PPO plan

Blue Cross® Premier PPO Bronze Saver

2017 plan year

You can buy this plan if you live in any Michigan county.

Overview

About this plan 

This is our lowest cost PPO plan for people over 30. You'll pay less each month, but you'll have a higher deductible. You won't pay anything for preventive care.


Availability 

You can buy this plan if you live in any Michigan county.


Plan type 

PPO. You choose the doctors you want to see. No referrals needed. 


Monthly premiums 

To give you an accurate price, we'll need some information. Use the link below to start the quoting process.


Deductible  What's a deductible?

If you have a family plan, and one member meets the individual deductible, Blue Cross will start paying covered benefits for that member only. The remainder of the family deductible has to be met by the remaining family members before Blue Cross will start paying covered benefits for the rest of the members on the plan.

In network

Individual: $7,150
Family: $14,300

Out of network

Individual: $14,300
Family: $28,600


Coinsurance  What is coinsurance?

In network

You pay $0.

Out of network

You pay $0.


Out-of-pocket maximum  What is an out-of-pocket maximum?

If you have a family plan, and one member meets the individual out-of-pocket maximum, Blue Cross will start paying 100% of the approved amount for covered benefits for that member only. The remainder of the family out-of-pocket maximum has to be met by the remaining family members before Blue Cross will start paying 100% of the approved amount for covered benefits for the rest of the members on the plan.

In network

Individual: $7,150
Family: $14,300

Out of network

Individual: $14,300
Family: $28,600


Office visits 

Primary care 

You pay $0 after deductible.


Specialist 

You pay $0 after deductible.


Urgent care center 

You pay $0 after deductible.


Emergency room 

You pay $0 after deductible.


Prescriptions 

Copays start at $0 after you meet your deductible. See the prescription tab for more details.


Dental 

This plan doesn't include dental coverage. See the dental tab for more details.


Vision 

This plan only includes vision coverage for children. See the vision tab for more details.


Related documents 

For this plan's most-used benefits, see the Summary of Benefits (PDF).

For even more details about this plan, see the Certificate of Coverage (PDF). Certificates are legal documents that describe the benefits of a health insurance plan. Your plan might have different benefits and limitations than those listed in this document.

Medical

In-network benefits 

When you go to a doctor or hospital that accepts this plan, that's called getting your care in-network. 

Because this plan is a PPO, you're covered when you go to a doctor or hospital that doesn't take this plan, but you'll pay more. That's called getting your care out-of-network. 


Preventive care 

Exams, prescriptions, tests and shots you get when you're well to prevent illness and injury 

Preventive medical care includes but is not limited to certain prescription drugs, immunizations, health maintenance exams, certain laboratory services, gynecologic exams, pap smear screening, mammogram screening, certain female contraceptives and female voluntary sterilization.

In network

You pay $0.

Out of network

You pay $0 after deductible.

Screening colonoscopy 

Copay applies to the first routine colonoscopy of the calendar year that's billed as preventive.

In network

You pay $0.

Out of network

You pay $0 after deductible.


Well-baby and well-child visits 

Children can get pediatric benefits until the end of the calendar year in which they turn 19.

In network

You pay $0.

Out of network

You pay $0 after deductible.


Office visits 

This plan's deductible applies to diagnostic and laboratory services you get during the office visit.

In network

Primary care: You pay $0 after deductible.

Specialist: You pay $0 after deductible.

Out of network

Primary care: You pay $0 after deductible.

Specialist: You pay $0 after deductible.

Retail health center visits  What's a retail health center?

For example, a clinic at a major pharmacy or retail store where you can get basic health care services on a walk-in basis. This plan's deductible applies to any diagnostic and laboratory services you get during the office visit.

In network

You pay $0 after deductible.

Out of network

You pay $0 after deductible.

Acupuncture 

This plan doesn’t cover acupuncture.


Online visits 

This plan includes 24/7 online health care through American Well®.

In network

You pay $0 after deductible.

Out of network

You pay $0 after deductible.


Laboratory and diagnostic services 

Lab tests 

In network

You pay $0 after deductible.

Out of network

You pay $0 after deductible.

Radiology services like X-rays, EKGs and ultrasounds 

In network

You pay $0 after deductible.

