Young Member Blue PPO Member Value Blue PPO
Health Savings Accounts What Is A Health Savings Account How Will I Save Money With An HSA How Can I Fund My HSA What Can I Use My HSA Funds For How To Set Up Your HSA Account
HSA-Qualified High Deductible Plans Comprehensive Major Medical PPO 1000
Comprehensive Major Medical PPO 2500 •   Benefit Chart •   Eligibility Requirements •   How To Apply For Coverage •   Premium Rates •   Preexisting Condition Waiting Period
Download the Brochure in PDF format
Blue Value Option PPO 2000

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 - 80% after deductible	Covered - 80% after deductible, plus 20% out-of-network copay
	For age 18 and older, once every 12 months (from the date of any previous pap smear)
Well-Baby and Child Care Visits	Not Covered	Not Covered
Childhood Immunizations	Not Covered	Not Covered
Fecal Occult Blood Screening • age 40 through 49, once every 3 years • age 50 and older, once every 2 years	Not Covered	Not Covered
Flexible Sigmoidoscopy Exam	Not Covered	Not Covered
Prostate Specific Antigen Screening	Not Covered	Not Covered
Cholesterol Screening	Not Covered	Not Covered
Mammography
Mammography Screening	Covered - 80% after deductible	Covered - 80% after deductible, plus 20% out-of-network copay
	One baseline for 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
Therapeutic Radiology	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 amounts paid during the last three months of the calendar year will not be applied to the deductible for the following year.
Deductible	$2,500 for a one-person contract, $5,000 for a family contract for calendar year 2004. Covered services for any member under the family contract are only paid after the full $5,000 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.