Blue Cross Blue Shield of Michigan

Blue Cross® Premier PPO Bronze Saver

Plan Overview

Combined Medical and Drug Deductible
  • Individual: $8,700
  • Family: $17,400
  • Per Person: $8,700
Combined Medical and Drug Out of Pocket Maximum
  • Individual: $8,700
  • Family: $17,400
  • Per Person: $8,700

Office Visit

Primary Doctor
  • CoPay: No Charge after deductible
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: Includes virtual and retail health clinic visits. Online visits are covered 100% before deductible on all plans except HSA eligible plans, online visits are covered 100% after deductible, when performed by a BCBSM selected vendor. 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: No Charge after deductible
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: Online visits are covered 100% before deductible on all plans except HSA eligible plans, online visits are covered 100% after deductible, when performed by a BCBSM selected vendor. 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: No Charge 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 the drug manufacturer may not be applied to a consumer’s deductible, cost-sharing or out of pocket maximum.
Non Preferred Brand Drugs
  • CoPay: No Charge 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 the drug manufacturer may not be applied to a consumer’s deductible, cost-sharing or out of pocket maximum.
Generic Drugs
  • CoPay: No Charge 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 the drug manufacturer may not be applied to a consumer’s deductible, cost-sharing or out of pocket maximum.
Specialty Drugs
  • CoPay: Not Applicable
  • CoInsurance: No Charge after deductible
  • Covered: Covered
  • Exclusions: The first specialty drug fill will be limited to a 15-day supply. Subsequent fills limited to a 15- or 30-day supply per 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 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: No Charge 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: No Charge 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: Not Applicable
  • CoInsurance: No Charge 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: No Charge 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: No Charge after deductible
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: 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
Basic Dental Care - Adult
  • Covered: Not Covered
Basic Dental Care - Child
  • Covered: Not Covered
Major Dental Care - Adult
  • Covered: Not Covered
Major Dental Care - Child
  • 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

  1. Products that are HSA eligible:

  2. Blue Cross® Premier PPO Bronze HSA

  3. Blue Cross® Premier PPO Silver Saver HSA

  4. Blue Cross® Preferred HMO Bronze Saver HSA

  5. Blue Cross® Select HMO Bronze Saver HSA

  6. 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: www.bcbsm.com/healthybluehsa.
* fee is subject to change

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We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program to get information on all of your options.

Attention: This website is operated by HealthMarkets Insurance Agency, Inc. and is not the Health Insurance Marketplace® website. HealthMarkets Insurance Agency, Inc. is licensed as an insurance agency nationwide except in MA. Not all agents are licensed to sell all products. Service and product availability varies by state. Sales agents may be compensated based on a consumer’s enrollment in an insurance plan. No obligation to enroll. Agent cannot provide tax or legal advice. Contact your tax or legal professional to discuss details regarding your individual business circumstances. Our quoting tool is provided for your information only. All quotes are estimates and are not final until consumer is enrolled. Medicare has neither reviewed nor endorsed this information.

HealthMarkets Insurance Agency offers the opportunity to enroll in either QHPs or off-Marketplace coverage. Please visit HealthCare.gov for information on the benefits of enrolling in a QHP. Off-Marketplace coverage is not eligible for the cost savings offered for coverage through the Marketplaces.

This information is not a complete description of benefits. Call the Plan’s customer service phone number for more information.

HMPLAN15560MI0350005ACA1

© 2024 HealthMarkets Insurance Agency. All rights reserved.

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program to get information on all of your options.

Attention: This website is operated by HealthMarkets Insurance Agency, Inc. and is not the Health Insurance Marketplace® website. HealthMarkets Insurance Agency, Inc. is licensed as an insurance agency nationwide except in MA. Not all agents are licensed to sell all products. Service and product availability varies by state. Sales agents may be compensated based on a consumer’s enrollment in an insurance plan. No obligation to enroll. Agent cannot provide tax or legal advice. Contact your tax or legal professional to discuss details regarding your individual business circumstances. Our quoting tool is provided for your information only. All quotes are estimates and are not final until consumer is enrolled. Medicare has neither reviewed nor endorsed this information.

HealthMarkets Insurance Agency offers the opportunity to enroll in either QHPs or off-Marketplace coverage. Please visit HealthCare.gov for information on the benefits of enrolling in a QHP. Off-Marketplace coverage is not eligible for the cost savings offered for coverage through the Marketplaces.

This information is not a complete description of benefits. Call the Plan’s customer service phone number for more information.

HMPLAN15560MI0350005ACA1

© 2024 HealthMarkets Insurance Agency. All rights reserved.

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program to get information on all of your options.

Attention: This website is operated by HealthMarkets Insurance Agency, Inc. and is not the Health Insurance Marketplace® website. HealthMarkets Insurance Agency, Inc. is licensed as an insurance agency nationwide except in MA. Not all agents are licensed to sell all products. Service and product availability varies by state. Sales agents may be compensated based on a consumer’s enrollment in an insurance plan. No obligation to enroll. Agent cannot provide tax or legal advice. Contact your tax or legal professional to discuss details regarding your individual business circumstances. Our quoting tool is provided for your information only. All quotes are estimates and are not final until consumer is enrolled. Medicare has neither reviewed nor endorsed this information.

HealthMarkets Insurance Agency offers the opportunity to enroll in either QHPs or off-Marketplace coverage. Please visit HealthCare.gov for information on the benefits of enrolling in a QHP. Off-Marketplace coverage is not eligible for the cost savings offered for coverage through the Marketplaces.

This information is not a complete description of benefits. Call the Plan’s customer service phone number for more information.

HMPLAN15560MI0350005ACA1