PPO plan

Blue Cross® Premier PPO Silver Off Marketplace

2018 plan year

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

Overview

About this plan 

This plan, which isn't offered on the Health Insurance Marketplace, offers a balance between coverage and out-of-pocket costs for those who aren't eligible for a subsidy.

Availability

You can buy this plan if you live in any Michigan county. Find doctors and hospitals that take this plan.

Plan type

PPO. You choose the doctors you want to see. No referrals needed. 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: $1,800
Family: $3,600

Out of network

Individual: $3,600
Family: $7,200

Coinsurance  What is coinsurance?

In network

You pay 20% of the cost 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% of the cost 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: $7,000
Family: $14,000

Out of network

Individual: $14,000
Family: $28,000

Office visits 

Primary care

You pay $30 after deductible.

Specialist

You pay $50 after deductible.

Urgent care center

You pay $75 after deductible, then 20%.

Emergency room

You pay $250 after in-network deductible, then 20%. Copay waived if you're admitted to the hospital.

Prescriptions 

You pay $15 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 go to a doctor or hospital that accepts this plan, that's called getting your care in network. Look for doctors and hospitals that take this plan.

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. 

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 have out-of-network cost sharing as long as you see a participating out-of-state provider. To find a participating out-of-state provider, call the number on the back of your Blue Cross ID card.

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

You pay $0.

Out of network

You pay 40% after deductible.

Screening colonoscopy

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 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 applies to 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

You pay 40% after deductible.

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

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

In network

You pay $30 after deductible.

Out of network

You pay 40% after deductible.

Online visits 

This plan includes online health care.

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 applies to tests and ultrasounds you get during the office visit.

In network

You pay $0.

Out of network

You pay 40% after deductible.

Postnatal visits

In network

You pay $30 after deductible.

Out of network

You pay 40% after deductible.

Emergency services 

Emergency room visit

You pay $250 after in-network deductible, then 20%. Copay waived if you're admitted to the hospital.

Transportation by ambulance

You pay 20% after in-network deductible.

Urgent care center visits

In network

You pay $75 after deductible, then 20%.

Out of network

You pay $75 after deductible, then 40%. Emergency services and accidental injuries have in-network cost sharing.

Hospitalization and other services 

Inpatient hospital care

Semi-private room. Blue Cross-participating facilities only. Needs prior authorization.

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. Needs prior authorization.

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. Needs prior authorization.

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. Needs prior authorization.

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. Needs prior authorization.

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 use 

Inpatient and residential mental health

Blue Cross-participating facilities only. Needs prior authorization.

In network

You pay 20% after deductible.

Out of network

You pay $40 after deductible.

Outpatient mental health services

Includes Blue Cross online visits. 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 after deductible.

Out of network

You pay 40% after deductible.

Inpatient and residential substance use

You pay 20% after deductible. Blue Cross-approved facilities only. Needs prior authorization.

Outpatient substance use services

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

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. Find a pharmacy.

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

Tier 1 - Generic

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

30-day supply: You pay $15 after deductible.

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

90-day supply: You pay $45 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 (mail order only): 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% of the cost after deductible (at least $80 and no more than $100).

60-day supply (mail order only): You pay 50% of the cost after deductible (at least $160 and no more than $200).

90-day supply: You pay 50% of the cost 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 40% 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 45% 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 Blue Cross ID card and providing the procedure code. Your provider can also provide this information upon request.