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Flexible Medical Benefits for Individuals
To stay healthy, you want to make sure you have access to the best health care possible. Flexible Blue II offers a wide range of medical benefits including preventive care to provide the protection you and your family need, when you need it.
Plan 1500 Benefits-at-a-Glance
Download Plan 1500 Benefits (90K PDF)| In-network | Out-of-network | |
| NOTE: All benefits, except preventive services, are subject to a 180-day waiting period for pre-existing conditions. | ||
| Benefit Highlights | ||
|---|---|---|
| Annual deductible | $1,500 per individual contract per calendar year. $3,000 per family contract (two or more members) per calendar year. Medical and drug expenses are combined to meet the integrated deductible. One or more family members may satisfy the family integrated deductible. The entire integrated deductible must be met before covered services are paid. |
$3,000 per individual contract per calendar year. $6,000 per family contract (two or more members) per calendar year. Medical and drug expenses are combined to meet the integrated deductible. One or more family members may satisfy the family integrated deductible. The entire integrated deductible must be met before covered services are paid. |
| Copays | 20% of the BCBSM-approved amount | 40% of the BCBSM-approved amount |
| Annual copay dollar maximum | $2,500 per individual contract. |
$5,000 per individual contract. $10,000 per family contract (two or more members). One or more family members may satisfy the family annual copay dollar maximum. Prescription drug copays and flat-dollar copays contribute to the annual copay dollar maximum. |
| Annual out-of-pocket maximum: The annual out-of-pocket maximum limits the amount members are responsible for paying each calendar year. Once the annual out-of-pocket maximum is met, most services are payable at 100% of the BCBSM-approved amount. | $4,000 per individual contract. $8,000 per family contract (two or more members). |
$8,000 per individual contract. $16,000 per family contract (two or more members). |
| Lifetime maximum (per member) | $5 million | |
| Fourth-quarter deductible carry-over |
Not applicable | |
| Preventive Services | ||
| Preventive medical care: Includes health maintenance exam, routine laboratory and radiology, fecal occult blood screening, flexible sigmoidoscopy, gynecological exam, childhood immunizations (through age 15), Pap smear screening, prostate specific antigen screening, well-baby and well-child exams (6 visits per year through age 1; 2 visits per year, ages 2 through 3; 1 visit per year, ages 4 through 15). | Covered — 100% with no deductible, up to a combined maximum of $500 per member, per calendar year. 90-day benefit waiting period applies. | Not covered |
| Mammography screening | Covered — 100% with no deductible. 90-day benefit waiting period applies | |
| Preventive dental | Not covered | |
| Preventive vision (VSP network provider only) | Not covered | |
| Physician Office Services | ||
| Office visits | Covered — 80% after deductible; 2 visits, per member, per calendar year | Not covered |
| Outpatient presurgical second opinion consultations | Covered — 100% after deductible | Not covered |
| Office consultations | Not covered | |
| Emergency and Urgent Care Services | ||
| Medical emergencies and accidental injuries | Covered — 80% after in-network deductible for all services other than physician services. You pay $150 for physician services (waived if admitted). | |
| Ambulance service: medically necessary, emergency ground transport and air ambulance | Covered — 80% after in-network deductible | |
| Urgent care | Covered — 80% after in-network deductible for all services other than physician services. You pay $50 for physician services. | |
| Diagnostic and Radiation Services | ||
| Ultrasound | Covered — 80% after deductible | Covered — 60% after deductible |
| Laboratory tests and pathology | Covered — 80% after deductible | Covered — 60% after deductible |
| EKGs | Covered — 80% after deductible | Covered — 60% after deductible |
| Diagnostic radiology and X-rays | Covered — 80% after deductible | Covered — 60% after deductible |
| Colonoscopies (diagnostic) | Covered — 80% after deductible | Covered — 60% after deductible |
| CT Scans and MRIs (BCBSM-participating facilities only) | Covered — 80% after deductible | Covered — 60% after deductible |
| Radiation therapy | Covered — 80% after deductible | Covered — 60% after deductible |
| Maternity Services | ||
| Delivery and newborn exam | Not covered (optional rider available) | |
| Pre and postnatal exams (office visits) |
Not covered (optional rider available) | |
