Benefits At-A-Glance
| In-Network | Out-of-Network | |
| Preventative Services | ||
| Health Maintenance Exam | Not Covered | Not Covered |
| Annual Gynecological Exam | Not Covered | Not Covered |
| Pap Smear Screening - laboratory services only | Not Covered | Not Covered |
| Well-Baby and Child Care | Not Covered | Not Covered |
| Immunizations | Not Covered | Not Covered |
| Mammography | ||
| Mammography Screening | Covered - 70% | Covered - 50% |
| One per calendar year | ||
| Physician Office Services | ||
| Office Visits | Not Covered | Not Covered |
| Outpatient and Home Visits | Not Covered | Not Covered |
| Office Consultations | Not Covered | Not Covered |
| Pre-Surgical Consultation | Covered - 100% | Covered - 80% |
| Emergency Medical Care | ||
| Ambulance Services - medically necessary | Covered - 70% | Covered - 70% |
| Hospital Emergency Room - approved diagnosis | Covered - 70% | Covered - 70% |
| Physician's Office - approved diagnosis | Covered - 70% | Covered - 70% |
| Urgent Care Center - approved diagnosis | Covered - 70% | Covered - 70% |
| Diagnostic Services | ||
| Laboratory and Pathology Tests | Covered - 70% | Covered - 40% |
| An additional 30% copayment is applied toward non-standard laboratory tests performed by a non-participating PLUS laboratory. Additional 30% copayment is not subject to Copay Dollar Maximum. | ||
| Diagnostic Tests and X-rays | Covered - 70% | Covered - 50% |
| Therapeutic Radiation | Covered - 70% | Covered - 50% |
| Maternity Services Provided by a Physician | ||
| Pre-Natal and Post-Natal Care | Not Covered | Not Covered |
| Delivery and Nursery Care | Covered - 70% | Covered - 50% |
| Hospital Care | ||
| Semi-Private Room, Inpatient Physician Care, General Nursing Care, Hospital Services and Supplies | Covered - 70% | Covered - 50% |
| Up to 120 days; 60-day renewal period | ||
| Inpatient Consultations | Covered - 70% | Covered - 50% |
| Chemotherapy | Covered - 70% | Covered - 50% |
| Alternatives to Hospital Care | ||
| Skilled Nursing Care | Not Covered | Not Covered |
| Hospice Care | Covered - 100% | Not Covered |
| Limited to the lifetime dollar maximum which is adjusted by the state | ||
| Home Health Care | Covered - 70% | Not Covered |
| Surgical Services | ||
| Surgery, includes all related surgical services, anesthesia and surgical assistance | Covered - 70% | Covered - 50% |
| Voluntary Sterilization | Covered - 70% | Covered - 50% |
| Human Organ Transplants | ||
| Specified Organ Transplants - in designated facilities only, when coordinated through the BCSM Human Organ Transplant Program (1-800-242-3504) | Covered - 100% | Not Covered |
| Up to $1 million maximum per specified organ transplant type | ||
| Bone Marrow - when coordinated through the BCBSM Human Organ Transplant Program (1-800-242-3504); specific criteria applies | Covered - 70% | Covered - 50% |
| Kidney, Cornea and Skin | Covered - 70% | Covered - 50% |
| Mental Health Care and Substance Abuse Treatment | ||
| Inpatient Mental Health Care and Substance Abuse Care | Covered - 70% | Covered - 50% |
| Up to 30 days; 60-day renewal | ||
| Outpatient Mental Health Care | ||
| Facility and Clinic | Not Covered | Not Covered |
| Physician's Office | Not Covered | Not Covered |
| Outpatient Substance Abuse Care | ||
| Acute care and specialty hospitals | Covered - 70% after deductible | Covered - 50% after deductible |
| Freestanding substance abuse facilities | Covered - 70% after deductible | Covered - 70% after deductible |
| Up to the state dollar amount which is adjusted annually | ||
| Other Services | ||
| Allergy Testing and Therapy | Not Covered | Not Covered |
| Chiropractic Spinal Manipulation | Not Covered | Not Covered |
| Durable Medical Equipment | Not Covered | Not Covered |
| Outpatient Diabetes Management Program | Covered - 70% | Covered - 50% |
| Outpatient Physical, Speech and Occupational Therapy | ||
| Facility and Clinic | Covered - 70% | Covered - 50% |
| Physician's Office - excludes speech and occupational therapy | Covered - 70% | Covered - 50% |
| Up to 60 consecutive days of treatment per condition per calendar year | ||
| Orthotic Appliances | Not Covered | Not Covered |
| Prosthetic Appliances | Covered - 70% | Covered - 50% |
| Private Duty Nursing | Not Covered | Not Covered |
| Deductible, Copays & Dollar Maximums | ||
| 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 | None | None |
| Copays - Fixed | None | None |
| Copays - Percent | 30% of the approved amount for most services | 50% of the approved amount for most services. Services without a network are covered at the in-network level. |
| Copay Dollar Maximums - Fixed | None | None |
| Copay Dollar Maximums - Percent | $2,500 combined family maximum Note: Once the annual copay maximum is reached, covered services in-network will be paid at 100% of the BCBSM approved amount for the remainder of the year. However, there is no limit to the 20% out of network sanction and is not subject to the combined copay dollar maximum. |
|
| Dollar Maximums | None, except as noted above | |
| Prescription Drug Coverage | ||
| Preferred Rx Prescription Drug Plan • Federal-legend drugs • State-controlled drugs • Needles and syringes |
Covered - 50% with a minimum copay of $10 and a maximum copay of $100 | Covered - 25% with a minimum copay of $10 and a maximum copay of $100 |
| $2,500 benefit maximum per individual each calendar year; renews January 1 | ||
| Network Pharmacy, In Michigan, a network pharmacy is a pharmacy that is part of the BCBSM Preferred Rx network. In other states, a network pharmacy is a pharmacy that is part of The MedImpact network. Network pharmacies will file claims for you and they will receive direct payment. Non-Network Pharmacy, Pharmacies not part of the BCBSM Preferred Rx or MedImpact network are called non-network pharmacies. If you go to a non-network pharmacy, you, not the pharmacist, will need to file your claim for payment. You are responsible for any difference between the cost of the prescription or refill and our payment. | ||
| Blue Advantage Rx | Once the prescription drug benefit maximum is exhausted, members may purchase eligible prescription drugs and supplies from BCBSM Preferred Rx pharmacies at a discounted rate. | |
| Mail Order Prescription Drugs | Not Covered | |
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. Additional limitations and exclusions may apply to covered services. An official description of benefits is contained in the applicable certificate and riders. Michigan Farm Bureau's health care coverage is underwritten by BCS Life Insurance Company and administered by Blue Cross Blue Shield of Michigan. BCS Life Insurance Company is a for-profit life insurer and member of an insurance services holding company. 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. Payment amounts are based on the Blue Cross Blue Shield of Michigan approved amount, less any applicable deductible and/or copay amounts required by the plan.
