Blue Cross® Premier PPO Gold
|Combined Medical and Drug Deductible|
|Combined Medical and Drug Out of Pocket Maximum|
Prescription Drug Information
|Preferred Brand Drugs|
|Non Preferred Brand Drugs|
Emergency and Urgent Care
|Urgent Care Facility|
|Labor and Delivery Hospital Stay|
|Pre and Postnatal Office Visit|
|Routine Eye Exams For Children|
Major Dental Care
|Routine Dental Checkups for Children|
|Routine Dental Checkups for Adults|
|Basic Dental Care - Adult|
|Basic Dental Care - Child|
|Major Dental Care - Adult|
|Major Dental Care - Child|
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® 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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