Overview
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.
Any coupon, rebate or other credits received directly or indirectly from the drug manufacturer may not be applied to a consumer's deductible, cost-sharing or out-of-pocket maximum.
In network
Individual: $600
Family: $1,200
Out of network
Not Covered.
Coinsurance
In network
You pay 10% after deductible.
You pay 50% after deductible for bariatric, temporomandibular joint, infertility, prosthetic and orthotic, and 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.
Any coupon, rebate or other credits received directly or indirectly from the drug manufacturer may not be applied to a consumer's deductible, cost-sharing or out-of-pocket maximum.
In network
Individual: $700Family: $1,400
Out of network
Not Covered.
Office Visits
Primary Care
Specialist
You pay $30 after deductible.
Urgent care center
Emergency Room
You pay $100 after deductible, then 10%.
Prescriptions
Copays start at $4 after deductible. See the prescriptions tab for more details.
Dental
Vision
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 and prescription drugs 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, pre-natal visits, gynecologic exams, pap smear screening, mammogram screening, certain female contraceptives, female voluntary sterilization, screening colonoscopy, well baby and well-child visits and pediatric vision.
Out of network
Not Covered
Office visits
This plan's deductible and coinsurance apply to allergy testing and diagnostic services you get during the office visit. Some diagnostic services require prior authorization.
In network
Primary care: You pay $10 including virtual, retail health and post-natal. Specialist: You pay $30 after deductible.
Out of network
Not Covered.
Online visits
In network
You pay $0 for Blue Cross medical online visits.
You pay $10 for Blue Cross behavioral health online visits.
Out of network
Not Covered
Emergency Services
Emergency room visit
You pay $100 after deductible, then 10%. Copay waived if you're admitted to the hospital.
Transportation by ambulance
You pay 10% after deductible.
Urgent care center visits
Except for emergencies or accidental injuries, you aren't covered out-of-network. Copay applies to urgent care visit only. This plan's deductible and coinsurance apply to radiology services you get during the urgent care visit.
Out of network
Not Covered.
Hospitalization and other services
Inpatient hospital care, maternity, delivery & newborn care, surgery, chemotherapy
Blue Care Network-participating facilities only. Certain services require prior authorization.
In network
You pay 10% after deductible.
Out of network
Not Covered
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 10% 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 10% 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 10% 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 10% 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 10% after deductible.
Out of network
Not Covered
Applied Behavior Analysis for specified autism spectrum disorder
Needs prior authorization.
In network
You pay 10% 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 10% after deductible.
Out of network
Not Covered
Outpatient mental health services
Copay applies to office visit only. Additional services are subject to the plan's deductible and coinsurance. Blue Care Network-approved providers and facilities only. Includes Blue Cross behavioral health online visits.
Out of network
Not Covered.
Residential substance use disorder treatment
Blue Care Network-approved facilities only. Needs prior authorization.
In network
You pay 10% after deductible.
Out of network
Not Covered.
Outpatient substance use disorder treatment
Blue Care Network-approved providers and facilities only. Includes Blue Cross behavioral health online visits.
Out of network
Not Covered.
Prescriptions
In-network benefits
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 per fill may apply for 30-day retail, 90-day retail and 90-day mail order. Opioid-containing medications are limited to no more than a 30-day supply per fill and first fills of select opioid containing medications will be limited to a 5-day supply. Refer to drug list for quantity limits and other exclusions.
Any coupon, rebate or other credits received directly or indirectly from the drug manufacturer may not be applied to a consumer's deductible, cost sharing or out-of-pocket maximum.
Find a pharmacy.
Out-of-network benefits
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 1 - Generic
Tier 1a - Preferred Generic
30-day supply: You pay $4 after deductible.
90-day supply: You pay $12 after deductible.
Commonly prescribed, generic versions of brand-name medications available for the lowest copay.
Tier 1b - Nonpreferred Generic
30-day supply: You pay $20 after deductible.
90-day supply: You pay $60 after deductible
Although these generic drugs have a higher copay, they’re less expensive than brand-name drugs.
Tier 2 - Preferred Brand
30-day supply: You pay up to $100 after deductible.
90-day supply: You pay up to $300 after deductible.Brand-name drugs not yet available as a generic.
Tier 3 - Nonpreferred Brand
30-day supply: You pay up to $150 after deductible.
90-day supply: You pay up to $450 after deductible.
Brand-name drugs that have generic or preferred brand alternatives.
Tier 4 - Preferred Specialty
You pay 40% after deductible.
Specialty drugs are limited to a 30-day supply. Some specialty drugs are limited to a 15-day supply.
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.
Tier 5 - Nonpreferred Specialty
You pay 45% after deductible.Specialty drugs are limited to a 30-day supply. Some specialty drugs are limited to a 15-day supply.
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.
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 and wellness
As part of your plan, you can:
- Call our 24-Hour Nurse Line and speak to a registered nurse.
- View our weekly Virtual Well-BeingSM webinars. Topics include mindfulness, finances, emotional health and more.
- Use our online well-being tools and resources through Blue Cross Health & Well-Being powered by WebMD®.
- Take part in our Tobacco Coaching program®.
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