BREAK--- III-A Administered Benefits MEDICATION INFUSION BENEFIT PROGRAM: Members who receive infusion treatments for the listed medical conditions may receive reimbursement for each infusion and other allowed travel expenses if infusion treatment is at a III-A Preferred Infusion Facility. Call the III-A Benefits Line to check eligibility. All medications may not be eligible. Multiple Sclerosis (MS) • Crohn's • Lupus Rheumatoid Arthritis (RA) • Inflammatory Bowel Disease • Colitis • Psoriasis BEHAVORIAL HEALTH MANAGEMENT PROGRAM: This program will reimburse eligible members for their deductible and coinsurance and other allowed travel expenses when inpatient treatment is at a III-A Preferred Behavioral Health Facility. Call the III-A Benefits Line to locate a III-A Preferred Behavioral Health Facility; enter treatment and successfully complete the recommended length of stay. Member MUST COMPLETE the Program per Shift Wellness to be eligible for reimbursement. Member is only eligible for one reimbursement per lifetime. ST. ALPHONSUS MATERNITY BENEFIT PROGRAM: Members who choose to deliver their baby at a St. Alphonsus facility will receive reimbursement for their deductible and coinsurance in the amount of $1,500. Go to iii-a.org for a III-A Claim Form to submit for reimbursement. If III-A is secondary medical coverage, the member may still participate and receive reimbursement. BARIATRIC SURGERY PROGRAM: The program will reimburse eligible members for the self-pay option (maximum $15,000) for outpatient Gastric Sleeve (Sleeve Gastrectomy) after a $2,000 member contribution. Surgery must be performed in United States. Reimbursement will apply to the following: • Consultation, • Related Lab Work • Surgery • Facility Fees • Anesthesia • Medically Necessary IV Fluids • Post-Surgery Follow-up Meal kits are excluded. Eligibility: • III-A enrollee or spouse over the age of 18. • Nonsurgical methods have been unsuccessful in treating obesity. • Must have a Body Mass Index (BMI) of 40 or higher, or at least 100 pounds over or twice the ideal weight for frame, age, height and sex specified in the 1983 Metropolitan Life Insurance table, or approval after a consultation with a III-A Nurse Practitioner. • Three health coaching visits with III-A and/or completion of Wondr Health Program pre-op. For Reimbursement: • Member must select and pay the self-pay cash price for surgery with the facility. • Member will submit documentation of medical necessity and a paid receipt to III-A for reimbursement up to $15,000 ($2,000 member contribution, $13,000 reimbursement from III-A). • Upon III-A receiving necessary documentation, III-A will issue a reimbursement payment to the member for eligible expenses. ---PAGE BREAK--- III-A Administered Benefits ACUPUNCTURE: 52 Acupuncture visits (up to $80 per visit). Acupuncturist must be state licensed and not “certified”. Find our Direct-Pay Acupuncture Network at iii-a.org. *If you are currently seeing a licensed Acupuncturist or wish to see one who is not in III-A Network, call the Benefits Line. III-A Network Acupuncturist (Best Option) III-A Direct-Pay Acupuncturists invoice III-A directly. Member pays any amount over $80. Out-of-Network Acupuncturist Acupuncturist collects payment at the time of service. Go to iii-a.org and complete the III-A Claim Form. AIR AMBULANCE: If you or your family member have a medically necessary air ambulance transport, the claim will be submitted and processed through Blue Cross of Idaho. III-A will reimburse the member’s deductible and/or out of pocket for this claim upon receipt of the member’s Explanation of Benefits (EOB) for any remaining balance. This is a household benefit (spouse and/or dependents up to age 26) whether or not covered by III-A. Dependents NOT enrolled in the III-A Plan: Claim will process through dependent’s medical insurance, then submit EOB to III-A for reimbursement. Go to iii-a.org and complete the III-A Claim Form. Eligible dependents without any insurance coverage: