|
|
| Benefit Highlights |
Individual Care Blue PPOSM |
|
In Network |
Out of Network |
| Annual deductible |
None |
None |
| Copays |
30% of the BCBSM–approved amount |
50% of the BCBSM–approved amount |
| Annual copay dollar maximum |
$2,500 per individual or family contract (two or more members), per calendar year. Prescription drug copays do not contribute to the annual copay dollar maximum. |
The out–of–network annual copay dollar maximum is unlimited. Prescription drug copays do not contribute to the in–network copay dollar maximum. |
| Annual out of pocket maximum: The annual out of pocket maximum limits the amount you will be responsible for paying each year. Once the annual out of pocket maximum is met, most services are payable at 100% of the BCBSM approved amount. |
$2,500 per individual or family contract (two or more members) |
No out–of–pocket maximum |
| Lifetime maximum per member |
$5 million |
| Fourth quarter deductible carryover |
Not applicable |
Not applicable |
| Preventive Services |
|
| Includes: health maintenance exam, routine laboratory and radiology, fecal occult blood screening, flexible sigmoidoscopy, gynecological exam, childhood immunizations (0 – 18 years), Pap smear screening, prostate specific antigen screening, well baby and well child exams |
Covered – 100% up to a combined maximum of $500 per member, per calendar year |
Not covered |
| Mammography |
Covered – 100% |
Covered – 100% |
| Physician Office Services |
|
| Office visits |
Covered – 70%; 2 per member, per calendar year |
Not covered |
| Outpatient presurgical second opinion consultations |
Covered – 100% |
Not covered |
| Office consultations |
Not covered |
Not covered |
| Emergency Services |
|
| Medical emergencies and accidental injuries |
Covered – 70% |
Covered – 70% |
| Ambulance service: medically necessary, ground transport and air ambulance |
Covered – 70% |
Covered – 70% |
| Benefit Highlights |
Individual Care Blue PPO SM |
|
In Network |
Out of Network |
| Diagnostic and Radiation Services |
|
| Ultrasound |
Covered – 70% |
Covered – 50% |
| Laboratory tests and pathology |
Covered – 70% |
Covered – 50% |
| EKGs |
Covered – 70% |
Covered – 50% |
| Diagnostic radiology and X rays |
Covered – 70% |
Covered – 50% |
| Colonoscopies (diagnostic) |
Covered – 70% |
Covered – 50% |
| CT scans and MRIs (BCBSM participating facilities only) |
Covered – 70% |
Covered – 50% |
| Radiation therapy |
Covered – 70% |
Covered – 50% |
| Maternity Services |
|
| Delivery and newborn exam |
Covered – 70% |
Covered – 50% |
| Prenatal and postnatal exams (office visits) |
Not covered |
Not covered |
| Laboratory tests and pathology |
Covered – 70% |
Covered – 50% |
| Inpatient Hospital Care |
|
| Semi private room: 120 days with 60 day renewal period (BCBSM approved facilities only) |
Covered – 70% |
Covered – 50% |
| Inpatient consultations |
Covered – 70% |
Covered – 50% |
| Complications of pregnancy |
Covered – 70% |
Covered – 50% |
| Surgical Care – Hospital or Outpatient |
|
| Inpatient surgical care |
Covered – 70% |
Covered – 50% |
| Outpatient surgical care |
Covered – 70% |
Covered – 50% |
| Physician surgical services |
Covered – 70% |
Covered – 50% |
| Alternatives to Hospitalization |
|
| Home health care (participating providers only) |
Covered – 70% |
| Hospice care: covered at a participating program up to the annual dollar maximum |
Covered – 100% |
| Outpatient Services |
|
| Outpatient physical, occupational and speech therapy: 60 consecutive days per condition |
Covered – 70% |
Covered – 50% |
| Chemotherapy (IV and oral) |
Covered – 70% |
Covered – 50% |
| Home infusion therapy (participating providers only) |
Covered – 70% |
| Voluntary sterilization |
Covered – 70% |
Covered – 50% |
| Prosthetics (participating providers only) |
Covered – 70% |
| Other medical benefits |
|
| Insulin, disposable needles and syringes dispensed with insulin, diabetic testing supplies |
Covered – 70% |
Covered – 50% |
| Outpatient diabetes management program |
Covered – 70% |
Covered – 50% |
| Contraceptives: physician administered, prescription drugs only, devices and contraceptive injectables (Implants are not covered) |
Covered – 70% |
Covered – 50% |
| Benefit Highlights |
Individual Care Blue PPO SM |
|
In Network |
Out of Network |
| Organ Transplantation |
| Bone marrow transplant |
Covered – 70% |
Covered – 50% |
| Kidney, cornea and skin transplants |
Covered – 70% |
Covered – 50% |
| Specified organ transplant: $1 million lifetime maximum per transplant type, included in the $5 million lifetime maximum (BCBSM designated facilities only) |
Covered – 100% |
| Mental Health and Substance Abuse Treatment |
| Inpatient mental health: 30 days with 60 day renewal period (BCBSM approved facilities only) |
Covered – 70% |
Covered – 50% |
| Outpatient mental health |
Not covered |
Not covered |
