Hometown East Silver 4000 CSR 94

Blue Cross of Idaho · 2026 plan year

Silver

Ind. deductible: $0
Family deductible: $0
Ind. OOP max: $1,400
Family OOP max: $1,400

Other cost-sharing reduction variants for this plan:

73% AV Level Silver Plan 87% AV Level Silver Plan Limited Cost Sharing Plan Variation Standard Silver Off Exchange Plan Standard Silver On Exchange Plan Zero Cost Sharing Plan Variation

More Blue Cross of Idaho plans in ID

MVN East Silver Connect 5500 PQA Southeast Silver Connect 5500 PQA Southeast Silver Connect 7100 PQA Southeast Gold Connect 2000 SLHP Gold CarePoint 2000

Live premium estimate

Benefits & cost sharing

Primary Care

Benefit	In-network
Preventive Care/Screening/Immunization	No charge
Primary Care Visit to Treat an Injury or Illness	$10.00

Specialist

Benefit	In-network
Specialist Visit	$25.00

Hospital

Benefit	In-network
Emergency Room Services	20.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)	20.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services	20.00% Coinsurance after deductible
Urgent Care Centers or Facilities	$25.00

Pharmacy

Benefit	In-network
Generic Drugs	$8.00
Non-Preferred Brand Drugs	40.00% Coinsurance after deductible
Preferred Brand Drugs	20.00% Coinsurance after deductible
Specialty Drugs	50.00% Coinsurance after deductible

Mental Health

Benefit	In-network
Mental/Behavioral Health Inpatient Services	20.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services	$10.00 + 20.00% Coinsurance after deductible

Other

Benefit	In-network
Accidental Dental	20.00% Coinsurance after deductible
Allergy Testing	20.00% Coinsurance after deductible
Chemotherapy	20.00% Coinsurance after deductible
Chiropractic Care	20.00% Coinsurance after deductible
Delivery and All Inpatient Services for Maternity Care	20.00% Coinsurance after deductible
Diabetes Education	$20.00
Dialysis	20.00% Coinsurance after deductible
Durable Medical Equipment	20.00% Coinsurance after deductible
Emergency Transportation/Ambulance	20.00% Coinsurance after deductible
Eye Glasses for Children	No charge
Habilitation Services	20.00% Coinsurance after deductible
Hearing Aids	20.00% Coinsurance after deductible
Home Health Care Services	20.00% Coinsurance after deductible
Hospice Services	No charge
Imaging (CT/PET Scans, MRIs)	20.00% Coinsurance after deductible
Infusion Therapy	20.00% Coinsurance after deductible
Inpatient Physician and Surgical Services	20.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services	20.00% Coinsurance after deductible
Nutritional Counseling	No charge
Other Practitioner Office Visit (Nurse, Physician Assistant)	$10.00
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)	20.00% Coinsurance after deductible
Outpatient Rehabilitation Services	20.00% Coinsurance after deductible
Prenatal and Postnatal Care	20.00% Coinsurance after deductible
Prosthetic Devices	20.00% Coinsurance after deductible
Radiation	20.00% Coinsurance after deductible
Reconstructive Surgery	20.00% Coinsurance after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy	20.00% Coinsurance after deductible
Rehabilitative Speech Therapy	20.00% Coinsurance after deductible
Routine Eye Exam for Children	No charge
Skilled Nursing Facility	20.00% Coinsurance after deductible
Substance Abuse Disorder Inpatient Services	20.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services	$10.00 + 20.00% Coinsurance after deductible
Transplant	20.00% Coinsurance after deductible
Well Baby Visits and Care	No charge
X-rays and Diagnostic Imaging	20.00% Coinsurance after deductible

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