III-A will reimburse a maximum of $2,000 of the medically necessary air ambulance claim. Go to iii-a.org and complete the III-A Claim Form. WIGS: Reimburse up to $300 per calendar year, based on medical necessity. Go to iii-a.org and complete the III-A Claim Form to submit for reimbursement. ---PAGE BREAK--- No-Cost Wellness Benefits WONDR HEALTH: DIGITAL WEIGHT LOSS PROGRAM Wondr Health is a personalized weight loss program backed by science and taught by renowned experts. It is tailored specifically to the user. It is a fully digital program. Upcoming program start dates: • January 29, 2024 • August 26, 2024 Join the waitlist for the upcoming session: VIRTUAL PHYSICAL THERAPY & PERSONAL TRAINING Hinge Health provides personalized care plans to help people accomplish their health goals related to musculoskeletal (back, muscle, and joint) health. It is a virtual Physical Therapy Program for those that are experiencing chronic pain (12 weeks or more of pain). Members and dependents 18+ enrolled in a III-A medical plan are eligible. No cost or benefit limit. No referral or diagnosis needed from a doctor. Visit or call (855) 902-2777 to see if you qualify. If you don’t qualify for Hinge Health, a Blue Cross of Idaho Physical Therapist or Personal Trainer will contact you for a virtual training and coaching plan. **Claims data may also trigger the BCI clinicians to reach out to members who may qualify for virtual sessions.** TOBACCO CESSATION Work with a certified tobacco cessation coach. Blue Cross of Idaho Tobacco Cessation Coaching Email BCI coaches directly at [EMAIL REDACTED] or call [PHONE REDACTED] Quit Aids: available at no cost with a prescription HEALTH COACHING Work one-on-one with a certified health coach on goal setting and lifestyle changes. Nutrition, physical activity and exercise, stress management, sleep, weight loss/maintenance, diabetes prevention, blood pressure, and/or cholesterol management, and tobacco cessation. To enroll, call or email [EMAIL REDACTED] and 208- 860-1979. ---PAGE BREAK--- No-Cost Wellness Benefits ONSITE WELLNESS SCREENINGS, FLU SHOTS, AND SKIN CHECKS Annually in Fall, III-A will bring a Nurse Practitioner and Dermatologist PA onsite for a no-cost annual wellness screening. Any member or spouse covered under the III-A medical plan may participate and children age 10 and over may receive a flu vaccine. Ask your HR/Clerk for your agency’s date and time, and how to sign-up. You can also attend any other agency’s wellness screening. WELLNESS WEDNESDAY WEBINARS Every month III-A features a wellness webinar that is either brain or body wellness-focused. 12pm PT/1pm MT via zoom. Go to iii-a.org and visit the calendar to register. 10/18/23: Boost Your Immunity 11/05/23: Emotional Intelligence 12/20/23: Mindfulness and Meditation 1/17/24: Time vs. Task Management 2/21/24: Unpacking Pain: Factors & How to Help 3/20/24: Mental Health Mayday (anxiety/stress) 4/17/24: Swapportunities and Food Hacks 5/15/24: Suicide Prevention and Intervention 6/26/24: Weighing in on Weight Management 7/17/24: Ask the Expert! NP Q & A Panel 8/21/24: Addiction and Recreational Drug Use 9/25/24: Fueling the Mind 10/16/24: Mental Health & Movement *Dates are subject to change. QUARTERLY WELLNESS CHALLENGES February 2024 - 28 Days of Heart Health May 2024 - MindFULLNESS Challenge July 2024 - Hydration Challenge October 2024 - WALKtober Fall 2024 - Wellness Screenings DIABETES PREVENTION PROGRAM If you qualify for this weight loss program, you’ll also get the tools you need to be successful—all at no cost to you! A Fitbit activity tracker, health coaching, meal planning, and a wireless scale. Visit the link to see if you qualify for a no-cost virtual or in -person Diabetes Prevention Program: http://solera4me.com/bcidaho Once enrolled, you’ll have access to a full year of leading weight loss programs like WeightWatchers®. ---PAGE BREAK--- No-Cost Wellness Benefits FIRST RESPONDER AND FAMILY HELPLINE - 24/7/365 PTSI assistance, substance