Blue Cross of Idaho

SAHA Southwest Gold Connect 2000

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Links

Plan Overview

Medical Deductible	Individual: $2,000 Family: $4,000 Per Person: $2,000
Prescription Drug Deductible	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical
Medical Out-of-Pocket Maximum	Individual: $5,500 Family: $11,000 Per Person: $5,500
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Office Visit

Primary Doctor	Standard: $20 Copay
Specialist	Standard: $50 Copay

Prescription Drug Information

Preferred Brand Drugs	Standard: $30 Copay after deductible
Non Preferred Brand Drugs	Standard: $50 Copay after deductible
Generic Drugs	Standard: $10 Copay
Specialty Drugs	Standard: 50% Coinsurance after deductible

Inpatient Coverage

Hospital Services	Standard: 20% Coinsurance after deductible
Inpatient Services	Standard: 20% Coinsurance after deductible

Emergency and Urgent Care

Emergency Room

Standard: $350 Copay after deductible

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