Please reference the Formulary Information section for the current year on this page to find the appropriate formulary. These include but are not limited to certain prenatal supplements, contraceptives, fluoride for children and tobacco cessation aids. The medical policies contained in this manual are the property of Blue Cross of Idaho. Please select Continue if you agree to these guidelines. Find an agentCall 1-888-492-2583 (TTY 711)8 a.m. - 6 p.m. Monday to Friday. Medical technology is constantly changing, and we reserve the right to review and update our policies periodically. Blue Cross of Idaho may require members to purchase a specialty drug through IngenioRX Specialty Pharmacy and have the medication shipped to their physician for administration OR physician may be required to buy-and-bill under Major Medical. If clinical safety and medical necessity for additional doses can be proven, you may request modification of the quantity limit through the Prior Authorization process. Blue Cross of Idaho Care Plus, Inc. is a Medicare Advantage plan with a Medicare contract. The Blue Cross of Idaho formularies list drugs approved for coverage under your policy. Medical Policy overview Use and Disclosure of Data The medical policies contained in this manual are the property of Blue Cross of Idaho. You must be logged-in to view this page. Specialty medications help patients manage rare and complex conditions, are typically high-cost, and require strict compliance and patient support. We work with healthcare providers who agree to provide services at discounted rates to help save you money. Some employers may purchase this expanded list of preventive drugs at a specified preventive benefit. Basic Plans. 2021 Blue Cross of Idaho Care Plus, Inc. (Blue Cross of Idaho Care Plus), an Independent Licensee of the Blue Cross Blue Shield Association, with services provided by Blue Cross of Idaho Health Service, Inc. Powered by Blue Cross of Idaho Care Plus, Inc. Powered by Blue Cross of Idaho Care Plus, Inc.Y0010_MK23219_M. The POS managed-care plans are statewide and available to small, mid-size and large group employers. With plans that offer a range of benefits, you can find an option that fits the needs of your employees and their families. company history. You can verify which formulary to use by checking the Prescription Drug Program section of your plan's Benefit Description, located under Beneftis & Coverage after logging in. Today, Blue Cross of Idaho and Regence BlueShield of Idaho remain separate companies, operating independently of each other. Select a Medicare approved doctor, specialist or hospital without a referraleven when you travel. For information specific to Medicare members, visit the Medicare Advantage Informationpage. IDENTITY THEFT PROTECTION Your healthcare coverage with Blue Cross of Idaho includes free credit monitoring, fraud detection and fraud resolution support. Blue Cross of Idaho's Summary of Benefits and Coverage (SBC) provides detailed information about your health coverage options and benefits. They focus on the primary care provider (PCP) guiding treatment and managing the members' care. Blue Cross of Idaho Medical Policy for determination of medical necessity versus investigational care are only applicable to Blue Cross of Idaho members. We're in your neighborhood. Coverage to keep you safe Designed to cover unexpected illnesses or injuries that could occur while you're between full benefit plans Fixed-copay doctor visits You pay a $45 copay for up to three visits with a doctor before you meet your deductible Flexible plan durations Any reproduction or dissemination of policies is expressly prohibited other than for the assistance in the care of our members. We do not offer every plan available in your area. An Independent Licensee of the Blue Cross and Blue Shield Association, BlueCard Pre-Service Review for Out-of-Area Members, Medicare Medicaid Coordinated Plan / Idaho Medicaid Plus, Prior Authorization Procedure Code Lookup. The prescribing physician should submit the PA request by logging on to our secure provider portal atproviders.bcidaho.com. Our $0 premium plan allows you more time to enjoy your life. The policies are used for the express purpose of assisting physicians and other healthcare providers in providing evidence based cost effective care. Like us on Facebook Blue Cross Blue Shield is enacting this policy because it doesn't want people to use the emergency room as their primary health care. This page is a general reference for Blue Cross of Idaho plan members with pharmacy benefits administered by Blue Cross of Idaho, with our PBM partner IngenioRx. This plan is offered in the following counties: Ada, Adams, Bannock, Bingham, Blaine, Boise, Bonner, Bonneville, Boundary, Canyon, Cassia, Clark, Elmore, Fremont, Gem, Gooding, Jefferson, Jerome, Kootenai, Latah, Lincoln, Madison, Minidoka, Nez Perce, Owyhee, Payette, Power, Shoshone, Twin Falls, Valley and Washington counties. With the Secure Blue Courage plan youll have the flexibility of selecting your own Medicare-approved physician, while gaining access to more services than Original Medicare provides. 