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Plan Benefit Summary
To compare the plans available to you, please make the appropriate selections below
    
QUICK REFERENCE: MEDICAL-SURGICAL AND HOSPITAL
BENEFITS
Benefits for the services listed are covered when obtained through Blue
Cross Blue Shield of Michigan’s Participating Provider Network. When
members choose to receive care outside the network, they have higher out-pocket
costs.
| Company Name: |
 |
| Plan Type: |
PPO |
| Monthly Premium: |
|
| Deductible: |
None |
Copayment:
|
Member pays 30% for general services
received in-network; 50% out-of-network;
50% for prescription drugs with a minimum copay of $10 and a maximum
copay of $100 for each drug |
Copay Dollar Maximums*:
|
$2,500 for hospital/medical-surgical services per contract
(Copayments for prescription drugs are not applied to this maximum |
Home, Outpatient and Office Visits :
|
Not covered |
Inpatient Medical Care, Unlimited Visits for General
Conditions:
|
Covered – 70%; 50% Out-of-Network |
| Consultations – Inpatient: |
Covered – 70%; 50% Out-of-Network |
Surgery, Technical Surgical Assistance:
|
Covered – 70%; 50% Out-of-Network |
Voluntary Sterilization:
|
Covered – 70%; 50% Out-of-Network |
Maternity Care – Delivery and Routine
Newborn Exam Only:
|
Covered – 70%; 50% Out-of-Network |
Mammography:
|
Covered – 70%; 50% Out-of-Network |
Covered – Semi-Private Room, 120 days:
|
Covered – 70%; 50% Out-of-Network |
| Chemotherapy: |
Covered – 70%; 50% Out-of-Network |
Outpatient Physical Therapy –
60 Consecutive Days Per Condition
|
Covered – 70%; 50% Out-of-Network |
Emergency Room – Approved Criteria :
|
Covered – 70% |
| Physician’s Services – Approved Diagnosis
: |
Covered – 70% |
Laboratory and Pathology Tests :
|
Covered – 70%; 50% Out-of-Network |
Diagnostic Tests and X-Rays :
|
Covered – 70%; 50% Out-of-Network |
Radiation Therapy :
|
Covered – 70%; 50% Out-of-Network |
Specified Organ Transplants –
Liver, Heart, Heart-Lung, and Pancreas:
|
Covered – 100% in approved
facility up to $1 million lifetime maximum for each specified organ
transplant type |
Bone Marrow Transplants:
|
Covered – 70%; 50% Out-of-Network |
Kidney, Cornea and Skin:
|
Covered – 70%; 50% Out-of-Network |
Hemodialysis – Outpatient and Home:
|
Covered – 70% |
Home Health Care:
|
Covered – 70% |
| Hospice Care: |
Covered – 100% up to the dollar amount required
by the state (changes each year) |
Prosthetic Appliances:
|
Covered – 70% |
Prescription Drugs:
|
Covered – 50% with a minimum copay of $10
and maximum of $100 for each drug; $2,500 annual benefit maximum per
member
|
* Once the copay maximum for the year (Jan. 1 through Dec. 31) has been
met, covered services will be paid at 100 percent of the BCBSM-approved
amount for the remainder of the year.
GENERAL DISCLAIMER
Do not cancel any current health insurance coverage until you receive an approval letter and insurance policy (insurance contract), from the insurance company you selected. Make sure you understand and agree with the terms of the policy. Pay close attention to the effective date, premium, benefits, limitations, exclusions, and riders.
The premiums and benefits shown are for comparison purposes only. Please review the evidence of coverage and plan contract for a detailed description of coverage benefits, limitations, and exclusions. Only the terms and conditions of coverage benefits listed in the policy are binding.
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