| Inpatient Hospital Care | ||
| Semi private room: 120 days with 60-day renewal (BCBSM-approved facilities only) | Covered — 80% after deductible | Covered — 60% after deductible |
| Inpatient consultations | Covered — 80% after deductible | Covered — 60% after deductible |
| Complications of pregnancy | Covered — 80% after deductible | Covered — 60% after deductible |
| Surgical Care — Hospital or Outpatient | ||
| Inpatient surgical care | Covered — 80% after deductible | Covered — 60% after deductible |
| Outpatient surgical care | Covered — 80% after deductible | Covered — 60% after deductible |
| Physician surgical services | Covered — 80% after deductible | Covered — 60% after deductible |
| Gender reassignment surgery and services |
Not covered | |
| Bariatric surgery and services | Not covered | |
| Alternatives to Hospitalization | ||
| Home health care: up to the annual maximum (BCBSM-participating providers only) | Covered — 80% after in-network deductible | |
| Hospice care: up to the annual dollar maximum (BCBSM-participating programs only) | Covered — 100% after in-network deductible | |
| Outpatient Services | ||
| Outpatient physical, occupational and speech therapy | Not covered | |
| Chemotherapy (IV and oral) | Covered — 80% after deductible | Covered — 60% after deductible |
| Home infusion therapy (BCBSM-participating providers only) | Covered — 80% after in-network deductible | |
| Voluntary sterilization | Covered — 80% after deductible | Covered — 60% after deductible |
| Prosthetics: mandated only (BCBSM-participating providers only) |
Covered — 80% after in-network deductible | |
| Other Medical Benefits | ||
| Insulin, disposable needles and syringes dispensed with insulin, diabetic testing supplies | Covered — 80% after deductible | Covered — 60% after deductible |
| Outpatient diabetes management program |
Covered — 80% after deductible | Covered — 60% after deductible |
| Contraceptives: physician-administered, prescription drugs only, devices and contraceptive injectables (implants are not covered) |
Covered — 80% after deductible | Covered — 60% after deductible |
| Organ Transplantation | ||
| Bone marrow transplants | Covered — 80% after deductible | Covered — 60% after deductible |
| Kidney, cornea and skin transplants |
Covered — 80% after deductible | Covered — 60% after deductible |
| Specified organ transplant: $1 million lifetime maximum per transplant type, included in the $5 million lifetime maximum (BCBSM-designated facilities only) |
Covered — 100% after in-network deductible | |
| Mental Health and Substance Abuse Treatment | ||
| Inpatient mental health (BCBSM-approved facilities only) | Covered — 80% after deductible, 30 days with 60-day renewal | Covered — 60% after deductible, 30 days with 60-day renewal |
| Outpatient mental health | Not covered | |
| Substance abuse: inpatient (residential) and outpatient, up to state-mandated benefit (BCBSM-approved facilities only) | Covered — 80% after deductible | Covered — 60% after deductible |
Return to top| Network Pharmacy | Non-network Pharmacy | |
| Prescription Drugs | ||
|---|---|---|
| Prescription drug benefits are subject to a 180-day waiting period for pre-existing conditions. Covered after the in-network integrated deductible. Medical and drug expenses combine to meet the integrated deductible. Prescription drug copays contribute to the annual copay dollar maximum. | ||
| Annual maximum | Covered — $2,500 per member, per calendar year after in-network integrated deductible, retail and mail order combined. Members who exhaust the annual maximum may purchase prescription drugs at the BCBSM-negotiated rate for the remainder of the calendar year. These expenses will not contribute to the in-network integrated deductible or annual copay dollar maximum. | |
| Retail (1-34 day supply) | Covered — 50% of the approved amount with $10 minimum and $100 maximum copay, after in-network integrated deductible | Members must pay the pharmacist the full cost of the drug. After the in-network integrated deductible, BCBSM will reimburse 80% of the BCBSM-approved amount for covered drugs, less the copay and the difference between the non-network pharmacy's charge and the BCBSM-approved amount for the drug. |
| 90-day retail (84-90 day supply) | Covered — 50% of the approved amount with a minimum of $20 and a maximum of $200 per prescription, after in-network integrated deductible | Not covered |
| Mail order (35-90 day supply) | Covered — 50% of the approved amount with a minimum of $20 and a maximum of $200 per prescription, after in-network integrated deductible | Not covered |
Note: Flexible Blue II 1500 is not available to group conversion.