misuse, mental performance, etc. GENERAL MEMBERSHIP HELPLINE - 24/7/365 Non-first responder members in crisis can call the III-A Benefits Line [PHONE REDACTED]. ON-SITE PEER SUPPORT TRAINING Basic Peer Support and Advanced Crisis Management Training are available. Members can attend an in-person Peer Support Training and receive ID POST credits and/or CE hours (meets NFPA Standard 1500). CRISIS RESPONSE AVAILABLE FOR CISM/CISD If you have a critical incident that occurs please call the III-A Benefits Line and we will coordinate with mental health providers to accommodate your needs. MENTAL HEALTH TRAININGS (ONSITE AND VIRTUAL) Can be requested by an agency at any time. Contact the Marketing & Education Manager to request a training or a list of available trainings. [EMAIL REDACTED] [PHONE REDACTED] ---PAGE BREAK--- This information is for comparison purposes only and not a complete description of benefits. All descriptions of coverage are subject to the provisions of the corresponding plan, which contains all the terms and conditions of coverage and exclusions and limitations. Certain services not specifically noted may be excluded. Please refer to the plan issued for a complete description of benefits, exclusions, limitations and conditions of coverage. If there is a difference between this comparison and its corresponding plan, the plan will control. ASC PPO 70-C BENEFITS OUTLINE Visit our Website at www.bcidaho.com to locate a Contracting Provider Deductibles (per Benefit Period) Individual In-Network Out-of-Network The Participant is responsible to pay these amounts: $3,000 Family (No Participant may contribute more than the Individual Deductible amount toward the Family Deductible) $6,000 Out-of-Pocket Limits (per Benefit Period) (See Plan for services that do not apply to the limit) (Includes applicable Deductible, Cost Sharing and Copayments) Individual Family (No Participant may contribute more than the Individual Out-of-Pocket Limit amount toward the Family Out-of- Pocket Limit) $3,500 $9,000 $9,000 $12,000 Cost Sharing Unless specified otherwise below, the Participant pays the following Cost Sharing amount 30% of Maximum Allowance after Deductible 50% of Maximum Allowance after Deductible Frequently used Covered Services - Some services may require Prior Authorization. Physician Office Visits (Additional services, such as laboratory, x-ray, and other Diagnostic Services are not included in the Office Visit.) $40 Copayment per visit Deductible and Cost Sharing Pediatric Physician Office Visits (For Participants under the age of eighteen (18). Includes Urgent Care visits. Includes mononucleosis testing, strep A and B testing, development screening(s), ear wax removal, removal of foreign body from ear, urine pregnancy tests, influenza A or B test, rapid RSV test, and pulse oximetry. All other additional services not listed above, such as laboratory, x-ray, and other Diagnostic Services are not included in the Pediatric Physician Office Visit Copayment.) No Charge (Deductible does not apply) Deductible and Cost Sharing ---PAGE BREAK--- Preventive Care Covered Services For specifically listed Covered Services Annual adult physical examinations; routine or scheduled well- baby and well-child examinations, including vision, hearing and developmental screenings; Dental fluoride application for Participants age 5 and under; Bone Density; Chemistry Panels; Cholesterol Screening; Colorectal Cancer Screening; Complete Blood Count (CBC); Diabetes Screening; Pap Test; PSA Test; Rubella Screening; Screening EKG; Screening Mammogram; Thyroid Stimulating Hormone (TSH); Transmittable Diseases Screening (Chlamydia, Gonorrhea, Human Immunodeficiency Virus (HIV); Human papillomavirus (HPV), Syphilis, Tuberculosis (TB); Hepatitis B Virus Screening; Sexually Transmitted Infections assessment; HIV assessment; Screening and assessment for interpersonal and domestic violence; Urinalysis (UA); Abdominal Aortic Aneurysm Screening and Ultrasound; Unhealthy Alcohol and