PPO plan

Blue Cross® Silver Extra with Dental and Vision, a Multi-State Plan - 70

2017 plan year

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

Overview

About this plan 

Looking for a complete package for the whole family? This PPO plan gives you medical, dental and vision coverage with one ID card. With low copays for office visits and generic drugs, it’s a great value, especially if you can get a subsidy.

Coverage level 

70 percent   73 percent     87 percent    94 percent

This is a Silver 70 plan. That means it covers about 70 percent of your health care costs. Depending on your income, you can qualify for different levels of subsidies. To find out which one you qualify for, you'll need to start the application and quoting process.


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: $3,500
Family: $7,000

Out of network

Individual: $7,000
Family: $14,000


Coinsurance  What is coinsurance?

In network

You pay 20% 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

You pay 40% for most services after deductible.

You pay 70% after deductible for bariatric, temporomandibular joint,  infertility, prosthetic and orthotic, and durable medical equipment services. 


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 $30.


Specialist 

You pay $65.


Urgent care center 

You pay $75.


Emergency room 

You pay $400 after in-network deductible.


Prescriptions 

Copays start at $15. See the prescription tab for more details.


Dental 

This plan covers dental care for all ages. See the dental tab for more details.


Vision 

This plan includes vision coverage. 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 

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

You pay 40% after deductible.

Screening colonoscopy 

Applies to the first routine or medically necessary colonoscopy of the calendar year.

In network

You pay $0.

Out of network

You pay 40% 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 40% after deductible.


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.

Specialist: You pay $65.

Out of network

You pay 40% after deductible.

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 $30.

Out of network

You pay 40% 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 $10.

Out of network

You pay 40% after deductible.


Laboratory and diagnostic services 

Lab tests 

In network

You pay 20% after deductible.

Out of network

You pay 40% after deductible.

Radiology services like X-rays, EKGs and ultrasounds 

In network

You pay 20% after deductible.

Out of network

You pay 40% after deductible.

Imaging services like MRIs 

Need prior authorization.

In network

You pay 20% after deductible.

Out of network

You pay 40% after deductible.

Allergy tests and shots 

In network

You pay 20% after deductible.

Out of network

You pay 40% after deductible.


Maternity and newborn care 

Hospital delivery and nursery care 

In network

You pay 20% after deductible.

Out of network

You pay 40% after deductible.

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

You pay 40% after deductible.

Postnatal visits 

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

In network

You pay $30.

Out of network

You pay 40% after deductible.


Emergency services 

Emergency room visit 

You pay $400 after in-network deductible. Copay waived if you 're admitted to the hospital.


Transportation by ambulance 

You pay 20% after in-network deductible.


Urgent care center visits 

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

In network

You pay $75.

Out of network

You pay 40% after deductible.


Hospitalization and other services 

Inpatient hospital care 

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

In network

You pay 20% after deductible.

Out of network

You pay 40% after deductible.

Surgery 

In network

You pay 20% after deductible.

Out of network

You pay 40% after deductible.

Home health care 

You pay 20% 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 20% after deductible.

Out of network

You pay 40% after deductible.

Chemotherapy 

In network

You pay 20% after deductible.

Out of network

You pay 40% after deductible.

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

PPO Blue Cross-participating facilities only.

In network

You pay 20% after deductible.

Out of network

You pay 40% after deductible.

Specified organ transplant, including heart, lung and liver 

You pay 20% after deductible. Blue Cross-participating facilities only.


Sleep studies 

Need prior authorization.

In network

You pay 20% after deductible.

Out of network

You pay 40% after deductible.

Bariatric surgery 

Covered once per lifetime.

In network

You pay 50% after deductible.

Out of network

You pay 70% after deductible.

Male voluntary sterilization 

In network

You pay 20% after deductible.

Out of network

You pay 40% 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 20% after deductible.

Out of network

You pay 40% 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 20% after deductible.

Out of network

You pay 40% after deductible.

Speech therapy 

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

In network

You pay 20% after deductible.

