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Individual: $3900

Family: $7800

Per Person: $3900

Individual: $0

Family: $0

Per Person: $0

Individual: $7700

Family: $15400

Per Person: $7700

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.

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.

CoPay: $100.00 Copay after deductible

CoInsurance: Not Applicable

Covered: Covered

Limit Quantity:

Limit Unit:

Benefit Explanation: Refer to drug list for quantity limits and other exclusions. May require prior authorization & step therapy. The penalty for not having prior authorization is denial of payment. Preventive drugs are covered with no out-of-pocket costs when health care reform requirements are met. 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.

CoPay: $150.00 Copay after deductible

CoInsurance: Not Applicable

Covered: Covered

Limit Quantity:

Limit Unit:

Benefit Explanation: Refer to drug list for quantity limits and other exclusions. May require prior authorization & step therapy. The penalty for not having prior authorization is denial of payment. Preventive drugs are covered with no out-of-pocket costs when health care reform requirements are met. 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.

CoPay: $15.00 Copay after deductible

CoInsurance: Not Applicable

Covered: Covered

Limit Quantity:

Limit Unit:

Benefit Explanation: Refer to drug list for quantity limits and other exclusions. May require prior authorization & step therapy. The penalty for not having prior authorization is denial of payment. Preventive drugs are covered with no out-of-pocket costs when health care reform requirements are met. 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.

CoPay: Not Applicable

CoInsurance: 40.00% Coinsurance after deductible

Covered: Covered

Limit Quantity:

Limit Unit:

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.

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.

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.

CoPay: $250.00 Copay after deductible

CoInsurance: 20.00% Coinsurance after deductible

Covered: Covered

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.

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.

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.

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.

CoPay:

CoInsurance:

Covered: Not Covered

Limit Quantity:

Limit Unit:

CoPay:

CoInsurance:

Covered: Not Covered

Limit Quantity:

Limit Unit:

Benefit Explanation: