HMO plan

Blue Cross® Select HMO Bronze HSA

2017 plan year

Pairs with a health savings account
You can buy this plan if you live in any Michigan county except Schoolcraft.

Overview

About this plan 

With this plan, you have a low monthly premium. But you pay more for health care services before we start sharing the cost with you. You choose a primary care physician from our Select network.


Availability 

You can buy this plan if you live in one of 18 counties (Bay, Calhoun, Clinton, Eaton, Genesee, Ingham, Kalamazoo, Livingston, Macomb, Monroe, Oakland, Ottawa, Saginaw, Shiawassee, St. Clair, Van Buren, Washtenaw, Wayne).


Plan type 

Select HMO. You'll choose a primary care physician from the Select network. Your doctor refers you to specialists in the broader HMO network. Except for emergencies or accidental injuries, you aren't covered out-of-network.


Health Savings Account 

You can pair this plan with a health savings account, or HSA, which you can use to pay for medical expenses.


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: $5,950
Family: $11,900

Out of network

Not covered


Coinsurance  What is coinsurance?

In network

You pay 40% for most services after deductible.

You pay 50% after deductible for bariatric, temporomandibular joint, infertility, prosthetic and orthotic, and durable medical equipment services.

Out of network

Not covered


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: $6,350
Family: $12,700

Out of network

Not covered


Office visits 

Primary care 

You pay $30 after deductible.


Specialist 

You pay $50 after deductible.


Urgent care center 

You pay $40 after deductible.


Emergency room 

You pay $250 after deductible, then 40%.


Prescriptions 

Copays start at $4 after 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 in the Mercy Health System, that's called getting your care in-network.

Because this plan is an HMO plan, other care isn't covered except in an emergency or when you get a referral from your primary care physician and authorization from your plan.


Preventive care 

Medical exams, prescription drugs and immunizations 

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

Not covered

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

Not covered


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

Not covered


Office visits 

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

In network

Primary care: You pay $30 after deductible.

Specialist: You pay $50 after deductible.

Out of network

Not covered

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

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

In network

You pay $40 after deductible.

Out of network

Not covered

Acupuncture 

This plan doesn’t cover acupuncture.


Online visits 

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

In network

You pay $30 after deductible.

Out of network

Not covered


Laboratory and diagnostic services 

Lab tests 

In network

You pay 40% after deductible.

Out of network

Not covered

Radiology services like X-rays, EKGs and ultrasounds 

In network

You pay 40% after deductible.

Out of network

Not covered

Imaging services like MRIs 

Need prior authorization.

In network

You pay 40% after deductible.

Out of network

Not covered

Allergy tests and shots 

In network

You pay 40% after deductible.

Out of network

Not covered


Maternity and newborn care 

Hospital delivery and nursery care 

In network

You pay 40% after deductible.

Out of network

Not covered

Prenatal visits 

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

In network

You pay $0.

Out of network

Not covered

Postnatal visits 

This plan's deductible and coinsurance apply to any tests you get during the office visit.

In network

You pay $30 after deductible.

Out of network

Not covered


Emergency services 

Emergency room visit 

You pay $250 after deductible, then 40%. Copay waived if you 're admitted to the hospital.


Transportation by ambulance 

You pay 40% after deductible.


Urgent care center visits 

You pay $40 after deductible. Except for emergencies or accidental injuries, you aren't covered out-of-network.

This plan's deductible and coinsurance apply to radiology services you get during the office visit.


Hospitalization and other services 

Inpatient hospital care 

Semi-private room. Blue Care Network-participating facilities only.

In network

You pay 40% after deductible.

Out of network

Not covered

Surgery 

In network

You pay 40% after deductible.

Out of network

Not covered

Home health care 

Blue Care Network-participating facilities only.

In network

You pay 40% after deductible.

Out of network

Not covered

Hospice care 

Blue Care Network-participating facilities only.

In network

You pay $0 after deductible.

Out of network

Not covered

Skilled nursing facility 

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

In network

You pay 40% after deductible.

Out of network

Not covered

Chemotherapy 

In network

You pay 40% after deductible.

Out of network

Not covered

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

Blue Care Network-participating facilities only.

In network

You pay 40% after deductible.

Out of network

Not covered

Specified organ transplant, including heart, lung and liver 

Blue Care Network-participating facilities only.