Note: The 90-day benefit waiting period for preventive services will be waived with proof of creditable coverage.
Note: Out-of-network and nonparticipating providers may bill members for the difference between BCBSM's approved amount and the provider's charge, even when referred.
Note: Maternity coverage and Flexible Blue Dental PlusSM coverage may be purchased separately with this plan.
Exclusions and limitations: Conditions covered by workers' compensation or similar law; services or supplies not specifically listed as covered under your benefit plan; services received before your effective date or after coverage ends; services you wouldn't have to pay for if you did not have this coverage; services or supplies that are not medically necessary; physical exams for insurance, employment, sports or school; any amounts in excess of BCBSM's approved amount; cosmetic surgery; dental care, dental implants or treatment to the teeth except as specifically stated in your benefit plan; hearing aids; infertility services; private duty nursing; eyeglasses or contact lenses; telephone, facsimile machine or any other type of electronic consultation; educational services, except as specifically provided or arranged by BCBSM; nutritional counseling; care or treatment furnished in a nonparticipating hospital, except as specifically stated in your benefit plan; personal comfort items; custodial care; services or supplies supplied to any person not covered under your benefit plan; services while confined in a hospital or other facility owned or operated by state or federal government, unless required by law; services provided by a
professional provider to a family member; services provided by any person who ordinarily resides in the covered person's home or who is a family member; any drug, medicine or device that is not FDA–approved, unless required by law; vitamins, dietary products and any other nonprescription supplements; dental services, except for dental injury; appliances or supplies; war or any act of war, whether declared or not; communication or travel time, lodging or transportation, except as stated in your benefit plan; foot care services, except as stated in your benefit plan; health clubs or health spas, aerobic and strength conditioning, work hardening programs and related material and products for these programs; hair prosthesis, hair transplants or implants; experimental treatments, except as stated in your benefit plan; weight loss programs; and alternative medicines or therapies.
This document is intended to be an easy–to–read summary. It is not a contract. Additional limitations and exclusions may apply to covered services. A complete description of benefits is contained in the applicable Blue Cross Blue Shield of Michigan certificate and riders. Payment amounts are based on the BCBSM–approved amount, less any applicable deductible and/or copay amounts required by the plan. All covered benefits are subject to a pre–existing conditions waiting period, unless noted otherwise. This coverage is provided pursuant to a contract entered into in the state of Michigan and shall be construed under the jurisdiction and according to the laws of the state of Michigan.
This document is intended to be an easy–to–read summary. It is not a contract. Additional limitations and exclusions may apply to covered services. A complete description of benefits is contained in the applicable Blue Cross Blue Shield of Michigan certificate and riders. Payment amounts are based on the BCBSM–approved amount, less any applicable deductible and/or copay amounts required by the plan. All covered benefits are subject to a pre–existing conditions waiting period, unless noted otherwise. This coverage is provided pursuant to a contract entered into in the state of Michigan and shall be construed under the jurisdiction and according to the laws of the state of Michigan.
Flexible Blue Maternity Benefits-at-a-Glance (Optional)
Download Optional Flexible Blue Maternity Benefits-at-a-Glance (52K PDF)| Benefit Highlights | In-network | Out-of-network |
| Delivery and newborn exam | Covered — 80% after deductible | Covered — 60% after deductible |
| Pre and postnatal exams (office visits) | Covered — 80% after deductible | Covered — 60% after deductible |
| Annual benefit maximum: This is the maximum amount BCBSM will pay for covered maternity services per calendar year. Benefits are subject to all applicable deductible and copay requirements and to the copayment and lifetime maximums mentioned elsewhere in your certificate. | $5,000 per calendar year for vaginal deliveries and elective or nonmedically necessary cesarean deliveries $7,500 per calendar year for medically necessary cesarean deliveries |
|
Note: Maternity coverage is optional and may be purchased with Flexible Blue IISM 1500 and 2500 plans. If the optional maternity coverage is not purchased at the same time as Flexible Blue II 1500 or 2500 (i.e., at a later date), the 180-day pre-existing condition waiting period for maternity benefits begins with the effective date of the optional maternity coverage, not the effective date of
Flexible Blue II 1500 or 2500.
