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 | Not Covered | Not Covered |
| Well-Baby and Child Care | Not Covered | Not Covered |
| Immunizations | Not Covered | Not Covered |
| Prostate Specific Antigen (PSA) Screening | Not Covered | Not Covered |
| Mammography | ||
| Mammography Screening | Covered - 70% after deductible | Covered - 50% after deductible |
| 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 | ||
| Hospital Emergency Room - approved diagnosis | Covered - 70% after deductible | Covered - 70% after deductible |
| Physician's Office - approved diagnosis | Covered - 70% after deductible | Covered - 70% after deductible |
| Ambulance Services - medically necessary | Covered - 70% after deductible | Covered - 70% after deductible |
| Urgent Care Center - approved diagnosis | Covered - 70% after deductible | Covered - 70% after deductible |
| Diagnostic Services | ||
| Laboratory and Pathology Tests | Covered - 70% after deductible | Covered - 40% after deductible |
| 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% after deductible | Covered - 50% after deductible |
| Radiation Therapy | Covered - 70% after deductible | Covered - 50% after deductible |
| Maternity Services Provided by a Physician | ||
| Pre-Natal and Post-Natal Care | Not Covered | Not Covered |
| Delivery and Nursery Care | Not Covered | Not Covered |
| Hospital Care | ||
| Semi-Private Room, Inpatient Physician Care, General Nursing Care, Hospital Services and Supplies Note: Non-emergency services must be rendered in participating hospital |
Covered - 70% after deductible | Covered - 50% after deductible |
| Up to 120 days; 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 - 100% | Not Covered |
| Limited to the lifetime dollar maximum which is adjusted annually by the state | ||
| Home Health Care | Covered - 70% after deductible | Covered - 70% after deductible |
| Surgical Services | ||
| Surgery, includes all related surgical services, anesthesia and surgical assistance | 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 (1-800-242-3504) | Covered - 100% after deductible | Not Covered |
| Up to $1 million maximum per transplant type | ||
| Bone Marrow - when coordinated through the BCBSM Human Organ Transplant Program (1-800-242-3504); specific criteria applies | Covered - 100% after deductible | Not Covered |
| Kidney, Cornea and Skin | Covered - 100% after deductible | Not Covered |
| Mental Health Care and Substance Abuse Treatment | ||
| Inpatient Mental Health Care and Substance Abuse Care | Covered - 70% after deductible | Covered - 50% after deductible |
| 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% after deductible | Covered - 50% after deductible |
| Outpatient Physical, Speech and Occupational Therapy | ||
| Facility and Clinic | Covered - 70% after deductible | Covered - 50% after deductible |
| Physician's Office - excludes speech and occupational therapy | Covered - 70% after deductible | Covered - 50% after deductible |
| Up to 60 consecutive days of treatment per condition per calendar year | ||
| Orthotic Appliances | Not Covered | Not Covered |
| Prosthetic Appliances | Covered - 70% after deductible | Covered - 50% after deductible |
| 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 | $1000 combined deductible | |
| Copays - Fixed | None | None |
| Copays - Percent | 30% of approved amount for most services | 50% of 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, excludes mental health care, substance abuse care and private duty nursing copays | $2,500 | None |
| Dollar Maximums | None, except as noted above | |
| Prescription Drug Coverage | ||
| Prescription Drug Plan | Not Covered | 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 arebased on the Blue Cross Blue Shield of Michigan approved amount, less any applicable deductible and/or copay amounts required by the plan.
