Blue Care Network of Michigan

Blue Cross® Preferred HMO Gold

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Plan Overview

Combined Medical and Drug Deductible	Individual: $850 Family: $1,700 Per Person: $850
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,700 Family: $17,400 Per Person: $8,700

Office Visit

Primary Doctor

CoPay: $30.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Includes Virtual and Retail Health Clinic visits. No charge for online visits when performed by a BCN selected vendor. Diagnostic 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: Referral required. The penalty for not having a referral is denial of payment. Diagnostic services are not included in the office visit copayment. These services are subject to the plan's deductible and coinsurance, if applicable. No charge for online visits when performed by a BCN selected vendor.

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 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: 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. No charge for Tier 1A contraceptives. 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: $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 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: 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. No charge for Tier 1A contraceptives. 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: $4.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered Exclusions: Quantity limits per fill may apply for 30-day retail, 90-day retail, and 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: 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. No charge for Tier 1A contraceptives. 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: 40.00% Coinsurance after deductible Covered: Covered Exclusions: Up to a 30-day supply per fill. Select specialty drugs require a 15-day supply for all fills. Benefit Explanation: Refer to drug list for quantity limits and other exclusions. BCN 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: 20.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Prior authorization required. 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: 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 Benefit Explanation: Emergency room visits will be covered at non-participating facilities for medical emergencies and accidental injuries only. Copayment waived if admitted inpatient into the hospital.
Urgent Care Facility	CoPay: $40.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Urgent Care visits will be covered at non-participating providers for medical emergencies and accidental injuries only.

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Prior authoriztion required. The penalty for not having prior authorization is denial of payment.
Pre and Postnatal Office Visit	CoPay: $30.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Prenatal visits are covered as preventive at no charge; in-network only. Postnatal visit is subject to the primary care visit copayment. 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: Out of network is paid up to the allowed amount. A child is defined as a member up to age 19.

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

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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