This document is intended to be an easy-to-read summary. It is not a contract. Additional limitations and exclusions may apply to covered services. A complete description of benefits is contained in the applicable Blue Cross Blue Shield of Michigan certificate and riders. Payment
amounts are based on the BCBSM-approved amount, less any applicable deductible and/or copay amounts required by the plan. All covered benefits are subject to a pre-existing conditions waiting period, unless noted otherwise. This coverage is provided pursuant to a contract entered into in the state of Michigan and shall be construed under the jurisdiction and according to the laws of the state of Michigan.
Plan 2500 Benefits-at-a-Glance
Download Plan 2500 Benefits (89K PDF)| In-network | Out-of-network | |
| NOTE: All benefits, except preventive services, are subject to a 180-day waiting period for pre-existing conditions. | ||
| Benefit Highlights | ||
|---|---|---|
| Annual deductible | $2,500 per individual contract per calendar year. $5,000 per family contract (two or more members) per calendar year. Medical and drug expenses are combined to meet the integrated deductible. One or more family members may satisfy the family integrated deductible. The entire integrated deductible must be met before covered services are paid. |
$5,000 per individual contract per calendar year. $10,000 per family contract (two or more members) per calendar year. Medical and drug expenses are combined to meet the integrated deductible. One or more family members may satisfy the family integrated deductible. The entire integrated deductible must be met before covered services are paid. |
| Copays | 20% of the BCBSM-approved amount | 40% of the BCBSM-approved amount |
| Annual copay dollar maximum | $2,500 per individual contract. $5,000 per family contract (two or more members). One or more family members may satisfy the family annual copay dollar maximum. Prescription drug copays and flat-dollar copays contribute to the annual copay dollar maximum. |
$5,000 per individual contract. $10,000 per family contract (two or more members). One or more family members may satisfy the family annual copay dollar maximum. Prescription drug copays and flat-dollar copays contribute to the annual copay dollar maximum. |
| Annual out-of-pocket maximum: The annual out-of-pocket maximum limits the amount members are responsible for paying each calendar year. Once the annual out-of-pocket maximum is met, most services are payable at 100% of the BCBSM-approved amount. | $5,000 per individual contract. $10,000 per family contract (two or more members). |
$10,000 per individual contract. $20,000 per family contract (two or more members). |
| Lifetime maximum (per member) | $5 million | |
| Fourth-quarter deductible carry-over |
Not applicable | |
| Preventive Services | ||
| Preventive medical care: Includes health maintenance exam, routine laboratory and radiology, fecal occult blood screening, flexible sigmoidoscopy, gynecological exam, childhood immunizations (through age 15), Pap smear screening, prostate specific antigen screening, well-baby and well-child exams (6 visits per year through age 1; 2 visits per year, ages 2 through 3; 1 visit per year, ages 4 through 15). | Covered — 100% with no deductible, up to a combined maximum of $500 per member, per calendar year. 90-day benefit waiting period applies. | Not covered |
| Mammography screening | Covered — 100% with no deductible. 90-day benefit waiting period applies | |
| Preventive dental | Not covered | |
| Preventive vision (VSP network provider only) | Not covered | |
| Physician Office Services | ||
| Office visits | Covered — 80% after deductible; 2 visits, per member, per calendar year | Not covered |
| Outpatient presurgical second opinion consultations | Covered — 100% after deductible | Not covered |
| Office consultations | Not covered | |
| Emergency and Urgent Care Services | ||
| Medical emergencies and accidental injuries | Covered — 80% after in-network deductible for all services other than physician services. You pay $150 for physician services (waived if admitted). | |
| Ambulance service: medically necessary, emergency ground transport and air ambulance | Covered — 80% after in-network deductible | |
| Urgent care | Covered — 80% after in-network deductible for all services other than physician services. You pay $50 for physician services. | |
| Diagnostic and Radiation Services | ||
| Ultrasound | Covered — 80% after deductible | Covered — 60% after deductible |
| Laboratory tests and pathology | Covered — 80% after deductible | Covered — 60% after deductible |
| EKGs | Covered — 80% after deductible | Covered — 60% after deductible |
| Diagnostic radiology and X-rays | Covered — 80% after deductible | Covered — 60% after deductible |
| Colonoscopies (diagnostic) | Covered — 80% after deductible | Covered — 60% after deductible |
| CT scans and MRIs (BCBSM-participating facilities only) | Covered — 80% after deductible | Covered — 60% after deductible |
