Hometown Southwest Silver Copay 3200 CSR 94

Blue Cross of Idaho · 2026 plan year

Silver

Ind. deductible: $0
Family deductible: $0
Ind. OOP max: $1,700
Family OOP max: $1,700

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	No charge

Specialist

Benefit	In-network
Specialist Visit	$5.00

Hospital

Benefit	In-network
Emergency Room Services	$250.00 Copay after deductible + 30.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)	30.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services	30.00% Coinsurance after deductible
Urgent Care Centers or Facilities	$20.00

Pharmacy

Benefit	In-network
Generic Drugs	$5.00
Non-Preferred Brand Drugs	$50.00 Copay after deductible
Preferred Brand Drugs	$30.00 Copay after deductible
Specialty Drugs	50.00% Coinsurance after deductible

Mental Health

Benefit	In-network
Mental/Behavioral Health Inpatient Services	30.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services	30.00% Coinsurance after deductible

Other

Benefit	In-network
Accidental Dental	30.00% Coinsurance after deductible
Allergy Testing	30.00% Coinsurance after deductible
Chemotherapy	30.00% Coinsurance after deductible
Chiropractic Care	$10.00
Delivery and All Inpatient Services for Maternity Care	30.00% Coinsurance after deductible
Diabetes Education	$20.00
Dialysis	30.00% Coinsurance after deductible
Durable Medical Equipment	30.00% Coinsurance after deductible
Emergency Transportation/Ambulance	30.00% Coinsurance after deductible
Eye Glasses for Children	No charge
Habilitation Services	$10.00
Hearing Aids	30.00% Coinsurance after deductible
Home Health Care Services	30.00% Coinsurance after deductible
Hospice Services	No charge
Imaging (CT/PET Scans, MRIs)	$200.00
Infusion Therapy	30.00% Coinsurance after deductible
Inpatient Physician and Surgical Services	30.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services	$10.00
Nutritional Counseling	No charge
Other Practitioner Office Visit (Nurse, Physician Assistant)	No charge
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)	30.00% Coinsurance after deductible
Outpatient Rehabilitation Services	$10.00
Prenatal and Postnatal Care	30.00% Coinsurance after deductible
Prosthetic Devices	30.00% Coinsurance after deductible
Radiation	30.00% Coinsurance after deductible
Reconstructive Surgery	30.00% Coinsurance after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy	30.00% Coinsurance after deductible
Rehabilitative Speech Therapy	30.00% Coinsurance after deductible
Routine Eye Exam for Children	No charge
Skilled Nursing Facility	30.00% Coinsurance after deductible
Substance Abuse Disorder Inpatient Services	30.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services	30.00% Coinsurance after deductible
Transplant	30.00% Coinsurance after deductible
Well Baby Visits and Care	No charge
X-rays and Diagnostic Imaging	$10.00

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