Out of network

You pay 40% after deductible.

Cardiac and pulmonary rehabilitation 

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

In network

You pay 20% after deductible.

Out of network

You pay 40% 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 20% after deductible.

Out of network

You pay 40% after deductible.

Speech therapy 

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

In network

You pay 20% after deductible.

Out of network

You pay 40% after deductible.

Applied Behavior Analysis for specified autism spectrum disorder 

Needs prior authorization.

In network

You pay 20% after deductible.

Out of network

You pay 40% after deductible.


Rehabilitative and habilitative devices 

Prosthetics and orthotics 

Blue Cross-participating providers only.

In network

You pay 50% after deductible.

Out of network

You pay 70% after deductible.

Durable medical equipment 

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

In network

You pay 50% after deductible.

Out of network

You pay 70% after deductible.

Diabetes supplies 

In network

You pay 20% after deductible.

Out of network

You pay 40% after deductible.

Outpatient diabetes self-management training 

In network

You pay 20% after deductible.

Out of network

You pay 40% after deductible.


Mental health/substance abuse 

Inpatient and residential mental health 

Blue Cross-participating facilities only.

In network

You pay 20% after deductible.

Out of network

You pay 40% after deductible.

Outpatient mental health services 

Copay applies to office visit only. This plan's deductible and coinsurance apply to additional services you get during the office visit.

In network

You pay $30.

Out of network

You pay 40% after deductible.

Inpatient and residential substance use 

You pay 20% after in-network deductible. Blue Cross-approved facilities only.

Outpatient substance use services 

You pay $30. Copay applies to office visit only. This plan's deductible and coinsurance apply to additional services you get during the office visit. Blue Cross-approved providers and facilities only.

Prescriptions

In-network coverage 

Using an in-network pharmacy will help keep your costs as low as possible. You can get 30- or 90-day prescriptions from retail or mail-order pharmacies. You can get 60-day prescriptions from mail-order pharmacies only.


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 which cost tier it falls under.


Tier 1 - Generic 

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

30-day supply: You pay $15.

60-day supply (mail order only): You pay $30.

90-day supply: You pay $45.


Tier 2 - Preferred brand 

Brand-name drugs not yet available as a generic.

30-day supply: You pay $50.

60-day supply (mail order only): You pay $100.

90-day supply: You pay $150.


Tier 3 - Nonpreferred brand 

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

30-day supply: You pay $100.

60-day supply (mail order only): You pay $200.

90-day supply: You pay $300.


Tier 4 - Preferred/nonpreferred specialty 

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

You pay 40%. Specialty drugs are limited to a 30-day supply. Some specialty drugs are limited to a 15-day supply.

Dental

In-network benefits 

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

Because this plan is a PPO, it shares the cost if you go to a dentist who doesn't take this plan. That's called getting your care out-of-network. But you'll save money if you stay in network.

For children (up to 19 years) 

Pediatric, or childrens' dental benefits, work differently than they do for adults. For example, there's no waiting period on services for children. And when you see a dentist in the preferred network, there's a limit on your share of the costs. That's called an out-of-pocket max. Children can get pediatric dental benefits until the end of the calendar year in which they turn 19. 

Out-of-pocket maximum for pediatric dental care 

In a year, you pay no more than:

  • $350 (one child)
  • $700 (two or more children)

Deductible for pediatric dental care  What's a deductible?

There is no deductible for in-network services. Out-of-network Class I services have no deductible. There is a deductible for out-of-network Class II and III services only. Class IV is not covered.

In network

You pay $0.

Out of network

One child: You pay $75.
Two children: You pay $150.
Three or more children: You pay $225.

Preventive services (Class I) 

Services like exams, cleaning and bitewing X-rays

In network

You pay $0.

Deductible: $0

Out of network

You pay 50%, up to your out-of-pocket max.

Deductible: $0

Restorative services (Class II) 

Services like fillings, root canals and other X-rays

In network

You pay 30%, up to your out-of-pocket max.