| Radiation therapy | Covered — 80% after deductible | Covered — 60% after deductible |
| Maternity Services | ||
| Delivery and newborn exam | Not covered (optional rider available) | |
| Pre- and postnatal exams (office visits) |
Not covered (optional rider available) | |
| Inpatient Hospital Care | ||
| Semi private room: 120 days with 60-day renewal (BCBSM-approved facilities only) | Covered — 80% after deductible | Covered — 60% after deductible |
| Inpatient consultations | Covered — 80% after deductible | Covered — 60% after deductible |
| Complications of pregnancy | Covered — 80% after deductible | Covered — 60% after deductible |
| Surgical Care — Hospital or Outpatient | ||
| Inpatient surgical care | Covered — 80% after deductible | Covered — 60% after deductible |
| Outpatient surgical care | Covered — 80% after deductible | Covered — 60% after deductible |
| Physician surgical services | Covered — 80% after deductible | Covered — 60% after deductible |
| Gender reassignment surgery and services |
Not covered | |
| Bariatric surgery and services | Not covered | |
| Alternatives to Hospitalization | ||
| Home health care: up to the annual maximum (BCBSM-participating providers only) | Covered — 80% after in-network deductible | |
| Hospice care: up to the annual dollar maximum (BCBSM-participating programs only) | Covered — 100% after in-network deductible | |
| Outpatient Services | ||
| Outpatient physical, occupational and speech therapy | Not covered | |
| Chemotherapy (IV and oral) | Covered — 80% after deductible | Covered — 60% after deductible |
| Home infusion therapy (BCBSM-participating providers only) | Covered — 80% after in-network deductible | |
| Voluntary sterilization | Covered — 80% after deductible | Covered — 60% after deductible |
| Prosthetics: mandated only (BCBSM-participating providers only) |
Covered — 80% after in-network deductible | |
| Other Medical Benefits | ||
| Insulin, disposable needles and syringes dispensed with insulin, diabetic testing supplies | Covered — 80% after deductible | Covered — 60% after deductible |
| Outpatient diabetes management program |
Covered — 80% after deductible | Covered — 60% after deductible |
| Contraceptives: physician-administered, prescription drugs only, devices and contraceptive injectables (implants are not covered) |
Covered — 80% after deductible | Covered — 60% after deductible |
| Organ Transplantation | ||
| Bone marrow transplants | Covered — 80% after deductible | Covered — 60% after deductible |
| Kidney, cornea and skin transplants |
Covered — 80% after deductible | Covered — 60% after deductible |
| Specified organ transplant: $1 million lifetime maximum per transplant type, included in the $5 million lifetime maximum (BCBSM-designated facilities only) |
Covered — 100% after in-network deductible | |
| Mental Health and Substance Abuse Treatment | ||
| Inpatient mental health (BCBSM-approved facilities only) | Covered — 80% after deductible, 30 days with 60-day renewal | Covered — 60% after deductible, 30 days with 60-day renewal |
| Outpatient mental health | Not covered | |
| Substance abuse: inpatient (residential) and outpatient, up to state-mandated benefit (BCBSM-approved facilities only) | Covered — 80% after deductible | Covered — 60% after deductible |
| Network Pharmacy | Non-network Pharmacy | |
| Prescription Drugs | ||
|---|---|---|
| Prescription drug benefits are subject to a 180-day waiting period for pre-existing conditions. Covered after the in-network integrated deductible. Medical and drug expenses combine to meet the integrated deductible. Prescription drug copayments contribute to the annual copayment dollar maximum. | ||
| Annual maximum | Covered — $2,500 per member, per calendar year after in-network integrated deductible, retail and mail order combined. Members who exhaust the annual maximum may purchase prescription drugs at the BCBSM-negotiated rate for the remainder of the calendar year. These expenses will not contribute to the in-network integrated deductible or annual copay dollar maximum. | |
| Retail (1-34 day supply) | Covered — 50% of the approved amount with $10 minimum and $100 maximum copay, after in-network integrated deductible | Members must pay the pharmacist the full cost of the drug. After the in-network integrated deductible, BCBSM will reimburse 80% of the BCBSM-approved amount for covered drugs, less the copay and the difference between the non-network pharmacy’s charge and the BCBSM-approved amount for the drug. |
| 90-day retail (84-90 day supply) | Covered — 50% of the approved amount with a minimum of $20 and a maximum of $200 per prescription, after in-network integrated deductible | Not covered |
| Mail order (35-90 day supply) | Covered — 50% of the approved amount with a minimum of $20 and a maximum of $200 per prescription, after in-network integrated deductible | Not covered |
Note: The 90-day benefit waiting period for preventive services will be waived with proof of creditable coverage.
