Blue Cross PPO Benefits

Kellogg School District Blue Cross of Idaho PPO Medical Plan September 1, 2007 to September 1, 2008
	In-Network	Out-of-Network*
PPO Network	Blue Cross of Idaho
Deductible	$300/$600
Coinsurance	Deductible/90%	Deductible/70%
Out-of-Pocket Max (does not include deductible)	$1,500/Individual	$3,000/Individual
Maximum Benefit	$1,000,000
Office Visits	Deductible/90%	Deductible/70%
Preventive Care	$20 Copay, 100% (see contract for limitations)	Not Covered
Lab Work	Deductible/90%	Deductible/70%
Hospital Inpatient***	Deductible/90%	Deductible/70%
Emergency Room	Deductible/90%	Deductible/70%
Accident Benefit	First $300 at 100%
Chiropractic - $800/Yr	Deductible/90%	Deductible/50%
Outpatient Physical. Therapy - $800/Yr	Deductible/90%	Deductible/70%
Mental Nervous./Chemical Dependency	See Inpatient/Outpatient Below
Inpatient*** - 8 days/Yr	Deductible/50%	Not Covered
Outpatient - 20 Visits/Yr	Deductible/50%	Not Covered
Prescription Drugs	$10 Generic/100% $20 Name Brand/100%****	Same as In-Network Member pays amounts over allowance
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.
** Lab & X-ray has the first $100 paid at 100%
*** Pre-Authorization is required for all inpatient hospital stays.
**** Retail: (30 day supply), Mail Order: (30 day supply, maintenance only)