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01-2017 LG NGF Preferred Blue Preferred BluePPO Summary of Benefits - 2017 Preferred Blue® PPO In-Network Out-of-Network Benefit Period* Deductible (Individual/Family) $2,000/$4,000 Coinsurance You pay 20% of the allowed amount You pay 40% of the allowed amount Individual Out-of-Pocket Limit (See Policy for services that do not apply to the limit.) (Includes applicable Deductible, Coinsurance and Copayments) $3,500 $5,000 Family Out-of-Pocket Limit (See Policy for services that do not apply to the limit.) (Includes applicable Deductible, Coinsurance and Copayments) $7,000 $10,000 COVERED SERVICES By choosing a non-contracting provider you may be responsible for the difference between what Blue Cross allows and what the non- contracting provider charges. Some services may require prior authorization. In-Network deductible and/or coinsurance payment required before insurance pays? In-Network Out-of-Network The amount you pay Advanced Imaging Services (Outpatient services only) (Magnetic Resonance Imaging (MRI), Magnetic Resonance Angiography (MRA), Computed Tomography Scan (CT Scan), Positron Emission Tomography (PET), Nuclear Cardiology) Yes You pay 20% of the allowed amount You pay 40% of the allowed amount Allergy Injections No You pay a $5 copayment (if this is the only service provided during the visit) You pay 40% of the allowed amount Ambulance Transportation Services Yes You pay 20% of the allowed amount Breastfeeding Support and Supply Services (Limited to one breast pump purchase per benefit period per insured) No You pay nothing of the allowed amount Chiropractic Care (Limited to 18 visits combined per insured, per benefit period) Yes You pay 20% of the allowed amount You pay 50% of the allowed amount Dental Services Related to Accidental Injury Yes You pay 40% of the allowed amount Diabetes Self-Management Education Services (Only for accredited providers approved by BCI.) No You pay a $30 copayment per visit Diagnostic Services (Including diagnostic mammograms) Yes You pay 20% of the allowed amount Durable Medical Equipment, Orthotic Devices, and Prosthetic Appliances Emergency Services** – Facility Services (Copayment waived if admitted) Yes You pay $100 copayment for hospital Outpatient emergency room visit, then you pay 20% of the allowed amount You pay $100 copayment for hospital Outpatient emergency room visit, then you pay 40% of the allowed amount Emergency Services** – Professional Services Yes You pay 20% of the allowed amount You pay 40% of the allowed amount Home Health Skilled Nursing Home Intravenous Therapy Yes You pay 80% of the allowed amount Hospice Services No You pay nothing of the allowed amount You pay 40% of the allowed amount Hospital Services (Inpatient and outpatient services at a licensed general hospital or ambulatory surgical facility.) Yes You pay 20% of the allowed amount Maternity Services and/or Involuntary Complications of Pregnancy Yes ---PAGE BREAK--- 01-2017 LG NGF Preferred Blue Preferred BluePPO COVERED SERVICES By choosing a non-contracting provider you may be responsible for the difference between what Blue Cross allows and what the non- contracting provider charges. Some services may require prior authorization. In-Network deductible and/or coinsurance payment required before insurance pays? In-Network Out-of-Network The amount you pay Mental Health– Inpatient (Facility and Professional Services) Yes You pay 20% of the allowed amount You pay 40% of the allowed amount Mental Health– Outpatient Services No You pay a $30 copayment per visit Facility and other Professional Services Yes You pay 20% of the allowed amount Outpatient Habilitation Therapy Services (Includes physical, speech and occupational therapies. Limited to 20 visits combined per insured, per benefit period.) Yes You pay 50% of the allowed amount You pay 80% of the allowed amount Outpatient Rehabilitation Therapy Services (Includes physical, speech and occupational therapies. Limited to 20 visits combined per insured, per benefit period.) Rehabilitation or Habilitation Services You pay 20% of the allowed amount You pay 40% of the allowed amount Physician Office Visit (Other services rendered during a physician office visit will be subject to deductible and coinsurance.) No You pay a $30 copayment Prescribed Contraceptive Services (Includes diaphragms, intrauterine devices (IUDs), implantables, injections and tubal ligation.) No You pay nothing of the allowed amount Post Mastectomy Reconstructive Surgery Yes You pay 20% of the allowed amount Skilled Nursing Facility (Limited to 30 days combined per insured, per benefit period.) Sleep Study Services Surgical/Medical (Professional Services) Therapy Services (Including chemotherapy, growth hormone therapy, radiation and renal dialysis.) Transplant Services Preventive Care Benefits (See the BCI Web site, www.bcidaho.com, for specifically listed preventive care services.) Yes/No You pay nothing for services specifically listed For services not specifically listed you pay deductible and coinsurance Immunizations (See the BCI Web site, www.bcidaho.com, for specifically listed immunizations.) No You pay nothing for listed immunizations *The specified period of time during which charges for covered services must be incurred in order to accumulate toward annual benefit limits, deductible amounts and out-of-pocket limits. **Emergency Services For the treatment of Emergency Medical Conditions or Accidental Injuries of sufficient severity to necessitate immediate medical care by, or that require Ambulance Transportation Service to, the nearest appropriate Facility Provider, BCI will provide In-Network benefits for Covered Services provided by either a Contracting or Noncontracting Facility Provider and facility-based Professional Providers only. If the nearest Facility Provider is Noncontracting, once the Insured is stabilized and is no longer receiving emergency care the Insured (at BCI’s option) may transfer to the nearest appropriate Contracting Facility Provider for further care in order to continue to receive In-Network benefits for Covered Services. If the Insured is required to transfer, transportation to the Contracting Facility Provider will be a Covered Service under the Ambulance Transportation Service provision of this Policy. This summary describes the general features of this program; it is not a contract. All provisions of the Group Master Policy apply to this program. Noncontracting providers may bill you for amounts over the maximum allowance. ---PAGE BREAK--- *For brand name drugs that have a corresponding generic substitute your pharmacist should fill your prescription with the generic (unless indicated otherwise by your physician) and you will pay the lowest copayment. If you purchase the brand name drug and it has a corresponding generic equivalent, you will be responsible for the difference in cost between the generic and brand name drug plus the applicable brand name copayment. Prescription Drug Option Prescription Benefits Retail and Mail Order (90 day supply with multiple copays) Generic You pay a $15 copayment Formulary Brand Name You pay a $30 copayment Non-Preferred Brand Name You pay a $45 copayment Prescribed Contraceptives You pay nothing for Women’s Preventive Prescription Drugs and devices as specifically listed on the BCI Web site, www.bcidaho.com; Deductible does not apply. The day supply allowed shall not exceed a 90-day supply at one time, as applicable to the specific contraceptive drug or supply. Out-of-Pocket Limit Individual: You pay $3,000 in Copayments and/or Coinsurance per Benefit Period for a combination of all Prescription Drug charges incurred. Family: You pay a combination of $6,000 in Copayments and/or Coinsurance per Benefit Period for a combination of all Prescription Drug charges incurred. When the Prescription Drug Out-of-Pocket Limit is met, the Prescription Drug Benefits payable will increase to 100% of the Allowed Charge or the Usual Charge for the remainder of the Benefit Period.