2. Members with plans compliant with the Affordable Care Act (ACA) have a ccess to a list of drugs mandated by the ACA at no cost. Secure Blue No Rx (PPO) is not available for new enrollments in 2021. Powered by Blue Cross of Idaho Care Plus, Inc. Blue Cross of Idaho Care Plus, Inc. is a Medicare Advantage plan with a Medicare contract. You deserve a Medicare plan that not only supports your continued good health but also your financial peace of mind. Drug cost will vary based on the formulary tier assignment of the drug. Government Programs Membership: 833-377-4266, An Independent Licensee of the Blue Cross and Blue Shield Association, BlueCard Pre-Service Review for Out-of-Area Members, Medicare Medicaid Coordinated Plan / Idaho Medicaid Plus, Prior Authorization Procedure Code Lookup, Medical Drugs Requiring Prior Authorization, Prior Authorization and/or Step Therapy requirements. Qualified Health Plan Formulary - 6 Tier for Metal Level Plans - For individual and small group Affordable Care Act plans that are available through the healthcare exchange at Your Health Idaho or directly through Blue Cross of Idaho. Check out some of the fantastic extra benefits you get from us. Preventive medications are generally prescribed for people who may be at risk for certain illness or condition, but are not yet showing symptoms. (Parts A and B) Original Medicare consists of Part A and Part B. Monthly Drug Premium *Included in Monthly Plan Premium. Enrollment in Blue Cross of Idaho Care Plus, Inc. depends on contract renewal. These benefits include coverage of self-administered medications, as well as some vaccines and specialty medications. The use of generic medications is a valuable way to reduce overall prescription drug costs without sacrificing quality. SHORT TERM PPO PLANS: (1 to 6 months) Call 1-888-492-2583 (TTY 711) 8 a.m. - 6 p.m. Monday to Friday Your Friend, the Health Insurance Agent Find a Certified Agent Find a Doctor Drug & Pharmacy Finder Blue Cross of Idaho Care Plus, Inc. is a Medicare Advantage plan with a Medicare contract. Blue Cross of Idaho has been in Idaho for over 75 years and our Customer Advocates are located right here in Idaho. Or call Blue Cross of Idaho Customer Service at 1-888-494-2583. We understand the important questions you may have about Medicare coverage. Not affiliated with or endorsed by any government agency. Blue Cross of Idaho Customer Service can assist with prior authorization questions and concerns. Any drug prescribed for off-label use indication also requires prior authorization. 2022 Plan Sales Guide Medicare Supplement Plan Extras (for plans effective after 3/1/2022) Outline of Coverage (includes monthly premium rates) 2022 Application Call 800-365-2345 or visit your local office if you have additional questions. Tier assignment can be determined utilizing the appropriate formulary. Your local agent is there for you. Benefits can be determined by referring to the members prescription drug section of the benefit plan summary, under Eligibility and Claims. We also know when to get out of the way and let you work with your healthcare provider to take control of your health. (under age 19) Pediatric vision benefits are now covered by the plan at 100% when using a participating provider. Out of network services are covered at 50%. Register for an educationalMedicare meeting near you. Some, but not all, ACA drugs are listed in the formularies. Please refer to the back of your patients Blue Cross of Idaho ID card to determine if their benefits are administered by Blue Cross of Idaho Rx. Drugs requiring prior authorization can be identified by the PA that follows the drug name. Providers may submit the Contraceptive Exception Request Form along with documentation showing the need for this alternate product instead of one already covered with no member cost share. Medication specific quantity limits are searchable in the formulary. Our dental plans boost your overall health and protect your pocketbook: Competitively priced plans Innovative plans cover services that members need and value If you are unsure about the formulary your plan uses, please contact Blue Cross of Idaho Rx Customer Care at the number on the back of your Blue Cross of Idaho member ID card to check costs for prescription drugs. An Independent Licensee of the Blue Cross and Blue Shield Association . Blue Cross of Idaho remains Idaho's oldest health insurer, with approximately one quarter of the state's population enrolled in its traditional, PPO, and managed care programs. There are a lot of choices to make and you get to start