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The Benefit Terms Glossary (Google doc) provides general definitions of common benefit terms.

Annual Deductible

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PlanCoverage
PPO Plan In-Network$350 per person maximum, $950 per family
PPO Plan Out-Of-Network$600 per person, $1700 per family
Traditional$500 per person, $1400 per family
High Deductible Plan In-Network$2000 per person, $4000 per family

Out of Pocket Maximum

As applicable, each policy year

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PlanCoverage
PPO Plan In-Network$3,250 per person maximum, $6,750 per family
PPO Plan Out-Of-Network$6,500 per person, $13,500 per family
Traditional$4,350 per person, $8,700 per family
High Deductible Plan In Network$5,000 per person, $10,000 per family
High Deductible Plan Out-of-Network$6,500 per person, $13,000 per family

Physician Office Visit

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Plan Coverage
PPO Plan In-NetworkPrimary Care Visit to treat an injury or illness:
  • Preventive care/screening immunization = $0 Copay/visit

  • All other In-Network = $20 Copay/visit, deductible does not apply

  • 20% coinsurance for all other services
Specialist Visit:
  • In-Network = $40 Copay/visit, deductible does not apply

  • 20% coinsurance for all other services
PPO Plan Out-Of-NetworkPrimary Care and Specialist Visit:
  • Preventive care/screening immunization = 40% coinsurance

  • 40% coinsurance for all other services
    Traditional
  • Preventive care/screening immunization = $0 Copay/visit

  • 30% coinsurance for all other services

    		•
    High Deductible Plan In-NetworkPrimary Care and Specialist Visit:
    • Preventive care/screening immunization = $0 Copay/visit

    • All other In-Network = $20 Copay/visit, deductible does not apply

    • 20% coinsurance for all other services
    High Deductible Plan Out-of-NetworkPrimary Care and Specialist Visit
    • Preventive care/screening immunization = 40% coinsurance

    • 40% coinsurance for all other services

      Hospital Services Emergency Ambulance Transportation Outpatient Surgery

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      PlanCoverage
      PPO Plan In-Network
    • Ambulatory Surgery Center Fee and Physician Fee = 10% coinsurance

    • All other facilities fee and physician fee = 20% coinsurance

      		•
      PPO Plan Out-Of-NetworkAll facility and physician fees = 40% coinsurance
      Traditional In-Network
    • Ambulatory Surgery Center Fee and Physician Fee = 20% coinsurance

    • All other facilities fee and physician fee = 30% coinsurance

      		•
      Traditional Out-Of-NetworkAll facility and physician fees = 30% coinsurance
      High Deductible Plan In-Network
    • Ambulatory Surgery Center Fee and Physician Fee = 10% coinsurance

    • All other facilities fee and physician fee = 20% coinsurance

      		•
      High Deductible Plan Out-Of-NetworkAll facility and physician fees = 40% coinsurance

      Employee Assistance Program (EAP)

      The Employee Assistance Program (EAP) covers six (6) visits of screening, short term counseling or referral services available per eligible employee or family member per plan year without charge, regardless of insurance plan enrollment. All requests for prior authorization for all mental health and/or substance abuse services and inquiries for EAP must be directed to ComPsych by calling 24/7 live assistance (800) 992-2687.

      Outpatient Psychotherapy Services

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      Plan,Coverage
      PPO Plan In-Network$0 copayment per visit
      PPO Plan Out-Of-Network40% coinsurance
      Traditional30% coinsurance
      High Deductible Plan In-Network20% coinsurance
      High Deductible Out-Of-Network40% coinsurance

      Psychiatric Outpatient Facility, Inpatient and Other Professional Services

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      PlanCoverage
      PPO Plan In-Network20% coinsurance
      PPO Plan Out-Of-Network40% coinsurance
      Traditional30% coinsurance
      High Deductible Plan Plan In-Network20% coinsurance
      High Deductible Plan Plan Out-Of-Network40% coinsurance

      Outpatient Rehabilitation Therapy Services

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      PlanCoverage
      PPO Plan In-Network20% coinsuranceOccupational and speech therapies are limited to 20 visits annual max.

      Physical therapy – 40 visits annual max.
      PPO Plan Out-Of-Network40% coinsuranceOccupational and speech therapies are limited to 20 visits annual max.

      Physical therapy – 40 visits annual max.
      Traditional30% coinsuranceOccupational and speech therapies are limited to 20 visits annual max.

      Physical therapy – 40 visits annual max.
      High Deductible Plan Plan In-Network20% coinsuranceOccupational and speech therapies are limited to 20 visits annual max.

      Physical therapy – 40 visits annual max.
      High Deductible Plan Plan Out-Of-Network40% coinsuranceOccupational and speech therapies are limited to 20 visits annual max.

      Physical therapy – 40 visits annual max.

      Wellness/Preventive Services

      Traditional, PPO Plan In-Network, and High Deductible Plans

      • All Affordable Care Act (ACC) listed preventative services will be covered 100% when in-network. No annual limits.
      • You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventative. Then check what your plan will pay for.
      • Visit Healthcare.gov for a list of Preventive Services.

      PPO Out-of-Network and High Deductible Out-of-Network Plans

      • 40% coinsurance

      Telehealth for Non-Urgent Medical or Behavioral Health Care: Regence Doctor on Demand

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      PlanCoverage
      Traditional0% Deductible Waived
      PPO Plan In-Network0% Deductible Waived
      PPO Plan Out-Of-NetworkNA
      High Deductible Plan In-Network0% Deductible Waived
      High Deductible Plan Out-Of-NetworkNA

      Prescription Drugs

      The State of Idaho health plan has a six-tier drug list, sometimes called a formulary. It’s important to note that there may be a difference in how certain drugs are classified compared to previous years. For more information on the change in drug tiers, please review the 6-Tier Benefit flyer.

      This Regence resource is a list of prescription generic, brand-name, and specialty drugs that have been approved by the FDA.

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      PREFERRED PROVIDER ORGANIZATION & TRADITIONAL PLANHIGH DEDUCTIBLE HEALTH PLAN (HDHP)
      Drug TiersIn-NetworkOut of NetworkIn-NetworkOut of Network
      1st Tier-Generic, highest value$10 co-pay, deductible does not apply / retail prescription20% coinsurance after
      Deductible (retail and mail
      order)      		20% coinsurance after
      Deductible (retail and mail
      order)
      $30 co-pay deductible does not apply / home delivery non-maintenance
      2nd Tier-Generic, moderate value
      		$10 co-pay, deductible does not apply / retail prescription
      $30 co-pay deductible does not apply / home delivery non-maintenance
      3rd Tier-Formulary Brand, moderate value$30 co-pay, deductible does not apply / retail prescription
      $90 co-pay deductible does not apply / home delivery non-maintenance
      4th Tier-Formulary Brand, lower value$60 co-pay, deductible does not apply / retail prescription
      $180 co-pay deductible does not apply / home delivery non-maintenance
      5th Tier-Formulary Specialty, moderate value$60 co-pay, deductible does not apply / specialty drug
      Out-of-Network      		 90% coinsurance deductible does not apply / specialty drug20% coinsurance specialty drug 90% coinsurance specialty drug
      6th Tier-Formulary Specialty, lower value$100 co-pay, deductible does not apply / specialty drug90% coinsurance deductible does not apply / specialty drug
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