Out of network

You pay $0 after deductible.

Imaging services like MRIs 

Need prior authorization.

In network

You pay $0 after deductible.

Out of network

You pay $0 after deductible.

Allergy tests and shots 

In network

You pay $0 after deductible.

Out of network

You pay $0 after deductible.


Maternity and newborn care 

Hospital delivery and nursery care 

In network

You pay $0 after deductible.

Out of network

You pay $0 after deductible.

Prenatal visits 

This plan's deductible applies to tests and ultrasounds you get during the office visit.

In network

You pay $0.

Out of network

You pay $0 after deductible.

Postnatal visits 

In network

You pay $0 after deductible.

Out of network

You pay $0 after deductible.


Emergency services 

Emergency room visit 

You pay $0 after in-network deductible.


Transportation by ambulance 

You pay $0 after in-network deductible.


Urgent care center visits 

Emergency services and accidental injuries have in-network cost-sharing.

In network

You pay $0 after deductible.

Out of network

You pay $0 after deductible.


Hospitalization and other services 

Inpatient hospital care 

Semi-private room. Blue Cross-participating facilities only.

In network

You pay $0 after deductible.

Out of network

You pay $0 after deductible.

Surgery 

In network

You pay $0 after deductible.

Out of network

You pay $0 after deductible.

Home health care 

You pay $0 after deductible. Blue Cross-participating agencies only.

Hospice care 

You pay $0 after deductible. Blue Cross-participating facilities only.

Skilled nursing facility 

Limited to a maximum of 45 days per member each calendar year. Blue Cross-participating facilities only.

In network

You pay $0 after deductible.

Out of network

You pay $0 after deductible.

Chemotherapy 

In network

You pay $0 after deductible.

Out of network

You pay $0 after deductible.

Organ transplants, including bone marrow, kidney, cornea and skin 

PPO Blue Cross-participating facilities only.

In network

You pay $0 after deductible.

Out of network

You pay $0 after deductible.

Specified organ transplant, including heart, lung and liver 

You pay $0 after deductible. Blue Cross-participating facilities only.

Sleep studies 

Need prior authorization.

In network

You pay $0 after deductible.

Out of network

You pay $0 after deductible.

Bariatric surgery 

Covered once per lifetime.

In network

You pay $0 after deductible.

Out of network

You pay $0 after deductible.

Male voluntary sterilization 

In network

You pay $0 after deductible.

Out of network

You pay $0 after deductible.

Artificial insemination 

This plan doesn’t cover artificial insemination.


Rehabilitative services  What are rehabilitative services?

Outpatient physical and occupational therapy 

Physical, occupational, chiropractic and osteopathic manipulative therapy limited to a combined maximum of 30 visits per member per calendar year.

In network

You pay $0 after deductible.

Out of network

You pay $0 after deductible.

Chiropractic spinal manipulation and osteopathic manipulative therapy 

Physical, occupational, chiropractic and osteopathic manipulative therapy limited to a combined maximum of 30 visits per member per calendar year.

In network

You pay $0 after deductible.

Out of network

You pay $0 after deductible.

Speech therapy 

Limited to a maximum of 30 visits per member each calendar year.

In network

You pay $0 after deductible.

Out of network

You pay $0 after deductible.

Cardiac and pulmonary rehabilitation 

Limited to a combined maximum of 30 visits per member each calendar year.

In network

You pay $0 after deductible.

Out of network

You pay $0 after deductible.


Habilitative services  What are habilitative services?

Outpatient physical and occupational therapy 

Limited to a combined maximum of 30 visits per member each calendar year.

In network

You pay $0 after deductible.

Out of network

You pay $0 after deductible.

Speech therapy 

Limited to a maximum of 30 visits per member each calendar year.

In network

You pay $0 after deductible.

Out of network

You pay $0 after deductible.

Applied Behavior Analysis for specified autism spectrum disorder 

Needs prior authorization.

In network

You pay $0 after deductible.

Out of network

You pay $0 after deductible.


Rehabilitative and habilitative devices 

Prosthetics and orthotics 

Blue Cross-participating providers only.

In network

You pay $0 after deductible.

Out of network

You pay $0 after deductible.

