Form No. 3-190 (10-14) Policy Form Numbers: 18-062-01/15 18-063-01/15 18-090-01/15
18-091-01/15 18-092-01/15 18-095-01/15 18-096-01/15
18-097-01/15 18-107-01/15 18-108-01/15 18-109-01/15
18-116-01/15 18-117-01/15 18-118-01/15 18-207-01/15
18-208-01/15 18-209-01/15 18-212-01/15 18-213-01/15
18-214-01/15 18-217-01/15 18-218-01/15 18-219-01/15
18-227-01/15 18-228-01/15 18-229-01/15
Cost Sharing Plans
for Individuals from
Blue Cross of IdahoChoose coverage
that fits.
HEALTH INSURANCE PLANS from BLUE CROSS OF IDAHO – Individuals
ANNUAL HOUSEHOLD INCOME
Family Size
CSR 73 CSR 87 CSR 94
1 $23,340 - $29,175 $17,505 - $23,340 $11,670 - $17,505
2 $31,460 - $39,325 $23,595 - $31,460 $15,730 - $23,595
3 $39, 580 - $49,475 $29,685 - $39,580 $19,790 - $29,685
4 $47,700 - $59,625 $35,775 - $47,700 $23,850 - $35,775
5 $55,820 - $69,775 $41,865 - $55,820 $27,910 - $41,865
6 $63, 940 - $79,925 $47,955 - $63,940 $31,970 - $47,955
7 $72, 060 - $90,075 $54,045 - $72,060 $36,030 - $54,045
8 $80,180 - $100,225 $60,135 - $80,180 $40,090 - $60,135
*This chart is for reference only. Your Health Idaho will determine your actual CSR eligibility.
GET AN EVEN BIGGER BREAK ON COSTS!If you qualify for financial assistance with you rmonthly premium payment, you might also qualify for additional savings on the out-of-pocket costs you have to pay when you use your insurance. This type of savings is called a cost-sharing reduction, or CSR, and is a Silver plan with reduced costs for deductibles, coinsurance or copayments.
If you qualify for a CSR, our Silver plans automatically have reduced out-of-pocket costs. CSRs are different from the monthly premium assistance because they are not tax credits and do not have to be listed when you file your taxes.
To enroll in a CSR plan, you have to buy your health insurance through the Idaho Health Insurance Exchange, called Your Health Idaho. This website, yourhealthidaho.org, will ask
you for information about your family, income and job and show you the CSR level you qualify for. Then you can choose a plan and enroll online.
YOU CAN GET THIS REDUCTION IF
• You get health insurance through Your Health Idaho • Your annual household income is below a certain level • You choose one of the Silver health insurance plans
Don’t forget—if you qualify for a CSR level, you also qualify for financial assistance with your monthly insurance premiums. Members of Native American tribes qualify for a separate CSR. See our Tribal Health Insurance Plans brochure for details.
Note: The cost-sharing reductions only apply to healthcare you get from an in-network provider. If you choose a Silver Connect plan, it is important to review the list of doctors in the ConnectedCare network to see if the plan meets your needs. You can search the list of providers at bcidaho.com/findaprovider.
CHOOSE COVERAGE THAT FITS – bcidaho.com
BLUE CROSS OF IDAHO HEALTH INSURANCE PLANS
Benefit details are for in-network coverage only. Not a comprehensive list of benefits. See our Health Insurance plans for Individuals brochure for a larger list of benefit and plan exclusions and limitations.
