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 Copay after deductible
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
Products that are HSA eligible:
Blue Cross® Premier PPO Bronze HSA
Blue Cross® Premier PPO Silver Saver HSA
Blue Cross® Preferred HMO Bronze Saver HSA
Blue Cross® Select HMO Bronze Saver HSA
Blue Cross® Local HMO Bronze Saver HSA
Blue Cross® Metro Detroit HMO Bronze Saver HSA
There is a $0* charge per month for our HSA. If you would like to learn more please visit:
1-817-813-4562, TTY 711
