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
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: $2,000
Family: $4,000
Out of network
Individual: $4,000
Family: $8,000
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 and infertility services.
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
Individual: $15,000
Family: $30,000
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
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
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
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
You pay 50% after in-network deductible. Blue Cross-participating providers only.
Durable medical equipment
For example, a wheelchair, walker or oxygen tank. You pay 50% after in-network deductible. Blue Cross-participating suppliers only.
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. 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. 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
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'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
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 Blue Cross ID card and providing the procedure code. Your provider can also provide this information upon request.