Durable medical equipment 

For example, a wheelchair, walker or oxygen tank. Blue Cross-participating suppliers only.

In network

You pay $0 after deductible.

Out of network

You pay $0 after deductible.

Diabetes supplies 

In network

You pay $0 after deductible.

Out of network

You pay $0 after deductible.

Outpatient diabetes self-management training 

In network

You pay $0 after deductible.

Out of network

You pay $0 after deductible.


Mental health/substance abuse 

Inpatient and residential mental health 

Blue Cross-participating facilities only.

In network

You pay $0 after deductible.

Out of network

You pay $0 after deductible.

Outpatient mental health services 

Out of network

You pay $0 after deductible.

In network

You pay $0 after deductible.

Inpatient and residential substance use 

You pay $0 after deductible. Blue Cross-approved facilities only.

Outpatient substance use services 

You pay $0 after deductible. Blue Cross-approved providers and facilities only.

Prescriptions

In-network coverage 

Using an in-network pharmacy will help you keep your costs as low as possible.


Out-of-network coverage 

When you use an out-of-network pharmacy, you pay the full cost of the prescription up front. After you meet your deductible and pay the copay, we'll reimburse 80 percent of the Blue Cross-approved amount for that drug. You pay the difference between the Blue Cross-approved amount and what the pharmacy charges.

Out-of-network drugs are limited to a 30-day supply. Mail order is not available.


Covered drugs 

What you pay for your medication depends on whether your plan covers the drug and its classification within the tier structure of prescription drugs. Purchasing in network will help you to keep your costs as low as possible.


Tier 1 - Generic 

Commonly prescribed, generic versions of brand-name medications available for the lowest copay.

30-day supply: You pay $0 after deductible.

60-day supply: You pay $0 after deductible.

90-day supply: You pay $0 after deductible.


Tier 2 - Preferred brand 

Brand-name drugs not yet available as a generic.

30-day supply: You pay $0 after deductible.

60-day supply: You pay $0 after deductible.

90-day supply: You pay $0 after deductible.


Tier 3 - Nonpreferred brand 

Brand-name drugs that have generic or preferred brand alternatives.

30-day supply: You pay $0 after deductible.

60-day supply: You pay $0 after deductible.

90-day supply: You pay $0 after deductible.


Tier 4 - Preferred specialty 

You pay $0 after deductible. Specialty drugs are limited to a 30-day supply. Some specialty drugs are limited to a 15-day supply.

Tier 5 - Nonpreferred specialty 

You pay $0 after deductible. Specialty drugs are limited to a 30-day supply. Some specialty drugs are limited to a 15-day supply.

Dental

Not included 

This plan doesn’t include dental coverage. We offer separate dental plans that cover adults and children and help pay for exams, cleanings, fillings and more.


Plans that include dental 

Want to cover your whole family from head to toe with one plan? You might be interested in:

Vision

For children 

You pay $0. This includes one eye exam each calendar year, standard lenses and frames or contact lenses.

Children can get pediatric benefits until the end of the calendar year in which they turn 19.


For adults 

This plan doesn’t include adult vision coverage. We offer a separate vision plan that helps pay for eye exams, glasses and more. We also offer dental plans that include vision coverage.


Plans that include vision 

Want to cover your whole family from head to toe with one plan? You might be interested in:

Features

Discounts 

Show your Blue Cross ID card and save on food, nutrition, fitness and travel.

  • Food and nutrition: Save on weight management services, organic groceries and fresh produce.
  • Fitness: Get discounts on yoga classes and workout gear, and access $25 monthly gym memberships.
  • Travel and recreation: Find a budget-friendly getaway or save on local adventures.

Online doctor visits 

This plan includes 24/7 online health care through American Well®.


BlueCard® 

Get in-network benefits when you see doctors outside of Michigan with BlueCard.


Health & Wellness 

Get access to a 24-hour nurse line, along with tools for living healthier and staying well on this site powered by WebMD®.




Notes

Depending on the health care services you need, your provider might have to get approval before providing that service. Use our website to find more information and a list of services that need approval.

Estimated pricing information for various procedures by in-network providers can be obtained by calling the Customer Service number listed on the back of your BCBSM ID card and providing the procedure code. Your provider can also provide this information upon request.