Benefits At-A-Glance
| In-Network | Out-of-Network | |
| Preventive Care Services | Payment for preventive services is limited to an annual combined benefit maximum of $500 per member. Preventive services are not covered when billed by a hospital or a facility. | |
| Health Maintenance Exam - includes chemical profile, complete blood count and urinalysis • age 18 through 39, once every 5 years • age 40 through 49, once every 3 years • age 50 and older, once every 2 years |
Covered - 100% | Not Covered |
| Annual Gynecological Exam | Covered - 100% for age 18 and older, once every 12 months | Not Covered |
| Pap Smear Screening - laboratory and pathology services | Covered - 100% for age 18 and older, once every 12 months | Not Covered |
| Well-Baby and Child Care Visits • 6 visits, birth through 12 months • 6 visits, 13 months through 23 months • 2 visits, 24 months through 35 months • 2 visits, 36 months through 47 months • 1 visit per birth year, 48 months through age 15 |
Covered - 100% | Not Covered |
| Childhood Immunizations | Covered - 100% | Not Covered |
| Fecal Occult Blood Screening • age 40 through 49, once every 3 years • age 50 and older, once every 2 years |
Covered - 100% | Not Covered |
| Flexible Sigmoidoscopy Exam | Covered - 100% for ages 50 and older, once every 5 years | Not Covered |
| Prostate Specific Antigen (PSA) Screening | Covered - 100% for ages 40 and older, once per year | Not Covered |
| Cholesterol Screening | Covered - 100%, once per year | Not Covered |
| Routine Radiology Services- includes chest X-ray and EKG | Covered - 100%, once per year | Not Covered |
| Mammography | ||
| Mammography Screening | Covered - 80% after deductible | Covered - 80% after deductible, plus 20% out-of-network copay |
| One baseline mammogram between ages 35 - 40; one per calendar year after age 40 | ||
| Physician Office Services | ||
| Office Visits | Covered - 80% after deductible | Covered - 80% after deductible, plus 20% out-of-network copay |
| Outpatient and Home Visits | Covered - 80% after deductible | Covered - 80% after deductible, plus 20% out-of-network copay |
| Office Consultations | Covered - 80% after deductible | Covered - 80% after deductible, plus 20% out-of-network copay |
| Urgent Care Visits | Covered - 80% after deductible | Covered - 80% after deductible, plus 20% out-of-network copay |
| Emergency Medical Care | ||
| Hospital Emergency Room | Covered - 80% after deductible | Covered - 80% after deductible |
| Ambulance Services - medically necessary | Covered - 80% after deductible | Covered - 80% after deductible |
| Diagnostic Services | ||
| Laboratory and Pathology Services | Covered - 80% after deductible | Covered - 80% after deductible, plus 20% out-of-network copay |
| Diagnostic Tests and X-rays | Covered - 80% after deductible | Covered - 80% after deductible, plus 20% out-of-network copay |
| Radiation Therapy | Covered - 80% after deductible | Covered - 80% after deductible, plus 20% out-of-network copay |
| Maternity Services Provided by a Physician | ||
| Prenatal and Postnatal Care - includes care provided by a certified nurse midwife | Covered - 80% after deductible | Covered - 80% after deductible, plus 20% out-of-network copay |
| Delivery and Nursery Care - includes delivery provided by a certified nurse midwife | Covered - 80% after deductible | Covered - 80% after deductible, plus 20% out-of-network copay |
| Hospital Care | ||
| Semi-Private Room, Inpatient Physician Care, General Nursing Care, Hospital Services and Supplies Note: Non-emergency services must be rendered in a participating hospital |
Covered - 80% after deductible | Covered - 80% after deductible, plus 20% out-of-network copay |
| Unlimited Days | ||
| Inpatient Consultations | Covered - 80% after deductible | Covered - 80% after deductible, plus 20% out-of-network copay |
| Chemotherapy | Covered - 80% after deductible | Covered - 80% after deductible, plus 20% out-of-network copay |
| Alternatives to Hospital Care | ||
| Skilled Nursing Care | Not Covered | Not Covered |
