Benefits At-A-Glance
| Preventative Services | |
| Health Maintenance Exam | Covered - $20 copay |
| Annual Gynecological Exam | Covered - $20 copay |
| Pap Smear Screening - laboratory services only | Covered - 100% |
| Well-Baby and Child Care | Covered - $20 copay |
| Immunizations | Covered - 100% |
| Mammography | |
| Mammography Screening | Covered - 100% |
| Physician Office Services | |
| Office Visits | Covered - $20 copay |
| Consulting Specialist Care - when referred | Covered - $20 copay |
| Emergency Medical Care | |
| Hospital Emergency Room - approved diagnosis | Covered - $25 copay |
| Physician's Office | Covered - $20 copay |
| Urgent Care Center | Covered - $10 copay |
| Ambulance Services - medically necessary | Covered - 100% |
| Diagnostic Services | |
| Laboratory and Pathology Tests | Covered - 100% |
| Diagnostic Tests and X-rays | Covered - 100% |
| Radiation Therapy | Covered - 100% |
| Maternity Services Provided by a Physician | |
| Pre-Natal and Post-Natal Care | Covered - $20 copay, per visit |
| Delivery and Nursery Care | Covered - 100% |
| Infertility Counseling and Treatment | Covered - 50% on all associated costs, excluding In Vitro Fertilization |
| Hospital Care | |
| Semi-Private Room, Inpatient Physician Care, General Nursing Care, Hospital Services and Supplies | Covered - 100%, unlimited days |
| Chemotherapy | Covered - 100% |
| Alternatives to Hospital Care | |
| Skilled Nursing Care | Covered - 100%, up to 45 days per calendar year |
| Hospice Care | Covered - 100%, up to 45 days/year in facility; $20 copay/home visits |
| Home Health Care | Covered - $20 copay |
| Surgical Services | |
| Surgery, including all related surgical services and anesthesia | Covered - 100% |
| Voluntary Sterilization | Covered - 50% on all associated costs |
| Human Organ Transplants | Covered - 100%, subject to medical criteria |
| Mental Health Care and Substance Abuse Treatment | |
| Inpatient Mental Health Care | Covered - 100%, up to 30 days per calendar year |
| Outpatient Mental Health Care | Covered - 50%, up to 20 visits per calendar year |
| Inpatient Substance Abuse Care | Covered - 50%, one program per 12 month period |
| Outpatient Substance Abuse Care | Covered - 50%, up to 20 visits per calendar year |
| Other Services | |
| Allergy Testing and Serum | Covered - 50% |
| Allergy Injections | Covered - $5 copay |
| Chiropractic Spinal Manipulation | Covered - $20 copay |
| Outpatient Physical, Speech and Occupational Therapy | Covered - $20 copay, limited to a 60-day period |
| Durable Medical Equipment | Covered - 50% |
| Prosthetic and Orthotic Appliances | Covered - 50% |
| Private Duty Nursing and Custodial Care | Not Covered |
| Prescription Drugs | Covered - $10 copay for generic drugs and $40 copay for brand name drugs. |
| Mail Order Prescription Drugs | Provides benefits to the Prescription Drug Plan for a 90 day supply of prescribed medications, with a $10 copay for generic drugs and $40 copay for brand name drugs for each 90 day prescription or refill. |
| Deductible, Copays and Benefit Maximums | |
| Deductible | None |
| Copays - Fixed | $5 for allergy injections, $20 for office visits, $10 for urgent care visits, $25 for emergency room visits $10/$40 for prescription drugs |
| Copays - Percent | 50% for selected services as noted above |
| Copay Dollar Maximums - Fixed | None |
| Copay Dollar Maximums - Percent | None |
| Dollar Maximums | None |
SERVICES MUST BE PROVIDED OR ARRANGED BY THE MEMBER'S PRIMARY CARE PHYSICIAN OR HEALTH PLAN
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.