| Substance abuse – inpatient (residential) and outpatient: up to state mandated benefit (BCBSM approved facilities only) |
Covered – 70% |
Covered – 50% |
| Prescription Drugs |
|
|
Network Pharmacy |
Non Network Pharmacy |
| Annual maximum |
Covered – $2,500 per member, per calendar year. If you exhaust your annual maximum, you may purchase prescription drugs at the BCBSM–negotiated rate for the remainder of the calendar year. |
| Retail (1 – 34 day supply) |
Covered – 50% of the approved amount with a minimum of $10 and a maximum of $100 per prescription. Prescription drug copays are not applied toward the annual copay dollar maximum. |
You must pay the pharmacist the full cost of the drug. BCBSM will reimburse you 75% of the BCBSM–approved amount for covered drugs obtained in the United States, less your 50% network copay. You are responsible for the difference between the non–network pharmacy’s charge and the BCBSM–approved amount for the drug. Prescription drug copays are not applied toward the annual copay dollar maximum. |
| 90 day retail (84 – 90 day supply) |
Not covered |
Not covered |
| Mail order (35 – 90 day supply) |
Not covered |
Not covered |
| Benefit Highlights |
Individual Care Blue PPO SM |
|
Network Pharmacy |
Non Network Pharmacy |
| Other Prescription Drug Benefits |
|
| Specialty drugs |
Covered – prescription drug copay applies. Specialty drugs are available at many retail pharmacies as well as by mail order through Option Care. A list of covered specialty drugs may be found on bcbsm.com. If you have any questions about specialty drugs, please call Option Care at 866–515–1355. |
Not covered |
| Contraceptives: self administered prescription drugs only |
Covered – prescription drug copay applies |
Covered – prescription drug copay applies |
| Drugs prescribed for cosmetic purposes |
Not covered |
Not covered |
| Elective drugs |
Covered – prescription drug copay applies |
Covered – prescription drug copay applies |
| Prescription drugs ordered on the Internet |
Not covered |
Not covered |
| Vaccines given solely to resist infectious diseases |
Not covered |
Not covered |
| Notes |
|
| Dispense as written (DAW) |
If you request a brand–name drug when a generic equivalent is available, and your physician has not indicated “Dispense as Written” or “DAW” on the prescription, you must pay the difference in cost between the brand–name drug dispensed and the maximum allowable cost for the generic, plus your copay, if applicable. |
| Prior authorization |
Not applicable |
| Step therapy |
Not applicable |
Note: Out–of–network (nonparticipating) providers may bill you for the difference between BCBSM’s approved amount and the provider’s charge, even if you are referred.
Exclusions and Limitations: Conditions covered by workers’ compensation or similar law; services or supplies not specifically listed as covered under your benefit plan; services received before your effective date or after coverage ends; services you wouldn’t have to pay for if you did not have this coverage; services or supplies that are not medically necessary; physical exams for insurance, employment, sports or school; any amounts in excess of BCBSM’s approved amount; cosmetic surgery; dental care, dental implants or treatment to the teeth except as specifically stated in your benefit plan; hearing aids; infertility services; private duty nursing; eyeglasses or contact lenses; telephone, facsimile machine or any other type of electronic consultation; educational services, except as specifically provided or arranged by BCBSM; nutritional counseling; care or treatment furnished in a nonparticipating hospital, except as specifically stated in your benefit plan; personal comfort items; custodial care; services or supplies supplied to any person not covered under your the benefit plan; services while confined in a hospital or other facility owned or operated by state or federal government, unless required by law; services provided by a professional provider to a family member; services provided by any person who ordinarily resides in the covered person’s home or who is a family member; any drug, medicine or device that is not FDA–approved, unless required by law; vitamins, dietary products and any other nonprescription supplements; dental services, except for dental injury; appliances or supplies; war or any act of war, whether declared or not; communication or travel time, lodging or transportation, except as stated in your benefit plan; foot care services, except as stated in your benefit plan; health clubs or health spas, aerobic and strength conditioning, work hardening programs and related material and products for these programs; hair prosthesis, hair transplants or implants; experimental treatments, except as stated in your benefit plan; weight loss programs; and alternative medicines or therapies.
