Blue Cross Blue Shield of Michigan Mutual Insurance Company

Blue Cross Premier PPO Gold

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Plan Overview

Combined Medical and Drug Deductible	Individual: $1,250.00 Family: $2500 Per Person: $1250
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,500.00 Family: $17000 Per Person: $8500

Office Visit

Primary Doctor

CoPay: $30.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Includes virtual, retail health clinic and medical evaluation at an affiliated immunization pharmacy visits. No charge for 24/7 medical virtual visits when performed through the BCBSM selected vendor app, except HSA eligible plans have no charge after deductible. Diagnostic and laboratory services are not included in the office visit copayment. These services are subject to the plan's deductible and coinsurance, if applicable.

Specialist

CoPay: $50.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: No charge for 24/7 medical virtual visits when performed through the BCBSM selected vendor app, except HSA eligible plans have no charge after deductible. Diagnostic and laboratory services are not included in the office visit copayment. These services are subject to the plan's deductible and coinsurance, if applicable.

Prescription Drug Information

Preferred Brand Drugs	CoPay: $100.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered Exclusions: Quantity limits per fill may apply for 30-day retail, 90-day retail and up to 90 day mail order. Opioid-containing medications are limited to no more than a 30-day supply per fill and first fills of select opioid containing medications will be limited to a 5-day supply. Benefit Explanation: Prior authorization, step therapy and quantity limits may apply to select drugs. The penalty for not having prior authorization is denial of payment. Any coupon, rebate, or other credits received directly or indirectly from an assistance program or the drug manufacturer may not be applied to a consumer?s deductible, cost-sharing or out of pocket maximum. For out-of-network providers, member must pay the full cost of the drug and submit to BCBSM for reimbursement.
Non Preferred Brand Drugs	CoPay: $150.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered Exclusions: Quantity limits per fill may apply for 30-day retail, 90-day retail and up to 90 day mail order. Opioid-containing medications are limited to no more than a 30-day supply per fill and first fills of select opioid containing medications will be limited to a 5-day supply. Benefit Explanation: Prior authorization, step therapy and quantity limits may apply to select drugs. The penalty for not having prior authorization is denial of payment. Any coupon, rebate, or other credits received directly or indirectly from an assistance program or the drug manufacturer may not be applied to a consumer?s deductible, cost-sharing or out of pocket maximum. For out-of-network providers, member must pay the full cost of the drug and submit to BCBSM for reimbursement.
Generic Drugs	CoPay: $15.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered Exclusions: Quantity limits per fill may apply for 30-day retail, 90-day retail and up to 90 day mail order. Opioid-containing medications are limited to no more than a 30-day supply per fill and first fills of select opioid containing medications will be limited to a 5-day supply. Benefit Explanation: Prior authorization, step therapy and quantity limits may apply to select drugs. The penalty for not having prior authorization is denial of payment. Any coupon, rebate, or other credits received directly or indirectly from an assistance program or the drug manufacturer may not be applied to a consumer?s deductible, cost-sharing or out of pocket maximum. For out-of-network providers, member must pay the full cost of the drug and submit to BCBSM for reimbursement.
Specialty Drugs	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered Exclusions: Specialty drugs are limited to a 30-day supply per fill, however some may be limited to a 15-day supply fill, depending on the medication. Benefit Explanation: BCBSM has contracted with an exclusive pharmacy network for specialty drugs. Call the customer service phone number on the back of your ID card for the pharmacy?s phone number or location nearest to you. If you obtain your specialty drugs from any other pharmacy, you are responsible for the total cost. Prior authorization, step therapy and quantity limits may apply to select drugs. The penalty for not having prior authorization is denial of payment. Any coupon, rebate, or other credits received directly or indirectly from an assistance program or the drug manufacturer may not be applied to a consumer?s deductible, cost-sharing or out of pocket maximum.

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered Benefit Explanation: BCBSM participating hospitals only. These services require prior authorization. The penalty for not having prior authorization is denial of payment.
Inpatient Services	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered Benefit Explanation: BCBSM participating hospitals only. These services require prior authorization. The penalty for not having prior authorization is denial of payment.

Emergency and Urgent Care

Emergency Room	CoPay: $250.00 Copay after deductible CoInsurance: 20.00% Coinsurance after deductible Covered: Covered
Urgent Care Facility	CoPay: $75.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: When the urgent care visit is for an emergency or accidental injury, in-network cost-sharing applies.

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered Benefit Explanation: BCBSM-participating hospitals only. These services require prior authorization. The penalty for not having prior authorization is denial of payment.
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: 0.00% Covered: Covered Benefit Explanation: Cost sharing does not apply for preventive services. Depending on the type of services, a copayment, coinsurance or deductible may apply.

Vision

Routine Eye Exams for Children

CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per Year
Benefit Explanation: A child is defined as a member up to the age of 19. Out of network is paid up to the allowed amount.

Major Dental Care

Routine Dental Checkups for Children	Covered: Not Covered
Routine Dental Checkups for Adults	Covered: Not Covered

The premiums shown include BCBSM's/BCN's estimates of applicable Federal and state taxes, fees and assessments. BCBSM's/BCN's estimates are subject to change. BCBSM/BCN will not reconcile or settle any amounts collected with actual amounts owed for such Federal and state taxes, fees, and assessments.

HSA Eligible Products