Drug Use Assessment; Breast Cancer (BRCA) Risk Assessment and Genetic Counseling and Testing for High Risk Family History of Breast or Ovarian Cancer; Newborn Metabolic Screening (PKU, Thyroxine, Sickle Cell); Health Risk Assessment for Depression; Newborn Hearing Test; Lipid Disorder Screening; Nicotine, Smoking and Tobacco-use Cessation Counseling Visit; Dietary Counseling and Physical Activity Behavioral Counseling; Behavioral Counseling for Participants who are overweight or obese; Preventive Lead Screening; Lung Cancer Screening for Participants age 50 and over, Hepatitis C Virus Infection Screening; Urinary Incontinence Screening; Urine Culture for Pregnant Women; Iron Deficiency Screening for Pregnant Women; Rh Incompatibility Screening for Pregnant Women; Diabetes Screening for Pregnant Women; Perinatal Depression Counseling and Intervention; Behavioral Counseling for Healthy Weight and Weight Gain in Pregnancy. The specifically listed Preventive Care Services may be adjusted accordingly to coincide with federal government changes, updates, and revisions. For services not specifically listed No Charge (Deductible does not apply) Deductible and Cost Sharing Deductible and Cost Sharing Deductible and Cost Sharing Immunizations Acellular Pertussis, Diphtheria, Haemophilus Influenza B, Hepatitis B, Influenza, Measles, Mumps, Pneumococcal (pneumonia), Poliomyelitis (polio), Rotavirus, Rubella, Tetanus, Varicella (Chicken Pox), Hepatitis A, Meningococcal, Human papillomavirus (HPV), and Zoster. All Immunizations are limited to the extent recommended by the Advisory Committee on Immunization Practices (ACIP) and may be adjusted accordingly to coincide with federal government changes, updates and revisions. Other immunizations not specifically listed may be covered at the discretion of BCI when Medically Necessary. No Charge (Deductible does not apply) Deductible and Cost Sharing No Charge (Deductible does not apply) Deductible and Cost Sharing TELEHEALTH SERVICES Telehealth Virtual Care Services Telehealth Virtual Care Services are available for any category of covered outpatient services. The amount of payment and other conditions for in- person services will apply to Telehealth Virtual Care Services. Please see the appropriate section of the Benefits Outline for those terms. ---PAGE BREAK--- COVERED SERVICES Some services may require Prior Authorization. In-Network Out-of-Network The Participant is responsible to pay these amounts: Allergy Injections • Administration Only • Allergy Serum $5 Copayment per visit if no other Office Visit Copayment is required for other Covered Services provided during the visit $20 Copayment Deductible and Cost Sharing Ambulance Transportation Services • Ground Ambulance Services • Air Ambulance Services (Payment for Out-of-Network Air Ambulance Services is based on the Qualifying Payment Amount. Out-of- Network Air Ambulance Services accumulate towards the In-Network Out-of-Pocket Limit.) Deductible and Cost Sharing Deductible and Cost Sharing Deductible and Cost Sharing Deductible and In-Network Cost Sharing Breastfeeding Support and Supply Services (Includes rental and/or purchase of manual or electric breast pumps. Limited to one breast pump purchase per Benefit Period, per Participant.) No Charge (Deductible does not apply) Deductible and Cost Sharing Cardiac Rehabilitation Therapy Services – Outpatient Up to a combined In-Network and Out-of-Network total of 36 visits per Participant, per Benefit Period. Deductible and Cost Sharing Deductible and Cost Sharing Chiropractic Care Services Up to a combined In-Network and Out of-Network total of 18 visits per Participant, per Benefit Period. (Additional services, such as laboratory, x-ray and other Diagnostic Services are not included in the Office Visit.) $40 Copayment Deductible and Cost Sharing Colonoscopies and Sigmoidoscopies (Preventive and Diagnostic) No Charge (Deductible does not apply) Deductible and Cost Sharing Dental Services Related to Accidental