Plan #11 - Benefits At-A-Glance
| In-Network | Out-of-Network | |
| Preventative Services | ||
| Health Maintenance Exam | Covered - 100%, one per calendar year | Not Covered |
| Annual Gynecological Exam | Covered - 100%, one per calendar year | Not Covered |
| Pap Smear Screening - laboratory services only | Covered - 100%, one per calendar year | Not Covered |
| Well-Baby and Child Care | Covered - 100% • 6 visits per year from birth through age 1 • 2 visits per year age 2 through 3 • 1 visit per year age 4 through 15 |
Not Covered |
| Immunizations | Covered - 100%, up through age 16 | Not Covered |
| Fecal Occult Blood Screening | Covered - 100%, one per calendar year | Not Covered |
| Flexible Sigmoidoscopy Exam | Covered - 100%, one per calendar year | Not Covered |
| Prostate Specific Antigen (PSA) Screening | Covered - 100%, one per calendar year | Not Covered |
| Mammography | ||
| Mammography Screening | Covered - 80% after deductible | Covered - 60% after deductible |
| One per calendar year, no age restrictions | ||
| Physician Office Services | ||
| Office Visits | Covered - $10 copay | Covered - 60% after deductible, must be medically necessary |
| Outpatient and Home Visits | Covered - 80% after deductible | Covered - 60% after deductible, must be medically necessary |
| Office Consultations | Covered - $10 copay | Covered - 60% after deductible, must be medically necessary |
| Emergency Medical Care | ||
| Hospital Emergency Room - approved diagnosis | Covered - $50 copay, waived if admitted or for an accidental injury | Covered - $50 copay, waived if admitted or for an accidental injury |
| Physician's Office - approved diagnosis | Covered - 100% | Covered - 100% |
| Urgent Care Center | Covered - $10 copay, waived if a medical emergency or accidental injury | Covered - 60% after deductible, waived if a medical emergency or accidental injury |
| Ambulance Services - medically necessary | Covered - 80% after deductible | Covered - 80% after deductible |
| Diagnostic Services | ||
| Laboratory and Pathology Tests | Covered - 80% after deductible | Covered - 60% after deductible |
| Diagnostic Tests and X-rays | Covered - 80% after deductible | Covered - 60% after deductible |
| Radiation Therapy | Covered - 80% after deductible | Covered - 60% after deductible |
| Maternity Services Provided by a Physician | ||
| Pre-Natal and Post-Natal Care | Covered - 100% | Covered - 60% after deductible |
| Delivery and Nursery Care | Covered - 80% after deductible | Covered - 60% after deductible |
| Hospital Care | ||
| Semi-Private Room, Inpatient Physician Care, General Nursing Care, Hospital Services and Supplies | Covered - 80% after deductible | Covered - 60% after deductible |
| Unlimited days | ||
| Inpatient Consultations | Covered - 80% after deductible | Covered - 60% after deductible |
| Chemotherapy | Covered - 80% after deductible | Covered - 60% after deductible |
| Alternatives to Hospital Care | ||
| Skilled Nursing Care | Covered - 80% after deductible | Covered - 80% after deductible |
| Up to 120 days per calendar year | ||
| Hospice Care | Covered - 100% | Covered - 100% |
| Limited to the lifetime dollar maximum which is adjusted by the state | ||
| Home Health Care | Covered - 80% after deductible | Covered - 80% after deductible |
| Unlimited visits | ||
| Surgical Services | ||
| Surgery, includes all related surgical services, anesthesia and surgical assistance | Covered - 80% after deductible | Covered - 60% after deductible |
| Voluntary Sterilization | Covered - 80% after deductible | Covered - 60% after deductible |
| Human Organ Transplants | ||
| Specified Organ Transplants - in designated facilities only, when coordinated through the BCSM Human Organ Transplant Program (800-242-3604) | Covered - 100% after deductible | Covered - in designated facilities only |
| Up to $1 million maximum per transplant type | ||
| Bone Marrow - when coordinated through the BCBSM Human Organ Transplant Program (800-242-3604); specific criteria applies | Covered - 80% after deductible | Covered - 60% after deductible |
| Kidney, Cornea and Skin | Covered - 80% after deductible | Covered - 60% after deductible |
| Mental Health Care and Substance Abuse Treatment | ||
| Inpatient Mental Health Care and Substance Abuse Care | Covered - 50% after deductible | Covered - 50% after deductible |
| Unlimited days, up to $15,000 annual, $30,000 lifetime maximum per member | ||
| Outpatient Mental Health Care | ||
| Facility and Clinic | Covered - 50% after deductible | Covered - 50% after deductible |
| Physician's Office | Covered - 50% | Covered - 50% after deductible |
| Up to $2,000 annual, $5,000 lifetime maximum, combined with inpatient maximum | ||
| Outpatient Substance Abuse Care | Covered - 50% after deductible | Covered - 50% after deductible |
| Up to the state-dollar amount which is adjusted annually | ||
| Other Services | ||
| Allergy Testing and Therapy - with approved diagnosis | Covered - 100% | Covered - 60% after deductible |
| Chiropractic Spinal Manipulation | Covered - 100% | Covered - 60% after deductible |
| Up to 24 visits per calendar year | ||
| Durable Medical Equipment | Covered - 80% after deductible | Covered - 80% after deductible |
| Outpatient Diabetes Management Program | Covered - 80% after deductible | Covered - 60% after deductible |
| Outpatient Physical, Speech and Occupational Therapy | ||
| Facility and Clinic | Covered - 80% after deductible | Covered - 80% after deductible |
| Physician's Office - excludes speech and occupational therapy | Covered - 80% after deductible | Covered - 60% after deductible |
| Up to 60 visits per calendar year | ||
| Prosthetic and Orthotic Appliances | Covered - 80% after deductible | Covered - 80% after deductible |
| Private Duty Nursing | Covered - 50% after deductible | Covered - 50% after deductible |
| Deductible, Copays & Dollar Maximums | ||
| Deductible | $1,000 per member, $2,000 family - Waived if service is performed in a PPO physician's office | $2,000 per member, $4,000 family - Out-of-network deductible amounts also apply toward the in-network deductible |
| Copays - Fixed | $10 for office visits and $50 for emergency room visits | $50 for emergency room visits |
| Copays - Percent | 20% for general services, waived if the service was performed in a PPO physician's office, and 50% for mental health care, substance abuse care and private duty nursing | 40% for general services and 50% for mental health care, substance abuse care and private duty nursing, services without a network are covered at the in-network level |
| Copay Dollar Maximums - Fixed | None | None |
| Copay Dollar Maximums - Percent | $1,000 per member, $2,000 family | $2,000 per member, $4,000 family, out-of-network copays also apply toward the in-network maximum |
| Dollar Maximums | $5 million lifetime per member for all covered services and as noted above for individual services | |
| Prescription Drug Coverage (optional) | ||
| Preferred Rx Prescription Drug Plan • 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 drug. |
|
| Mail Order Prescription Drugs ($20) | Provides benefits to the Prescription Drug Plan for a 90-day supply of prescribed medications, with a $20 copay for each 90-day prescription or refill. | |
NOTE: A 365-day waiting period is applied for pre-existing medical conditions, removal of tonsils and/or adenoids, and voluntary sterilization.
This is intended as an easy-to-read summary. It is not a contract. An official description of benefits is contained in 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.