CSR 73 SILVER CHOICE & SILVER CONNECT 4000
SILVER CHOICE & SILVER CONNECT 3000
SILVER CHOICE & SILVER CONNECT 2000
SILVER CHOICE & SILVER CONNECT NO DEDUCTIBLE
Benefit Details
DeductibleBase
$4,000 individual
$8,000 family
You pay $2,900
individual $5,800 family
Base $3,000
individual $6,000 family
You pay $2,500
individual $5,000 family
Base $2,000
individual $4,000 family
You pay $2,000
individual $4,000 family
Base $0 You pay $0
Coinsurance Base 30% You pay 30% Base 30% You pay 30% Base 30% You pay 30% Base 50% You pay 50%
Annual Out-of-Pocket Maximum
Base $6,350
individual $12,700
family
You pay $5,200
individual $10,400
family
Base $6,350
individual $12,700
family
You pay $5,200
individual $10,400
family
Base $6,350
individual $12,700
family
You pay $4,650
individual $9,300 family
Base $6,350
individual $12,700
family
You pay $5,200
individual $10,400
family
Brand-name Prescription
Deductible
Base $2,350 per person
You pay $2,300
per personBase $1,000
per personYou pay $1,000
per personBase $1,000
per personYou pay $1,000
per personBase $0
per personYou pay $0 per person
CSR 87 SILVER CHOICE & SILVER CONNECT 4000
SILVER CHOICE & SILVER CONNECT 3000
SILVER CHOICE & SILVER CONNECT 2000
SILVER CHOICE & SILVER CONNECT NO DEDUCTIBLE
Benefit Details
DeductibleBase
$4,000 individual
$8,000 family
You pay $150
individual $300 family
Base $3,000
individual $6,000 family
You pay $150
individual $300 family
Base $2,000
individual $4,000 family
You pay $150
individual $300 family
Base $0 You pay $0
Coinsurance Base 30% You pay 30% Base 30% You pay 20% Base 30% You pay 20% Base 50% You pay 25%
Annual Out-of-Pocket Maximum
Base $6,350
individual $12,700
family
You pay $2,250
individual $4,500 family
Base $6,350
individual $12,700
family
You pay $2,250
individual $4,500 family
Base $6,350
individual $12,700
family
You pay $2,250
individual $4,500 family
Base $6,350
individual $12,700
family
You pay $2,250
individual $4,500 family
Brand-name Prescription
Deductible
Base $2,350 per person
You pay $150 per person
Base $1,000 per person
You pay $150 per person
Base $1,000 per person
You pay $150 per person
Base $0 per person
You pay $0 per person
CSR 94 SILVER CHOICE & SILVER CONNECT 4000
SILVER CHOICE & SILVER CONNECT 3000
SILVER CHOICE & SILVER CONNECT 2000
SILVER CHOICE & SILVER CONNECT NO DEDUCTIBLEBenefit Details
DeductibleBase
$4,000 individual
$8,000 familyYou pay $0
Base $3,000
individual $6,000 family
You pay $0Base
$2,000 individual
$4,000 familyYou pay $0 Base $0 You pay $0
Coinsurance Base 30% You pay 10% Base 30% You pay 10% Base 30% You pay 10% Base 50% You pay 10%
Annual Out-of-Pocket Maximum
Base $6,350
individual $12,700
family
You pay $1,000
individual $2,000 family
Base $6,350
individual $12,700
family
You pay $900
individual $1,800 family
Base $6,350
individual $12,700
family
You pay $700
individual $1,400 family
Base $6,350
individual $12,700
family
You pay $1,750
individual $3,500 family
Brand-name Prescription
Deductible
Base $2,350 per person
You pay $0 per person
Base $1,000 per person
You pay $0 per person
Base $1,000 per person
You pay $0 per person
Base $0 per person
You pay $0 per person
STREET ADDRESS
1010 17th Street Lewiston, ID 83501
MAILING ADDRESS
P.O. Box 1468 Lewiston, ID 83501 208-746-0531
Lewiston
STREET ADDRESS
275 South 5th Avenue Suite 150
Pocatello, ID 83201
MAILING ADDRESS
P.O. Box 2578 Pocatello, ID 83206 208-232-6206
Pocatello
STREET ADDRESS
1431 North Fillmore Street Suite 200
Twin Falls, ID 83301
MAILING ADDRESS
P.O. Box 5025 Twin Falls, ID 83303-5025 208-733-7258
Twin Falls
STREET ADDRESS
3000 East Pine Avenue Meridian, ID 83642-5995
MAILING ADDRESS
P.O. Box 7408 Boise, ID 83707 208-387-6683 800-365-2345
Meridian
CLAIMS INQUIRIES
(208) 331-7347 | 800-627-1188
STREET ADDRESS
1910 Channing WayIdaho Falls, ID 83404
MAILING ADDRESS
P.O. Box 2287 Idaho Falls, ID 83403 208-522-8813
Idaho Falls
Coeur d’Alene1450 Northwest Boulevard, Suite 106
Coeur d’Alene, ID 83814 208-666-1495
P.O. Box 7408 · Boise, ID · 83707 1 888 GO CROSS (1 888-462-7677)
bcidaho.com
© 2014 by Blue Cross of Idaho, an independent licensee of the Blue Cross and Blue Shield Association
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