Note: Out-of-network and nonparticipating providers may bill members for the difference between BCBSM's approved amount and the provider's charge, even when referred.
Note: Maternity coverage and Flexible Blue Dental PlusSM coverage may be purchased separately with this plan.
Exclusions and limitations: Conditions covered by workers' compensation or similar law; services or supplies not specifically listed as covered under your benefit plan; services received before your effective date or after coverage ends; services you wouldn't have to pay for if you did not have this coverage; services or supplies that are not medically necessary; physical exams for insurance, employment, sports or school; any amounts in excess of BCBSM's approved amount; cosmetic surgery; dental care, dental implants or treatment to the teeth except as specifically stated in your benefit plan; hearing aids; infertility services; private duty nursing; eyeglasses or contact lenses; telephone, facsimile machine or any other type of electronic consultation; educational services, except as specifically provided or arranged by BCBSM; nutritional counseling; care or treatment furnished in a nonparticipating hospital, except as specifically stated in your benefit plan; personal comfort items; custodial care; services or supplies supplied to any person not covered under your benefit plan; services while confined in a hospital or other facility owned or operated by state or federal government, unless required by law; services provided by a professional provider to a family member; services provided by any person who ordinarily resides in the covered person's home or who is a family member; any drug, medicine or device that is not FDA-approved, unless required by law; vitamins, dietary products and any other nonprescription supplements; dental services, except for dental injury; appliances or supplies; war or any act of war, whether declared or not; communication or travel time, lodging or transportation, except as stated in your benefit plan; foot care services, except as stated in your benefit plan; health clubs or health spas, aerobic and strength conditioning, work hardening programs and related material and products for these programs; hair prosthesis, hair transplants or implants; experimental treatments, except as stated in your benefit plan; weight loss programs; and alternative medicines or therapies.
This document is intended to be an easy-to-read summary. It is not a contract. Additional limitations and exclusions may apply to covered services. A complete description of benefits is contained in the applicable Blue Cross Blue Shield of Michigan certificate and riders. Payment amounts are based on the BCBSM-approved amount, less any applicable deductible and/or copay amounts required by the plan. All covered benefits are subject to a pre-existing conditions waiting period, unless noted otherwise. This coverage is provided pursuant to a contract entered into in the state of Michigan and shall be construed under the jurisdiction and according to the laws of the state of Michigan.
This document is intended to be an easy-to-read summary. It is not a contract. Additional limitations and exclusions may apply to covered services. A complete description of benefits is contained in the applicable Blue Cross Blue Shield of Michigan certificate and riders. Payment amounts are based on the BCBSM-approved amount, less any applicable deductible and/or copay amounts required by the plan. All covered benefits are subject to a pre-existing conditions waiting period, unless noted otherwise. This coverage is provided pursuant to a contract entered into in the state of Michigan and shall be construed under the jurisdiction and according to the laws of the state of Michigan.
Flexible Blue Maternity Benefits-at-a-Glance (Optional)
Download Optional Flexible Blue Maternity Benefits-at-a-Glance (52K PDF)| Benefit Highlights | In-network | Out-of-network |
| Delivery and newborn exam | Covered — 80% after deductible | Covered — 60% after deductible |
| Pre and postnatal exams (office visits) | Covered — 80% after deductible | Covered — 60% after deductible |
| Annual benefit maximum: This is the maximum amount BCBSM will pay for covered maternity services per calendar year. Benefits are subject to all applicable deductible and copay requirements and to the copayment and lifetime maximums mentioned elsewhere in your certificate. | $5,000 per calendar year for vaginal deliveries and elective or nonmedically necessary cesarean deliveries $7,500 per calendar year for medically necessary cesarean deliveries |
|
Note: Maternity coverage is optional and may be purchased with Flexible Blue IISM 1500 and 2500 plans. If the optional maternity coverage is not purchased at the same time as Flexible Blue II 1500 or 2500 (i.e., at a later date), the 180-day pre-existing condition waiting period for maternity benefits begins with the effective date of the optional maternity coverage, not the effective date of
Flexible Blue II 1500 or 2500.