Injury Deductible and Cost Sharing Deductible and Cost Sharing Dermatological Skin Biopsies and Pathology (Preventive and Diagnostic) No Charge (Deductible does not apply) Deductible and Cost Sharing Diabetes Self-Management Education Services $40 Copayment Deductible and Cost Sharing Diagnostic Services - Laboratory and X-ray Deductible and Cost Sharing Deductible and Cost Sharing Durable Medical Equipment, Orthotic Devices and Prosthetic Appliances Deductible and Cost Sharing Deductible and Cost Sharing Emergency Services – Facility Services (Copayment waived if admitted) (Payment for Out-of-Network Emergency Services is based on the Qualifying Payment Amount.) $100 Copayment per hospital Outpatient emergency room visit, then Deductible and In-Network Cost Sharing. Emergency Services accumulate towards the In-Network Out-of-Pocket Limit. Emergency Services – Professional Services (Payment for Out-of-Network Emergency Services is based on the Qualifying Payment Amount.) Deductible and In-Network Cost Sharing. Emergency Services accumulate towards the In-Network Out-of-Pocket Limit. Hearing and Hearing Aid Exams $40 Copayment per visit (Deductible does not apply) Deductible and Cost Sharing ---PAGE BREAK--- COVERED SERVICES Some services may require Prior Authorization. In-Network Out-of-Network The Participant is responsible to pay these amounts: Home Health Skilled Nursing Care Services Deductible and Cost Sharing Deductible and Cost Sharing Home Intravenous Therapy Deductible and Cost Sharing Deductible and 80% Cost Sharing Hospice Services No Charge (Deductible does not apply) Deductible and Cost Sharing Hospital Services Deductible and Cost Sharing Deductible and Cost Sharing Inpatient Rehabilitation or Habilitation Services Deductible and Cost Sharing Deductible and Cost Sharing Mammograms (Diagnostic) (See Preventive Care for Screening Mammography benefit.) Breast Ultrasounds No Charge (Deductible does not apply) Deductible and Cost Sharing Maternity Services and/or Involuntary Complications of Pregnancy Deductible and Cost Sharing Deductible and Cost Sharing Mental Health and Substance Use Disorder Inpatient Services • Inpatient Facility and Professional Services Deductible and Cost Sharing Deductible and Cost Sharing Mental Health and Substance Use Disorder Outpatient Services • Outpatient Services • Pediatric Outpatient Services (For Participants under the age of eighteen • Facility and other Professional Services $40 Copayment per visit No Charge (Deductible does not apply) Deductible and Cost Sharing Deductible and Cost Sharing Outpatient Applied Behavioral Analysis (ABA) • Pediatric Outpatient Applied Behavioral Analysis (ABA) (For Participants under the age of eighteen $40 Copayment per visit No Charge (Deductible does not apply) Deductible and Cost Sharing Treatment for Autism Spectrum Disorder Covered the same as any other illness, depending on the services rendered. Please see the appropriate section of the Benefits Outline. Visit limits do not apply to Treatments for Autism Spectrum Disorder, and related diagnoses. Outpatient Habilitation Physical Therapy Services Up to a combined In-Network and Out-of-Network total of 30 visits per Participant, per Benefit Period. (Additional services, such as, x-ray and other Diagnostic Services are not included in the Therapy Services Copayment.) $40 Copayment per visit Deductible and Cost Sharing Outpatient Habilitation Therapy Services • Outpatient Occupational Therapy • Outpatient Speech Therapy Up to a combined In-Network and Out-of-Network total of 20 visits per Participant, per Benefit Period. Deductible and Cost Sharing Deductible and Cost Sharing Outpatient Rehabilitation Physical Therapy Services Up to a combined In-Network and Out-of-Network total of 30 visits per Participant, per Benefit Period. (Additional services, such as, x-ray and other Diagnostic Services are not included in the Therapy Services Copayment.) $40 Copayment per visit Deductible and Cost Sharing ---PAGE BREAK--- COVERED