making those choices when you near the age of 65, or when you retire at 65 and no longer get health insurance from your employer.Common myths about medicare|Medicare FAQs. Some medications may have limits on how many doses are covered under your patient's policy. When a drug requires prior authorization, Blue Cross of Idaho may determine the most appropriate method of benefit administration (Major Medical vs. Pharmacy) through the authorization process. These plans include comprehensive medical and prescription drug coverage through Blue Cross of Idaho, life insurance coverage of $25,000 per employee, $5,000 for spouse and $5,000 for dependent (s), AD&D, and $125/week short-term disability coverage. We give you the tools you need to make informed decisions. These vaccines include: For members on a Qualified Health Plan, physicians may submit a Formulary Exception Request with complete clinical documentation to request coverage for a non-formulary drug when all therapeutically equivalent generic drugs within the same class have been tried and are contraindicated for use. Blue Cross of Idaho goes beyond original Medicare to offer a range of comprehensive plans to meet your needs and budget, as well as the expertise to step in and help you through the Medicare process if you ever need a hand. You may also refer to the Medical Policies section of the website for information regarding criteria for certain prescription drugs. This page is a general reference for Blue Cross of Idaho plan members with pharmacy benefits administered by Blue Cross of Idaho, with our PBM partner IngenioRx. Several Blue Cross of Idaho High Deductible Health Plan (HDHP) or HSA policies offer coverage for a list of preventive medications, not subject to the deductible requirements of the plan. Members with ACA compliant plans also have the option to request coverage of an alternate contraceptive product at no cost, that would normally result in costs for the member. Powered by Blue Cross of Idaho Care Plus . The Medicare plans represented are PDP, HMO, PPO or PFFS plans with a Medicare contract. This plan is offered in the following counties: These plans have a POS benefit, in- and out-of-network benefit, and require members to select a PCP. Medicare - Medicare Advantage Information, Commercial - Medical Drugs Requiring Prior Authorization. However, when this option is chosen, your patient will pay the cost difference between the name brand and generic medications, in addition to their co-pays associated with the brand name medication prescribed. No referral is needed with a POS managed-care plan. We're in your neighborhood. Give your employees access to preventive, basic and major dental services with Blue Cross of Idaho dental coverage. Kit de inscripcin combinado Secure Blue Courage, Nondiscrimination Notice and Language Assistance, $0 in-network primary care physician visits, No cost for most annual preventive screenings, Telehealth services, including virtual physical therapy, Hearing exams and deeply discounted hearing aids. For drugs approved for self-administration and covered under the member's pharmacy benefit, refer to the appropriate formulary(see the current year "Formulary Information" section above)to determine if the drug prescribed requires prior authorization. 600K+ People covered by Blue Cross of Idaho 1.4K+ Employees working at Blue Cross of Idaho to serve our members 100+ More than 100 partnerships with nonprofits across the state 4K+ Your local agent is there for you. When you see an in-network provider, you get the most out of your health benefits. Additional formulary information coming soon. You can learn more about cost-sharing, coverage limitations, and if you need a referral to see a specialist. Specialty prescriptions may be submitted by phone to FastStart at 833-203-1742 or faxed to 833-263-2871. VIEW YOUR SBC Coordination of Benefits Medicare Advantage offers you the benefits you need with the affordable coverage you deserve. We understand when to step in and help you through the health insurance process. Search Tools > Find a Provider National BlueCard Directory Resources & Forms > Applications & Forms In most cases, members must purchase their specialty medications through IngenioRX Specialty Pharmacy. Albertsons companies, including Jewel-Osco and Safeway, you can find a provider here. And with one of Idaho's largest provider networks, chances are your current healthcare providers are already working with us. This exclusive arrangement helps to facilitate lower costs on specialty medications and provide patient support through the treatment process. You can also contact one of our district offices at 800-345-4550. policies & procedures overview. Staying Healthy: Screenings, Tests and Vaccines, Ease of Getting Needed Care and Seeing Specialists, Health Plan Provides Information or Help when Members Need