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Blue Cross of Idaho Health Service, Inc.   -   KCN North Silver 6850 CSR 94

Deductible & Out-of-Pocket
Deductible
Out-of-pocket max
Doctor Visit
Additional Information
Primary Care Visit
$20.00 Copay
80.00% Coinsurance after deductible
Specialist Visit
$50.00 Copay
80.00% Coinsurance after deductible
Other Practitioner Office Visit (Nurse, Physician Assistant)
$20.00 Copay
80.00% Coinsurance after deductible
Preventive Care/Screening/Immunization
No Charge
80.00% Coinsurance after deductible
Tests
Additional Information
Laboratory Outpatient and Professional Services
20.00% Coinsurance after deductible
80.00% Coinsurance after deductible
X-rays and Diagnostic Imaging
20.00% Coinsurance after deductible
80.00% Coinsurance after deductible
Imaging (CT/PET scans, MRIs)
$250.00 Copay
20.00% Coinsurance after deductible
$250.00 Copay
80.00% Coinsurance after deductible
Drugs
Additional Information
Generic Drugs
$10.00 Copay
$10.00 Copay
Preferred Brand Drugs
$30.00 Copay
$30.00 Copay
Non-Preferred Brand Drugs
$50.00 Copay after deductible
$50.00 Copay after deductible
Specialty Drugs
30.00% Coinsurance after deductible
30.00% Coinsurance after deductible
Outpatient
Additional Information
Outpatient Facility Fee
20.00% Coinsurance after deductible
80.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services
20.00% Coinsurance after deductible
80.00% Coinsurance after deductible
Urgent Care
Additional Information
Emergency Room Services
20.00% Coinsurance after deductible
80.00% Coinsurance after deductible
Emergency Transportation/Ambulance
20.00% Coinsurance after deductible
80.00% Coinsurance after deductible
Urgent Care
$20.00 Copay
80.00% Coinsurance after deductible
Hospital
Additional Information
Inpatient Hospital Services
20.00% Coinsurance after deductible
80.00% Coinsurance after deductible
Inpatient Physician and Surgical Services
20.00% Coinsurance after deductible
80.00% Coinsurance after deductible
Mental / Behavioral Health
Additional Information
Mental/Behavioral Health Outpatient Services
$20.00 Copay
80.00% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services
20.00% Coinsurance after deductible
80.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services
$20.00 Copay
80.00% Coinsurance after deductible
Substance Abuse Disorder Inpatient Services
20.00% Coinsurance after deductible
80.00% Coinsurance after deductible
Pregnancy
Additional Information
Prenatal and Postnatal Care
20.00% Coinsurance after deductible
80.00% Coinsurance after deductible
Delivery and All Inpatient Services for Maternity Care
20.00% Coinsurance after deductible
80.00% Coinsurance after deductible
Other Special Needs
Additional Information
Home Healthcare Services
20.00% Coinsurance after deductible
80.00% Coinsurance after deductible
Outpatient Rehabilitation Services
20.00% Coinsurance after deductible
80.00% Coinsurance after deductible
Habilitation Services
20.00% Coinsurance after deductible
80.00% Coinsurance after deductible
Skilled Nursing Facility
20.00% Coinsurance after deductible
80.00% Coinsurance after deductible
Durable Medical Equipment
20.00% Coinsurance after deductible
80.00% Coinsurance after deductible
Hospice Services
No Charge
80.00% Coinsurance after deductible
Chiropractic Care
20.00% Coinsurance after deductible
80.00% Coinsurance after deductible
Acupuncture
Not covered
Not covered
Rehabilitative Speech Therapy
20.00% Coinsurance after deductible
80.00% Coinsurance after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy
20.00% Coinsurance after deductible
80.00% Coinsurance after deductible
Well Baby Visits and Care
No Charge
80.00% Coinsurance after deductible
Allergy Testing
20.00% Coinsurance after deductible
80.00% Coinsurance after deductible
Diabetes Education
$20.00 Copay
80.00% Coinsurance after deductible
Nutritional Counseling
No Charge
80.00% Coinsurance after deductible
Children's Vision
Additional Information
Eye Exam for Children
No Charge
50.00% Coinsurance
Eye Glasses for Children
No Charge
50.00% Coinsurance
Dental
Additional Information
Accidental Dental
20.00% Coinsurance after deductible
80.00% Coinsurance after deductible
Basic Dental Care (Adult)
Not covered
Not covered
Basic Dental Care (Child)
Not covered
Not covered
Dental Check Up (Child)
Not covered
Not covered
Major Dental Care (Adult)
Not covered
Not covered
Major Dental Care (Child)
Not covered
Not covered
Orthodontia (Adult)
Not covered
Not covered
Orthodontia (Child)
Not covered
Not covered
Routine Dental Services (Adult)
Not covered
Not covered

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