Blue Value Benefits

Kellogg School District Blue Cross of Idaho Blue Value Medical Plan September 1, 2007 to September 1, 2008
	In-Network	Out-of-Network*
PPO Network	Blue Cross of Idaho
Deductible	$250/Individual, $500/Family	$500 Individual, $1,000/Family
Coinsurance	90%	70%
Out-of-Pocket Max (does not include deductible)	$1,500/Individual	$3,000/Individual
Maximum Benefit	$1,000,000
Office Visits	$20 PCP/$40 non-PCP	Deductible/90%
Preventive Care	$20 PCP/$40 non-PCP	Not Covered
Lab Work	Deductible/90%	Deductible/90%
Hospital Inpatient**	Deductible/90%	Deductible/90%
Emergency Room	Deductible/90%	Deductible/90%
Maternity	Deductible/90%	Deductible/90%
Accident Benefit	Plan Provisions
Chiropractic - $800/Yr	Deductible/90%	Deductible/50%
Outpatient Physical, Speech & Occupational Therapies (limited to a combine total of $2,000 per member/calendar yr.)	Deductible/50%	Deductible/50%
Ment. Nerv./Chem. Dep.
Inpatient - 8 days/Yr***	Deductible/50%	Deductible/50%
Outpatient - 20 Visits/Yr	Deductible/50%	Deductible/50%
Prescription Drugs	Generic: $10 Copay Formulary/Non Formulary: $20 Copay
Information provided is in summary format. Any difference between the summary provided and the actual contract will be settled in favor of the contract.

*Non-Preferred Providers will be reimbursed for the majority of services at 70% of the contracted Preferred Provider rate, therefore you may also incur potential "balance billing" from the provider.
**Pre-Authorization is required for all inpatient hospital stays.