It, Coordination of Members' Health Care Services, Diagnostic radiology services (e.g., MRI), Prosthodontics, other oral/maxillofacial surgery, other services, Outpatient group therapy visit with a psychiatrist, Outpatient individual therapy visit with a psychiatrist, Physical therapy and speech and language therapy visit, Durable medical equipment (e.g., wheelchairs, oxygen), Prosthetics (e.g., braces, artificial limbs). They are independent, certified, knowledgeable and they won't cost you a thing! You can identify if Blue Cross of Idaho Rx administers benefits as the Blue Cross of Idaho Rx Customer Service phone number is on the back of the ID card, below the main Blue Cross of Idaho Customer Service number. And with one of Idahos largest provider networks, chances are your provider is already working with us. Good oral health is a key part of your overall health, so Blue Cross of Idaho offers flexible and affordable dental plans that enhance your medical coverage. You have the option to require a prescription be filled for the brand name medication when a generic equivalent exists, by ordering the prescription with a Dispense as Written (DAW) condition. 800-627-1188 Blue Extras! At its headquarters in . last updated: 01/03/2022. If you don't have an insurance agent, you can search using our Find a Broker tool. Medicare Supplement insurance plans do not include prescription drug coverage. Enrollment in Blue Cross of Idaho Care Plus, Inc. depends on contract renewal. Drugs requiring step therapy can be identified by the ST that follows the drug name. What your patient pays for prescription medications is subject to the prescription benefits available for each specific tier. Certain medications may require step therapy, the trial of one or more cost-effective medications, prior to approval for a higher cost therapeutic treatment plan. Preventive care does not include medications prescribed for treatment of an existing illness or condition. Not all plans offer all of these benefits. The formularies include brand name as well as generic drugs that have undergone rigorous testing and are approved by the Food and Drug Administration (FDA). Access Plan Formulary - 6 Tier for Access Plans - for individual plans that are available directly through Blue Cross of Idaho. Refer to the Provider Administrative Policiesfor information about the prior authorization process and timeframes. For our Host members, the determination of medical necessity versus investigational care is determined by the Home Plan Medical Policy, as related to its administration of the Members benefits and coverage. These benefits include coverage of self-administered medications, as well as some vaccines and specialty medications. Take a look at our plans to get started. Drugs and medical injectables received in an outpatient setting may also require prior authorization. The formularies also provide information regarding the following: Qualified Health Plan Formulary - 6 Tier for Metal Level Plans - for individual and small group Affordable Care Act plans that are available through the healthcare exchange at Your Health Idaho or directly through Blue Cross of Idaho. Turning 65 soon? Refer to the appropriatepage to locate prior authorization requirements for drugs typically administered in an outpatient setting. Hours of operation: October 1 to March 31: 8 a.m. to 8 p.m., seven days a week, April 1 to September 30, 8 a.m. to 8 p.m., Monday through Friday. Benefits may vary by carrier and location. What to Consider When Shopping for Medicare, $7,000 In and Out-of-network / $5,600 In-network, $350 per day for days 1 through 5 / $0 per day for days 6 through 90, $350 per day for days 1 through 10 / $0 per day for days 11 through 90, $0 per day for days 1 through 20 / $196 per day for days 21 through 100, $100 per day for days 1 through 12 / $196 per day for days 13 through 100, Best Continuing Care Retirement Community (CCRC), Best Medicare Advantage Plan Companies 2023, Medicare Advantage Plans in 83616 (Ada County), Blue Cross of Idaho Medicare Advantage Plans in Idaho, Find Continuing Care Retirement Communites, California Do Not Sell My Personal Information Request. Medicare Advantage plans provide these benefits through a contract with the government, and are offered by companies like Blue Cross of Idaho Care Plus, Inc. With convenient Medicare Supplement coverage, you can visit any provider you choose. Although generic drugs are chemically the same as their brand counterparts, they are typically sold at substantial discounts from the branded price. Enrollment in plans depends on contract renewal. And doctors and analysts have a lot to say about it. Our Blue Cross of Idaho Foundation for Health, established in 2001, is committed to addressing the root causes of some of Idaho's most pressing issues impacting health. $5,000 In and Out-of-network / $3,400 In-network Maximum out-of-pocket enrollee responsibility (does not include prescription drugs) $5,000 In and Out-of-network / $3,400 In-network Optional. Blue Cross of Idaho members now have access to Sharecare, an app to help you eat better, lower stress and get more active! If we deny your request for coverage or you have questions regarding your prior authorization, please call Blue Cross of Idaho's Customer Service. Self-Injectable medications will process under the pharmacy benefit. 