This document is intended to be an easy–to–read summary. It is not a contract. Additional limitations and exclusions may apply to covered services. A complete description of benefits is contained in the applicable Blue Cross Blue Shield of Michigan certificate and riders. Payment amounts are based on the BCBSM–approved amount, less any applicable deductible and/or copay amounts required by the plan. All covered benefits are subject to a pre–existing conditions waiting period, unless noted otherwise. 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.
CF 4945 APR 08
| Benefit Highlights |
Value Blue PPOSM |
|
In Network |
Out of Network |
| Annual deductible |
$1,000 per individual contract, per calendar year. $2,000 per family contract (two or more members), per calendar year. Two or more members must meet the family deductible. If the individual deductible has been met by one family member, but not the family deductible, we will pay covered services only for that member. Covered services for the remaining family members will be paid when the full family deductible has been met. |
$1,000 per individual contract, per calendar year. $2,000 per family contract (two or more members), per calendar year. Two or more members must meet the family deductible. If the individual deductible has been met by one family member, but not the family deductible, we will pay covered services only for that member. Covered services for the remaining family members will be paid when the full family deductible has been met. |
| Copays |
30% of the BCBSM–approved amount |
50% of the BCBSM–approved amount |
| Annual copay dollar maximum |
$2,500 per individual or family contract |
The out–of–network annual copay dollar maximum is unlimited. Out–of–network copays do not contribute to the in–network copay dollar maximum. |
| Annual out of pocket maximum: The annual out of pocket maximum limits the amount you will be responsible for paying each year. Once the annual out of pocket maximum is met, most services are payable at 100% of the BCBSM approved amount. |
$3,500 per individual contract. $4,500 per family contract (two or more members). |
No out–of–pocket maximum |
| Lifetime maximum per member |
$5 million |
| Fourth quarter deductible carryover |
Any amount you pay toward your deductible during the last three months of the calendar year will be applied to your deductible for the following calendar year. We will not apply amounts paid under other contracts toward your deductible. |
| Preventive Services |
|
| Includes: health maintenance exam, routine laboratory and radiology, fecal occult blood screening, flexible sigmoidoscopy, gynecological exam, childhood immunizations (0 – 18 years), Pap smear screening, prostate specific antigen screening, well baby and well child exams |
Not covered |
Not covered |
| Mammography |
Covered – 70% after deductible |
Covered – 50% after deductible |
| Physician Office Services |
|
| Office visits |
Not covered |
Not covered |
| Outpatient presurgical second opinion consultations |
Covered – 100% after deductible |
Not covered |
| Office consultations |
Not covered |
Not covered |
| Emergency Services |
|
| Medical emergencies and accidental injuries |
Covered – 70% after in–network deductible |
Covered – 70% after in–network deductible |
| Ambulance service: medically necessary, ground transport and air ambulance |
Covered – 70% after in–network deductible |
Covered – 70% after in–network deductible |
| Benefit Highlights |
Value Blue PPO |
|
In Network |
Out of Network |
| Diagnostic and Radiation Services |
|
| Ultrasound |
Covered – 70% after deductible |
Covered – 50% after deductible |
| Laboratory tests and pathology |
Covered – 70% after deductible |
Covered – 50% after deductible |
| EKGs |
Covered – 70% after deductible |
Covered – 50% after deductible |
| Diagnostic radiology and X rays |
Covered – 70% after deductible |
Covered – 50% after deductible |
| Colonoscopies (diagnostic) |
Covered – 70% after deductible |
Covered – 50% after deductible |
| CT scans and MRIs (BCBSM participating facilities only) |
Covered – 70% after deductible |
Covered – 50% after deductible |
| Radiation therapy |
Covered – 70% after deductible |
Covered – 50% after deductible |
| Maternity Services |
|
| Delivery and newborn exam |
Covered – 70% after deductible |
Covered – 50% after deductible |
| Prenatal and postnatal exams (office visits) |
Not covered |
Not covered |
| Laboratory tests and pathology |
Covered – 70% after deductible |
Covered – 50% after deductible |
| Inpatient Hospital Care |
|
| Semi private room: 120 days with 60 day renewal period (BCBSM approved facilities only) |
Covered – 70% after deductible |
Covered – 50% after deductible |
| Inpatient consultations |
Covered – 70% after deductible |
Covered – 50% after deductible |
| Complications of pregnancy |
Covered – 70% after deductible |
Covered – 50% after deductible |
| Surgical Care – Hospital or Outpatient |
|
| Inpatient surgical care |
Covered – 70% after deductible |
Covered – 50% after deductible |
| Outpatient surgical care |
Covered – 70% after deductible |
Covered – 50% after deductible |
| Physician surgical services |
Covered – 70% after deductible |
Covered – 50% after deductible |
| Alternatives to Hospitalization |
|
| Home health care (participating providers only) |
| | | | | | | |