SERVICES Some services may require Prior Authorization. In-Network Out-of-Network The Participant is responsible to pay these amounts: Outpatient Rehabilitation Therapy Services • Outpatient Occupational Therapy • Outpatient Speech Therapy Up to a combined In-Network and Out-of-Network total of 20 visits per Participant, per Benefit Period. Deductible and Cost Sharing Deductible and Cost Sharing Palliative Care Services No Charge (Deductible does not apply) Deductible and Cost Sharing Post-Mastectomy/Lumpectomy Reconstructive Surgery Deductible and Cost Sharing Deductible and Cost Sharing Prescribed Contraceptive Services (Includes diaphragms, intrauterine devices (IUDs), implantables, injections, tubal ligation and vasectomy.) No Charge (Deductible does not apply) Deductible and Cost Sharing PSA Tests and Pap Smears (Diagnostic) (See Preventive Care for Screening PSA Tests and Pap Smears benefits.) No Charge (Deductible does not apply) Deductible and Cost Sharing Skilled Nursing Facility Up to a combined In-Network and Out-of-Network total of 30 days per Participant, per Benefit Period. Deductible and Cost Sharing Deductible and Cost Sharing Surgical/Medical (Professional Services) Deductible and Cost Sharing Deductible and Cost Sharing Therapy Services (Including Radiation, Chemotherapy, Renal Dialysis and Growth Hormone) Deductible and Cost Sharing Deductible and Cost Sharing Transplant Services Deductible and Cost Sharing Deductible and Cost Sharing Be aware that your actual costs for services provided by an Out-of-Network Provider may exceed this Plan’s Out-of-Pocket Limit for Out-of-Network services. Except as provided by the No Surprises Act, Out-of-Network Providers can bill you for the difference between the amount charged by the Provider and the amount allowed by Blue Cross of Idaho, and that amount is not counted toward the Out-of-Network Out-of-Pocket Limit. This information is for comparison purposes only and not a complete description of benefits. All descriptions of coverage are subject to the provisions of the corresponding plan, which contains all the terms and conditions of coverage and exclusions and limitations. Certain services not specifically noted may be excluded. Please refer to the plan issued for a complete description of benefits, exclusions, limitations and conditions of coverage. If there is a difference between this comparison and its corresponding plan, the plan will control. ---PAGE BREAK--- What is Hinge Healt h? Scan the QR code to learn more or apply at hinge.healt h/ iiia or call (855) 902-2777 How does t he program work? Hinge Health provides personalized care plans to help people accomplish their health goals related to musculoskeletal (back, muscle, and joint ) health. How does Hinge Healt h help? They assess your condition and match you to a care team to help personalize your treatment to you. Who is in my care t eam? Depending on your treatment plan, your care team could include a physical therapist and a health coach. You will keep the same care team throughout your experience. What could be included in my t reat ment plan? 1. Access t o t he Hinge Healt h app with guided exercise therapy 2. Virt ual visit s with members of your care team 3. Kit wit h a t ablet and t ools to assist in guiding exercise therapy How much does t he program cost ? It's free for eligible members. This includes access to your care team, the Hinge Health app, and any materials that we send to assist in your care. Who is eligible? Members and dependents 18+ enrolled in a III-A medical plan through Blue Cross of Idaho are eligible. How do I apply? Take a short online questionnaire following the link below, telling us about your pain. No referral or diagnosis needed from a doctor. Exercise t herapy made easy Follow along in the app for simple, 10-minute exercise therapy sessions. Treat ment f rom your care t eam Get help overcoming pain, recovering from an injury, preparing for surgery, and more! ---PAGE BREAK--- Scan the