In network

You pay 40% after deductible.

Out of network

Not covered

Sleep studies 

Need prior authorization.

In network

You pay 40% after deductible.

Out of network

Not covered

Bariatric surgery 

Covered once per lifetime.

In network

You pay 50% after deductible.

Out of network

Not covered

Male voluntary sterilization 

In network

You pay 40% after deductible.

Out of network

Not covered

Artificial insemination 

This plan doesn’t cover artificial insemination.


Rehabilitative services  What are rehabilitative services?

Outpatient physical and occupational therapy 

Physical and occupational therapy limited to a combined maximum of 30 visits per member each calendar year.

In network

You pay 40% after deductible.

Out of network

Not covered

Chiropractic spinal manipulation and osteopathic manipulative therapy 

Chiropractic and osteopathic manipulative therapy limited to a combined maximum of 30 visits per member each calendar year.

In network

You pay 40% after deductible.

Out of network

Not covered

Speech therapy 

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

In network

You pay 40% after deductible.

Out of network

Not covered

Cardiac and pulmonary rehabilitation 

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

In network

You pay 40% after deductible.

Out of network

Not covered


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 40% after deductible.

Out of network

Not covered

Speech therapy 

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

In network

You pay 40% after deductible.

Out of network

Not covered

Applied Behavior Analysis for specified autism spectrum disorder 

Needs prior authorization.

In network

You pay 40% after deductible.

Out of network

Not covered


Rehabilitative and habilitative devices 

Prosthetics and orthotics 

Blue Care Network-participating providers only.

In network

You pay 50% after deductible.

Out of network

Not covered

Durable medical equipment 

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

In network

You pay 50% after deductible.

Out of network

Not covered

Diabetes supplies 

In network

You pay 40% after deductible.

Out of network

Not covered

Outpatient diabetes self-management training 

In network

You pay 40% after deductible.

Out of network

Not covered


Mental health/substance abuse 

Inpatient and residential mental health 

Blue Care Network-participating facilities only.

In network

You pay 40% after deductible.

Out of network

Not covered

Outpatient mental health services 

Out of network

You pay 40% after deductible.

In network

Not covered

Inpatient and residential substance use 

Blue Care Network-approved facilities only.

Out of network

You pay 40% after deductible.

In network

Not covered

Outpatient substance use services 

Blue Care Network-approved providers and facilities only.

Out of network

You pay 40% after deductible.

In network

Not covered

Prescriptions

In-network coverage 

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


Out-of-network coverage 

This plan doesn't cover prescriptions you get at an out-of-network pharmacy.


Covered drugs 

What you pay for your medication depends on whether your plan covers the drug and which cost tier it falls under.


Tier 1a - Preferred generic 

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

30-day supply: You pay $4 after deductible.

60-day supply: You pay $8 after deductible.

90-day supply: You pay $12 after deductible.


Tier 1b - Nonpreferred generic 

Although these generic drugs have a higher copay, they’re less expensive than brand-name drugs.

30-day supply: You pay $20 after deductible.

60-day supply: You pay $40 after deductible.

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


Tier 2 - Preferred brand 

Brand-name drugs not yet available as a generic.

30-day supply: You pay 25% after deductible (at least $40 and no more than $100).

60-day supply: You pay 25% after deductible (at least $80 and no more than $200).

90-day supply: You pay 25% after deductible (at least $120 and no more than $300).


Tier 3 - Nonpreferred brand 

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

30-day supply: You pay 50% after deductible (at least $80 and no more than $100).

60-day supply: You pay 50% after deductible (at least $160 and no more than $200).

90-day supply: You pay 50% after deductible (at least $240 and no more than $300).


Tier 4 - Preferred specialty 

Generic and brand-name drugs used to treat complex health conditions. They usually need special handling and approval.

You pay 20%. Specialty drugs are limited to a 30-day supply. Some specialty drugs are limited to a 15-day supply.


Tier 5 - Nonpreferred specialty 

Because there are less expensive alternatives available for the drugs in this tier, you’ll pay more for them at the pharmacy.

You pay 25%. 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 BCBSM or BCN 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 $25 monthly gym memberships, plus discounts on yoga classes and workout gear.
  • 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®.


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 BCN ID card and providing the procedure code. Your provider can also provide this information upon request.