HMO plan

Blue Cross® Select
HMO Bronze

2018 plan year

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 20 counties (Bay, Calhoun, Clinton, Eaton, Genesee, Ingham, Kalamazoo, Kent, Livingston, Macomb, Monroe, Muskegon, Oakland, Ottawa, Saginaw, Shiawassee, St. Clair, Van Buren, Washtenaw, Wayne). Look for doctors and hospitals that take this plan.

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. What’s the difference between HMO and PPO plans?

Monthly premiums 

To give you an accurate price, we'll need some information. Find a plan to get a quote.

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: $7,350
Family: $14,700

Out of network

Not covered

Coinsurance  What is coinsurance?

In network

You pay $0.

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

Not covered

Out of network

Not covered

Office visits 

Primary care

You pay $30.

Specialist

You pay $0 after deductible.

Urgent care center

You pay $40.

Emergency room

You pay $0 after deductible.

 

Prescriptions 

You pay $0 after you meet your deductible.

Dental 

This plan doesn't include dental coverage. 

Vision 

This plan only includes vision coverage for children. 

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 see the primary care physician you chose from the plan's list, or get a referral to a doctor or hospital that takes this plan, that's called getting your care in network. Look for doctors and hospitals that take this plan.

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.

If you have an emergency or accidental injury outside of Michigan, your care is covered with in-network cost sharing. Any scheduled services you receive outside of Michigan are not covered.

Online visits have nationwide coverage with in-network cost-sharing.

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

Not covered

Out of network

Not covered

Screening colonoscopy

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

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 apply to diagnostic services you get during the office visit.

In network

Primary care: You pay $30.

Specialist: You pay $0 after deductible.

Out of network

Not covered

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

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

In network

You pay $40.

Out of network

Not covered

Online visits 

This plan includes online health care.

In network

You pay $30.

Out of network

Not covered

Laboratory and diagnostic services 

Lab tests

In network

You pay $0.

Out of network

Not covered

Radiology services like X-rays, EKGs and ultrasounds

In network

You pay $0 after deductible.

Out of network

Not covered

Imaging services like MRIs

Need prior authorization.

In network

You pay $0 after deductible.

Out of network

Not covered

Allergy tests and shots

In network

You pay $0 after deductible.

Out of network

Not covered

Maternity and newborn care 

Hospital delivery and nursery care

In network

You pay $0 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 $0 after deductible.

Out of network

Not covered

Emergency services 

Emergency room visit

You pay $0 after deductible. 

Transportation by ambulance

You pay $0 after deductible.

Urgent care center visits

You pay $40. 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. Needs prior authorization.

In network

You pay $0 after deductible.

Out of network

Not covered

Surgery

In network

You pay $0 after deductible.

Out of network

Not covered

Home health care

Blue Care Network-participating facilities only.

In network

You pay $0 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. Needs prior authorization.

In network

You pay $0 after deductible.

Out of network

Not covered

Chemotherapy

In network

You pay $0 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 $0 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 $0 after deductible.

Out of network

Not covered

Sleep studies

Need prior authorization.

In network

You pay $0 after deductible.

Out of network

Not covered

Bariatric surgery

Covered once per lifetime.

In network

You pay $0 after deductible.

Out of network

Not covered

Male voluntary sterilization

In network

You pay $0 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. Needs prior authorization.

In network

You pay $0 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. Needs prior authorization.

In network

You pay $0 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 $0 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 $0 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. Needs prior authorization.

In network

You pay $0 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 $0 after deductible.

Out of network

Not covered

Applied Behavior Analysis for specified autism spectrum disorder

Needs prior authorization.

In network

You pay $0 after deductible.

Out of network

Not covered

Rehabilitative and habilitative devices 

Prosthetics and orthotics

Blue Care Network-participating providers only.

In network

You pay $0 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 $0 after deductible.

Out of network

Not covered

Diabetes supplies

In network

You pay $0 after deductible.

Out of network

Not covered

Outpatient diabetes self-management training

In network

You pay $0 after deductible.

Out of network

Not covered

Mental health/substance use 

Inpatient and residential mental health

Blue Care Network-participating facilities only. Needs prior authorization.

In network

You pay $0 after deductible.

Out of network

Not covered

Outpatient mental health services

Includes Blue Cross online visits.

In network

You pay $30.

Out of network

Not covered

Inpatient and residential substance use

Blue Care Network-approved facilities only. Needs prior authorization.

In network

You pay $0 after deductible.

Out of network

Not covered

Outpatient substance use services

Blue Care Network-approved providers and facilities only. Includes Blue Cross online visits.

In network

You pay $30.

Out of network

Not covered

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. Find a pharmacy.

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. Certain drugs may need prior authorization. Look on this list to find a drug (PDF).

Tier 1a - Preferred generic

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

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

90-day supply: You pay $0 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 $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.

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.

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

 

Tier 4 - Preferred specialty

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

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

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

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. See our Blue Dental® plans.

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.

Features

Discounts 

Through Blue365®, Blue Cross members can save on a variety of products and services, including:

  • Weight management programs, organic groceries and fresh produce
  • Yoga classes, workout gear and gym memberships
  • Discounted admission to Michigan attractions

Online doctor visits 

This plan includes online health care.

Health & Wellness 

As part of your plan, you can:


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.