Deductible: $0

Out of network

You pay 50% after deductible, up to your out-of-pocket max.

Deductible:

  • $75 (one member)
  • $150 (two members)
  • $225 (three or more members)

Major restorative services (Class III) 

Services like crowns, bridges, dentures and major oral surgery

In network

You pay 50%, up to your out-of-pocket max.

Deductible: $0

.

Out of network

You pay 50% after deductible, up to your out-of-pocket max.

Deductible:

  • $75 (one member)
  • $150 (two members)
  • $225 (three or more members)

For adults (19 years or older) 

Anyone who is 19 or older when their plan begins is considered an adult. There's a limit on what your plan pays for dental benefits for adults in a year. It's called an annual benefit maximum. Once you've reached that limit, you pay for all your dental care.

There's also a waiting period for adults for Class II and Class III services. We've listed them below.

Annual benefit maximum for adult dental care  What is an annual benefit maximum?

Each year, the benefit max is $1,200 for each adult for in-network dental care. Up to $800 of this total may be used toward out-of-network care.

Deductible for adult dental care  What's a deductible?

There is no deductible for in-network services. Out-of-network Class I services have no deductible. There is a deductible for out-of-network Class II and III services only. Class IV is not covered.

In network

You pay $0.

Out of network

One member: You pay $75.
Two members: You pay $150.
Three or more members: You pay $225.

Preventive services (Class I) 

Services like exams, cleaning and bitewing X-rays.

In network

You pay $0.

Deductible: $0

Out of network

You pay 50% until you reach your benefit max, then 100%.

Deductible: $0

Restorative services (Class II) 

Services like fillings, root canals and other X-rays.

In network

You pay 30% until you reach your benefit max, then 100%.

Waiting period: 6 months

Deductible: $0

Out of network

You pay 50% after deductible until you reach your benefit max, then 100%.

Waiting period: 6 months

Deductible:

  • $75 (one member)
  • $150 (two members)
  • $225 (three or more members)

Major restorative services (Class III) 

Services like crowns, bridges, dentures and major oral surgery.

In network

You pay 50% until you reach your benefit max, then 100%.

Waiting period: 12 months

Deductible: $0

Out of network

You pay 50% after deductible until you reach your benefit max, then 100%.

Waiting period: 12 months

Deductible:

  • $75 (one member)
  • $150 (two members)
  • $225 (three or more members)

Vision

In-network benefits 

When you go to an eye doctor that accepts this plan, that's called getting your care in-network. Because this plan is a PPO, it shares the cost if you go to an eye doctor that doesn't take this plan. That's called getting your care out-of-network. But you'll save money if you stay in network.

For children (up to 19 years) 

This plan 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.

In network

You pay $0.

Out of network

You pay $0.

You are responsible for the difference between the Blue Cross-approved amount and the provider's charge.


For adults (19 years or older) 

Vision benefits work a little differently for adults. There's a limit on what your plan pays toward the cost of eyeglasses or contacts. It's called an annual allowance. Once you've reached that limit, you're responsible for paying all costs.

Eye exam 

Coverage is one exam by a provider each year.

In network

You pay $10.

Out network

You pay $10.

Standard lenses and frames, or contact lenses 

Each calendar year, this plan shares the costs for prescription eyeglasses or contact lenses, but not both.

In network

You pay $25 with a $130 annual allowance.

Out of network

You pay $25 with a $100 annual allowance.

You pay the difference between the Blue Cross-approved amount and the provider's charge, less the $25 copay.


More 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 $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®.


BlueCard® 

When members that are enrolled in this product are outside of the Blue Cross® PPO Silver Extra with Dental and Vision, a Multi-State Plan service area in Michigan, they will receive in-network benefits and will access care from providers in the BlueCard PPO network.

The member cost sharing when members are treated by out of area providers in the BlueCard PPO network is in-network cost share.

When members receive care outside the service area by providers that are not part of the BlueCard PPO network, member cost sharing is out-of-network cost share.


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.