SOM Retirees: PPO Medicare Supplemental

Medicare Supplemental coverage provides benefits that may not be covered under Medicare Part A or Part B
Works with Original Medicare
Preventive care services are 100% covered

In-network Individual Deductible

$400

In-network Family Deductible

$800

Retirees get access to our extensive PPO network as well as out-of-network doctors and hospitals
Coverage is included for emergency room care, prescription drug coverage, and behavioral health services including substance use disorders
Self-administered drugs provided in the hospital outpatient setting are 100% covered
Value-added services such as Blue365^®, Blue Cross Health & Well-Being^SM and the Engagement Center
Manage your account 24 hours a day, seven days a week with the BCBSM app

See what's covered and how much you'll pay.

In-network deductible

$400 per individual, $800 per family

In-network out-of-pocket maximum

$2,000 per individual, $4,000 per family

PCP office visit copay

Up to $20 per visit

$400

$800

$2,000

$4,000

10% for most services

Up to $20 copay

Up to $50 copay (waived if admitted as inpatient)

10% after deductible


	$400
	$800
	$2,000
	$4,000
	10% for most services
	Up to $20 copay
	Up to $50 copay (waived if admitted as inpatient)
	10% after deductible

State Health Plan PPO Medicare Supplemental