Benefits At-A-Glance
| Preventative Services | |
| Health Maintenance Exam | Not Covered |
| Annual Gynecological Exam | Not Covered |
| Pap Smear Screening - laboratory services only | Covered - 80% after deductible, one every 12 months |
| Well-Baby and Child Care | Not Covered |
| Immunizations | Not Covered |
| Proctoscopic Exam | Not Covered |
| Mammography | |
| Mammography Screening | Covered - 80% after deductible, one baseline for ages 35-40, one annually after age 40 |
| Physician Office Services | |
| Diagnostic Office Visits (Routine visits not covered) | Covered - 80% after deductible |
| Outpatient and Home Visits | Covered - 80% after deductible |
| Office Consultations | Covered - 80% after deductible |
| Emergency Medical Care | |
| Hospital Emergency Room - approved diagnosis | Covered - 80% after deductible |
| Physician's Office - approved diagnosis | Covered - 80% after deductible |
| Urgent Care Center | Covered - 80% after deductible |
| Ambulance Services - medically necessary | Covered - 80% after deductible |
| Diagnostic Services | |
| Laboratory and Pathology Tests | Covered - 80% after deductible |
| Diagnostic Tests and X-rays | Covered - 80% after deductible |
| Radiation Therapy | Covered - 80% after deductible |
| Maternity Services Provided by a Physician | (subject to a 12 month preexisting waiting period) |
| Pre-Natal and Post-Natal Care | Covered - 80% after deductible, includes care provided by a Certified Nurse Midwife |
| Delivery and Nursery Care | Covered - 80% after deductible, includes delivery provided by a Certified Nurse Midwife |
| Hospital Care | |
| Semi-Private Room, Inpatient Physician Care, General Nursing Care, Hospital Services and Supplies | Covered - 80% after deductible, unlimited days |
| Inpatient Consultations | Covered - 80% after deductible |
| Chemotherapy | Covered - 80% after deductible |
| Alternatives to Hospital Care | |
| Skilled Nursing Care | Not Covered |
| Hospice Care | Covered - 100%, limited to the lifetime dollar maximum which is adjusted periodically by the state |
| Home Health Care | Covered - 80% after deductible, unlimited visits |
| Surgical Services | |
| Surgery, includes related surgical services, anesthesia and surgical assistance | Covered - 80% after deductible |
| Voluntary Sterilization - subject to a 12 month waiting period | Covered - 80% after deductible |
| Human Organ Transplants | |
| Specified Organ Transplants - in designated facilities only, when coordinated through the BCBSM Human Organ Transplant Program (1-800-242-3504) | Covered - 100%, up to $1 million maximum per transplant type |
| Bone Marrow - in designated facilities only, when coordinated through the BCBSM Human Organ Transplant Program (1-800-242-3504) | Covered - 80% after deductible |
| Kidney, Cornea and Skin | Covered - 80% after deductible |
| Mental Health Care and Substance Abuse Treatment | |
| Inpatient Mental Health Care and Substance Abuse Care | Covered - 50% after deductible |
| Outpatient Mental Health Care | Covered - 50% after deductible |
| Outpatient Substance Abuse Care | Covered - 50% after deductible, up to the state-dollar amount which is adjusted annually |
| Other Services | |
| Allergy Testing and Therapy | Covered - 80% after deductible |
| Chiropractic Spinal Manipulation | Covered - 80% after deductible, up to 38 medically necessary visits per calendar year |
| Durable Medical Equipment | Covered - 80% after deductible |
| Outpatient Diabetes Management Program | Covered - 80% after deductible |
| Outpatient Physical, Speech and Occupational Therapy | Covered - 80% after deductible, unlimited treatment |
| Private Duty Nursing | Covered - 80% after deductible |
| Prosthetic and Orthotic Appliances | Covered - 80% after deductible |
| Deductible, Copays and Benefit Maximums | Note: If you receive care from a nonparticipating provider, even when referred, you may be billed for the difference between our approved amount and the provider's charge. |
| Deductible Options | • $250 per member, $500 family • $500 per member, $1000 family • $1000 per member, $2000 family • $1500 per member, $3000 family |
| Copays | 20% for general services and 50% for mental health care, substance abuse care and private duty nursing |
| Copay Dollar Maximums - excludes mental health care, substance abuse care and private duty nursing copays | $1,000 per family per calendar year |
| Benefit Maximums | $5 million lifetime per member and as noted above for individual services |
| Prescription Drug Coverage (Optional. Available for additional premium.) | |
| Covered Services: • Federal-legend drugs • State-controlled drugs • Needles and syringes |
Network Pharmacy, a Preferred Rx pharmacy in Michigan or a PAID Prescriptions, Inc. pharmacy outside Michigan: 100% of approved amount minus a 20% copayment, ($20 minimum payment) for each covered prescription drug. Non-Network Pharmacy, a pharmacy not part of the Preferred Rx or PAID networks: Blue Cross Blue Shield of Michigan will reimburse you 75% of the approved amount less your copayment for each covered prescription. |
| Mail Order Prescription Drugs ($20) | Provides benefits to the Prescription Drug plan up to a 90-day supply of prescribed medications when authorized, with a $20 copay for each 90-day prescription or refill. |
| Rider PD-XED, Excludes Elective Drugs | Excludes coverage for elective drugs. Note: Elective drugs are health habit and reproductive drugs such as those that treat sexual impotency or infertility, help in weight loss or help to stop smoking. They are not designed to treat acute or chronic illnesses or prescribed for medical conditions that have no demonstrable physical harm if not treated. |
There is a 12 month preexisting condition waiting period for all new applicants. This waiting period for coverage applies to those conditions for which you have had medical advice, diagnosis, care or treatment recommended or received within six months prior to enrollment. There is also a 12 month waiting period for maternity care, removal of tonsils and/or adenoids and voluntary sterilization.
This is intended as an easy-to-read summary. It is not a contract. Additional limitations and exclusions may apply to covered services. For an official description of benefits, please see the applicable Blue Cross Blue Shield certificate and riders. Payment amounts are based on the Blue Cross Blue Shield approved amount, less any applicable deductible and/or copay amounts required by the plan. This coverage is provided pursuant to a contract entered into in the state of Michigan and shall be construed under the jurisdiction and according to the laws of the state of Michigan.
