Benefits At-A-Glance
| In-Network | Out-of-Network | |
| Preventive Care Services | ||
| Health Maintenance Exam | Not Covered | Not Covered |
| Annual Gynecological Exam | Not Covered | Not Covered |
| Pap Smear Screening - laboratory and pathology services | Covered - 70% after deductible | Covered - 50% after deductible |
| For age 18 and older, once every 12 months (from the date of any previous pap smear) | ||
| Well-Baby and Child Care | Not Covered | Not Covered |
| Childhood Immunizations | Not Covered | Not Covered |
| Fecal Occult Blood Screening | Not Covered | Not Covered |
| Flexible Sigmoidoscopy Exam | Not Covered | Not Covered |
| Prostate Specific Antigen (PSA) Screening | Not Covered | Not Covered |
| Cholesterol Screening | Not Covered | Not Covered |
| Mammography | ||
| Mammography Screening | Covered - 70% after deductible | Covered - 50% after deductible |
| One baseline for ages 35-40; one anually after age 40 | ||
| Physician Office Services | ||
| Office Visits | Not Covered | Not Covered |
| Outpatient and Home Visits | Not Covered | Not Covered |
| Office Consultations | Not Covered | Not Covered |
| Urgent Care Visits | Not Covered | Not Covered |
| Emergency Medical Care | ||
| Hospital Emergency Room | Covered - 70% after deductible | Covered - 50% after deductible |
| Ambulance Services - medically necessary | Covered - 70% after deductible | Covered - 70% after deductible |
| Diagnostic Services | ||
| Laboratory and Pathology Services | Covered - 70% after deductible | Covered - 50% after deductible |
| Diagnostic Tests and X-rays | Covered - 70% after deductible | Covered - 50% after deductible |
| Therapeutic Radiology | Covered - 70% after deductible | Covered - 50% after deductible |
| Maternity Services Provided by a Physician | ||
| Prenatal and Postnatal Care - includes care provided by a certified nurse midwife | Covered - 70% after deductible | Covered - 50% after deductible |
| Delivery and Nursery Care - includes delivery provided by a certified nurse midwife | Covered - 70% after deductible | Covered - 50% after deductible |
| 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 - 70% after deductible | Covered - 50% after deductible |
| Up to a maximum of 365 days with a 60-day renewal period | ||
| Inpatient Consultations | Covered - 70% after deductible | Covered - 50% after deductible |
| Chemotherapy | Covered - 70% after deductible | Covered - 50% after deductible |
| Alternatives to Hospital Care | ||
| Skilled Nursing Care | Not Covered | Not Covered |
| Hospice Care | Covered - 70% after deductible | Covered - 70% after deductible |
| Limited to dollar maximum which is adjusted periodically | ||
| Home Health Care | Covered - 70% after deductible | Covered - 70% after deductible |
| Surgical Services | ||
| Surgery - includes related surgical services Includes surgery in BCBSM-approved ambulatory facilities |
Covered - 70% after deductible | Covered - 50% after deductible |
| Voluntary Sterilization | Covered - 70% after deductible | Covered - 50% 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 - 70% after deductible | Covered - 70% 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 applies | Covered - 70% after deductible | Covered - 50% after deductible |
| Kidney, Cornea and Skin | Covered - 70% after deductible | Covered - 50% after deductible |
| Mental Health Care and Substance Abuse Treatment | ||
| Inpatient Mental Health Care and Substance Abuse Treatment | Covered - 50% after deductible | Covered - 50% after deductible |
| Up to a maximum of 30 days with a 60-day renewal period | ||
| Outpatient Mental Health Care | Not Covered | Not Covered |
| 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 | Not Covered | Not Covered |
| Chiropractic Spinal Manipulation | Not Covered | Not Covered |
| Durable Medical Equipment | Not Covered | Not Covered |
| Outpatient Diabetes Management Program | Covered - 70% after deductible | Covered - 50% after deductible |
| Outpatient Physical, Speech and Occupational Therapy | ||
| Facility and Clinic | Covered - 70% after deductible | Covered - 70% after deductible |
| Physician's Office - excludes speech and occupational therapy | Covered - 70% after deductible | Covered - 50% after deductible |
| A combined maximum of 60 visits per calendar year for physical therapy in the outpatient department of a hospital as well as in the physician's office | ||
| Prosthetic and Orthotic Appliances | Covered - 70% after deductible, only for certain external prosthetics | Covered - 70% after deductible, only for certain external prosthetics |
| Private Duty Nursing | Not Covered | Not Covered |
| Prescription Drugs | Not Covered | Not Covered |
| Deductible, Copays & Dollar Maximums | ||
| Deductible | $2,000 for a one-person contract, $4,000 for a family contract for calendar year 2004. Covered services for any member under the family contract are only paid after the full $4,000 deductible is met. Note: The federal government determines new deductibles each year based on increases in the Consumer Price Index. Please call your local customer service center for an annual update. |
|
| Copays | 30% for general services and 50% for mental health care and substance abuse treatment | 50% for all covered services Note: Services without a network are covered at the in-network level. |
| Copay Dollar Maximums | $3,000 per member, $6,000 per family per calendar year | $5,000 per member, $10,000 per family per calendar year |
| Dollar Maximums | None except as noted for hospice care, transplants and outpatient substance abuse treatment | |
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.
