Overview
About this plan
This off-marketplace plan is for people who live in Southeast Michigan who aren't eligible for a health insurance subsidy. You can only get care from certain doctors and hospitals. But you’ll have a low monthly payment. And you pay nothing for preventive care.
Availability
You can buy this plan if you live in Macomb, Oakland or Wayne county. Find doctors and hospitals that take this plan.
Plan type
Metro Detroit HMO. You'll choose a primary care physician to guide you through the health care system. 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
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: $2,400
Family: $4,800
Out of network
Not covered
Coinsurance
In network
You pay 30% after deductible.
You pay 50% after deductible for bariatric, temporomandibular joint, infertility, prosthetic and orthotic services, and for durable medical equipment services.
Out of network
Not covered
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: $7,500
Family: $15,000
Out of network
Not covered
Office visits
Primary care
You pay $30.
Specialist
You pay $50 after deductible.
Urgent care center
You pay $40.
Emergency room
You pay $250 after deductible, then 30%.
Prescriptions
Copays start at $4 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
You pay $0.
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 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 $50 after deductible.
Out of network
Not covered
Retail health clinic visits
This plan's deductible and coinsurance apply to any diagnostic and laboratory 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 30% after deductible.
Out of network
Not covered
Imaging services like MRIs
Need prior authorization.
In network
You pay 30% after deductible.
Out of network
Not covered
Allergy tests and shots
In network
You pay 30% after deductible.
Out of network
Not covered
Maternity and newborn care
Hospital delivery and nursery care
In network
You pay 30% 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 30%. Copay waived if you're admitted to the hospital.
Transportation by ambulance
You pay 30% 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 30% after deductible.
Out of network
Not covered
Surgery
In network
You pay 30% after deductible.
Out of network
Not covered
Home health care
Blue Care Network-participating agencies only.
In network
You pay 30% 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 30% after deductible.
Out of network
Not covered
Chemotherapy
In network
You pay 30% 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 30% 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 30% after deductible.
Out of network
Not covered
Sleep studies
Need prior authorization.
In network
You pay 30% 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 30% after deductible.
Out of network
Not covered
Artificial insemination
This plan doesn’t cover artificial insemination.
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 30% 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 30% 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 30% 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 30% after deductible.
Out of network
Not covered
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 30% 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 30% after deductible.
Out of network
Not covered
Applied Behavior Analysis for specified autism spectrum disorder
Needs prior authorization.
In network
You pay 30% 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 30% after deductible.
Out of network
Not covered
Outpatient diabetes self-management training
In network
You pay 30% 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 30% after deductible.
Out of network
Not covered
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.
Out of network
Not covered
Inpatient and residential substance use
Blue Care Network-approved facilities only. Needs prior authorization.
In network
You pay 30% after deductible.
Out of network
Not covered
Outpatient substance use services
Blue Care Network-approved providers and facilities only. 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
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. Quantity limits may apply. Select opioids are limited to a five-day supply for the first order. Opioid refills are limited to a 30-day supply.
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 $4 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.
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).
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).
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'll need to use AllianceRx Walgreens Prime to fill prescriptions within this tier.
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'll need to use AllianceRx Walgreens Prime to fill prescriptions within this tier.
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:
- Call our 24-Hour Nurse Line to get help and advice from a registered nurse
- Use the many tools and resources available online through Blue Cross Health & Wellness, 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.