2023 Documents. Group Dental Plans Optimal Dental plan These policies may not apply to all lines of business such as the Federal Employee Program, Medicare Advantage, and certain self-insured groups. NOTE: If you need medical services before you receive your member ID card, you or the healthcare provider may contact Blue Cross of Idaho at 800-365-2345 to verify your coverage. If you're looking to make a change, you may save money by staying blue. First tier drugs have the lowest cost, with costs increasing as the tiers increase. 2022 Blue Cross of Idaho Care Plus, Inc. (Blue Cross of Idaho Care Plus), an Independent Licensee of the Blue Cross Blue Shield Association, with services provided by Blue Cross of Idaho Health Service, Inc. Contact your insurange agent or Blue Cross of Idaho account representative to find an affordable health coverage option for your business. Enrollment in Blue Cross of Idaho Care Plus, Inc. depends on contract renewal. The policies are used for the express purpose of assisting physicians and other healthcare providers in providing evidence based cost effective care. Blue Cross of Idaho Rx Customer Care can assist members and providers with questions and can provide detailed explanations regarding pharmacy benefits and claims. If you need assistance with other documents please call a Customer Advocate toll free at 1-888-494-2583 (TTY 711). Blue Cross of Idaho will send you a member ID card with your policy after we approve your application. If you have questions about becoming a contracting pharmacy, please use this link to initiate your request. Requests must be submitted with supporting clinical documentation to substantiate medical necessity. Limits are established with the manufacturers and the U.S. Food and Drug Administrations (FDA) recommendations and accepted medical practices. Learn all about your Medicare options so you are prepared when you are ready to enroll. These plans work with Original Medicare to fill the gaps not covered by Medicare alone. The Secure Blue Courage (PPO) plan is available in 31 counties in Idaho. PA requests may also be submitted by fax using thePharmacy Prior Authorization Form. Powered by Blue Cross of Idaho Care Plus, Inc. Blue Cross of Idaho Care Plus, Inc. is a Medicare Advantage plan with a Medicare contract. Every year, Medicare evaluates plans based on a 5-star rating system. Our medical policies are designed for informational purposes only and are not an explanation of benefits, or a contract. Plus, you can lower your out-of-pocket expenses when you choose a provider from the Blue Cross of Idaho Care Plus PPO network. Generic drugs are equivalent to brand-name drugs in dosage, safety, strength, route of administration, quality, performance characteristics and intended use. Blue Cross of Idaho partners with IngenioRx to provide pharmacy benefits to most of our membership. In addition to Part C and Part D benefits, our Secure Blue Courage plan offers a lot of supplemental benefits that you can take advantage of to stay your healthiest. If you believe that Blue Cross of Idaho has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with Blue Cross of Idaho's Grievances and Appeals Department at: Manager, Grievances and Appeals 3000 East Pine Avenue, Meridian, Idaho 83642 Please visit the form for additional details. The Secure Blue Courage (PPO) plan is available in 31 counties in Idaho. Infusion drugs may apply to the pharmacy benefit or the major medical benefit. Some policies cover preventive vaccines at 100 percent; therefore a member does not have copayment. Please reference the "Formulary Information" section on this page to find the appropriate formulary. You can find the number on the back of your ID card, or you can write to us at the following address: Appeals and Grievance Coordinator Blue Cross of Idaho PO Box 7408 Boise, ID 83707 The policies contain information regarding claims submission, medical necessity guidelines, and other information to assist in filing of claims to Blue Cross of Idaho. Download the freeMedicare for Idaho booklet today to find all of the information you need to get started.ESPAOL: Medicare para Idaho. Whether you are new to Medicare or returning as a valued member, we will show you how to get the most out of your health plan. Summary of Benefits (spanish version) 800-627-1188; . 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