| Hospice Care | Covered - 80% after deductible | Covered - 80% after deductible |
| Limited to dollar maximum which is adjusted periodically | ||
| Home Health Care | Covered - 80% after deductible | Covered - 80% after deductible |
| Surgical Services | ||
| Surgery - includes related surgical services Includes surgery in BCBSM-approved ambulatory facilities |
Covered - 80% after deductible | Covered - 80% after deductible, plus 20% out-of-network copay |
| Voluntary Sterilization | Covered - 80% after deductible | Covered - 80% after deductible, plus 20% out-of-network copay |
| Human Organ Transplants | ||
| Specified Organ Transplants - in designated facilities only, when coordinated through the BCSM Human Organ Transplant Program (800-242-3604) | Covered - 80% after deductible | Covered - 80% after deductible 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 apply | Covered - 80% after deductible | Covered - 80% after deductible, plus 20% out-of-network copay |
| Kidney, Cornea and Skin | Covered - 80% after deductible | Covered - 80% after deductible, plus 20% out-of-network copay |
| Mental Health Care and Substance Abuse Treatment | ||
| Inpatient Mental Health Care | Covered - 50% after deductible | Covered - 50% after deductible, plus 20% out-of-network copay |
| Inpatient Substance Abuse Treatment | Covered - 50% after deductible | Covered - 50% after deductible, plus 20% out-of-network copay |
| Up to $15,000 annual, $30,000 lifetime maximum | ||
| Outpatient Mental Health Care | Covered - 50% after deductible | Covered - 50% after deductible, plus 20% out-of-network copay |
| Outpatient Substance Abuse Treatment - in approved facilities | Covered - 50% after deductible | Covered - 50% after deductible |
| Up to the state-dollar amount which is adjusted annually | ||
| Other Services | ||
| Allergy Testing and Therapy | Covered - 80% after deductible | Covered - 80% after deductible, plus 20% out-of-network copay |
| Chiropractic Spinal Manipulation | Covered - 80% after deductible | Covered - 80% after deductible, plus 20% out-of-network copay |
| Up to 38 medically necessary visits per calendar year | ||
| Durable Medical Equipment | Covered - 80% after deductible | Covered - 80% after deductible |
| Outpatient Diabetes Management Program | Covered - 80% after deductible | Covered - 80% after deductible, plus 20% out-of-network copay |
| 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 - 80% after deductible, plus 20% out-of-network copay |
| Unlimited treatment | ||
| Prosthetic and Orthotic Appliances | Covered - 80% after deductible | Covered - 80% after deductible |
| Private Duty Nursing | Covered - 50% after deductible | Covered - 50% after deductible |
| Prescription Drugs | Not Covered | Not Covered |
| Deductible, Copays & Dollar Maximums | ||
| Deductible | $1,000 for a one-person contract, $2,000 for a family contract for calendar year 2004. Covered services for any member under the family contract are only paid after the full $2,000 deductible is met. Note: The federal government determines new deductibles each year based on increases in the Consumer Price Index. Please call the Farm Bureau Personalized Customer Service unit at 1-800-527-1649 for an annual update. |
|
| Copays - Percent Copays | 20% for general services and 50% for mental health care, substance abuse treatment and private duty nursing | |
| Copays - Out-of-Network Percent Copays | Not applicable | 20% (this amount is in addition to applicable CMM copays) Note: Services without a network are covered at the in-network level. |
| Copay Dollar Maximums - Percent Copays | $1,000 per family per calendar year | |
| Copay Dollar Maximums - Out-of-Network Percent Copays | Not applicable | $1,000 per family per calendar year |
| Dollar Maximums | $1 million lifetime per covered specified human organ transplant type and a separate $5 million lifetime per member for other covered services and as noted above for individual services | |
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.
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.