QR code to learn more or apply at hinge.healt h/ iiia-oe or call (855) 902-2777 Eligibility: Members and dependents 18+ enrolled in the Blue Cross of Idaho medical plan through III-A are eligible. *Participants with chronic knee and back pain after 12 weeks. Bailey, et al. Digital Care for Chronic Musculoskeletal Pain: 10,000 Participant Longitudinal Cohort Study. JMIR. (2020). You and your eligible family members get access to Hinge Health?s programs for back, knee, neck, hip, shoulder, foot, ankle, pelvic floor, elbow, wrist and hand. All at zero cost t o you, which can include: - Technology for inst ant feedback in t he app - Unlimit ed 1-on-1 healt h coaching - Personalized exercise t herapy On average, Hinge Health has helped over 300K participants reduce their pain as much as 68%.* Hinge Health will be available begining Oct ober 1, 2023. Sign up for the waitlist today! Conquer back and joint pain wit hout drugs or surgery Sign up for t he wait list t oday! ---PAGE BREAK--- • Preventive care is when you see a doctor or have a screening when you do not have any signs of a medical problem. • Covered preventative care services with an in-network providers will have no cost to you. Preventive care benefits for services from out-of-network providers are subject to your out-of- Preventative Care Benefits Services for Adults (18+) Services for Children (17 and under) • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • Note: Your provider must bill these services as preventive/wellness services. For complete descriptions of your policy, please contact III-A staff. ---PAGE BREAK--- DIABETIC MEMBERS: Call the III-A Benefits Line to discuss cost-saving benefits that may be available to you. NEVER LEAVE THE PHARMACY WITHOUT YOUR PRESCRIBED MEDICATIONS. Call the III-A Benefits Line if something is incorrect. ProAct Prescription Drug Benefits Save on your maintenance medications through mail order with ProAct! III-A Pharmacy Benefit Copays: RETAIL PHARMACY: 30 DAY SUPPLY Generic (Tier Up to $10 Brand Name (Tier Up to $25 Non-Preferred Drugs (Tier Up to $40 MAIL ORDER PHARMACY: 90 DAY SUPPLY *MOST COST SAVINGS Generic (Tier Up to $20 Brand Name (Tier Up to $50 Non-Preferred Drugs (Tier Up to $80 SPECIALITY PHARMACY: 30 DAY SUPPLY LIMIT Contact the III-A Benefits Line to discuss the specialty med options and savings opportunity. ProAct Mail-Order Pharmacy: ProActPharmacyServices.com (866) 287-9885 Noble Specialty Pharmacy (Specialty Medications): (888) 843-2040 ---PAGE BREAK--- **Medication Prior-Authorizations must be submitted to ProAct.** ---PAGE BREAK--- DELTA DENTAL OF IDAHO www.deltadentalid.com Customer Service PO BOX 2870 (208) 489-3580 Boise, ID 83701 (800) 356-7586 Oct 2023 Summary of ---PAGE BREAK--- Life Insurance Benefit Amount: $20,000 Accelerated Death Benefit: 25%, 50%, or 75% of face value with remainder paid at time of death Portability: If you retire, reduce your hours to less than fulltime, or leave your employer, you can take this coverage with you. Life, Accidental Death & Dismemberment (AD&D) Insurance: Complete the OneAmerica Beneficiary Designation Form and give it to your employer. Keep this form updated. Other: Free Online Will Preparation: Create a will online including property, funeral and burial instructions, and guardianship for children. Legal Guidance: Get a free 30-minute consultation and a 25% reduction in fees to talk with an attorney regarding: divorce, adoption, family law, wills, trusts and more. Financial Resources: Financial experts can assist with a wide range of issues: retirement planning, taxes, relocation, mortgages, insurance, budgeting, debt, bankruptcy and more. Work-Life Solutions: Referrals and resources for just about anything on your to-do list, such as: Finding child and elder care, hiring movers or home repair contractors, planning events, locating pet care, and more. Travel Assistance Program Call: (855) 387-9727 Online: guidanceresources.com Additional Resources ---PAGE BREAK--- ---PAGE BREAK---