This document is intended to be an easy-to-read summary. It is not a contract. Additional limitations and exclusions may apply to covered services. A complete description of benefits is contained in the applicable Blue Cross Blue Shield of Michigan certificate and riders. Payment
amounts are based on the BCBSM-approved amount, less any applicable deductible and/or copay amounts required by the plan. All covered benefits are subject to a pre-existing conditions waiting period, unless noted otherwise. This coverage is provided pursuant to a contract entered into in the state of Michigan and shall be construed under the jurisdiction and according to the laws of the state of Michigan.
Plan 5000 Benefits-at-a-Glance
Download Plan 5000 Benefits (87K PDF)| In-network | Out-of-network | |
| NOTE: All benefits, except preventive services, are subject to a 180-day waiting period for pre-existing conditions. | ||
| Benefit Highlights | ||
|---|---|---|
| Annual deductible | $5,000 per individual contract per calendar year. $10,000 per family contract (two or more members) per calendar year. Medical and drug expenses are combined to meet the integrated deductible. One or more family members may satisfy the family integrated deductible. The entire integrated deductible must be met before covered services are paid. |
$10,000 per individual contract per calendar year. $20,000 per family contract (two or more members) per calendar year. Medical and drug expenses are combined to meet the integrated deductible. One or more family members may satisfy the family integrated deductible. The entire integrated deductible must be met before covered services are paid. |
| Copays | 20% of the BCBSM-approved amount | 40% of the BCBSM-approved amount |
| Annual copay dollar maximum | $800 per individual contract. $1,600 per family contract (two or more members). One or more family members may satisfy the family annual copay dollar maximum. Prescription drug copays and flat-dollar copays contribute to the annual copay dollar maximum. |
$1,600 per individual contract. $3,200 per family contract (two or more members). One or more family members may satisfy the family annual copay dollar maximum. Prescription drug copays and flat-dollar copays contribute to the annual copay dollar maximum. |
| Annual out-of-pocket maximum: The annual out-of-pocket maximum limits the amount members are responsible for paying each calendar year. Once the annual out-of-pocket maximum is met, most services are payable at 100% of the BCBSM-approved amount. | $5,800 per individual contract. $11,600 per family contract (two or more members). |
$11,600 per individual contract. $23,200 per family contract (two or more members). |
| Lifetime maximum (per member) | $5 million | |
| Fourth-quarter deductible carry-over |
Not applicable | |
| Preventive Services | ||
| Preventive medical care: Includes health maintenance exam, routine laboratory and radiology, fecal occult blood screening, flexible sigmoidoscopy, gynecological exam, childhood immunizations (through age 15), Pap smear screening, prostate specific antigen screening, well-baby and well-child exams (6 visits per year through age 1; 2 visits per year, ages 2 through 3; 1 visit per year, ages 4 through 15). | Covered — 100% with no deductible, up to a combined maximum of $500 per member, per calendar year. 90-day benefit waiting period applies. | Not covered |
| Mammography screening | Covered — 100% with no deductible. 90-day benefit waiting period applies | |
| Preventive dental | Not covered | |
| Preventive vision (VSP network provider only) | Not covered | |
| Physician Office Services | ||
| Office visits | Covered — 80% after deductible; 2 visits per member, per calendar year | Not covered |
| Outpatient presurgical second opinion consultations | Covered — 100% after deductible | Not covered |
| Office consultations | Not covered | |
| Emergency and Urgent Care Services | ||
| Medical emergencies and accidental injuries | Covered — 80% after in-network deductible for all services other than physician services. You pay $150 for physician services (waived if admitted). | |
| Ambulance service: medically necessary, emergency ground transport and air ambulance | Covered — 80% after in-network deductible | |
| Urgent care | Covered — 80% after in-network deductible for all services other than physician services. You pay $50 for physician services. | |
| Diagnostic and Radiation Services | ||
| Ultrasound | Covered — 80% after deductible | Covered — 60% after deductible |
| Laboratory tests and pathology | Covered — 80% after deductible | Covered — 60% after deductible |
| EKGs | Covered — 80% after deductible | Covered — 60% after deductible |
| Diagnostic radiology and X-rays | Covered — 80% after deductible | Covered — 60% after deductible |
| Colonoscopies (diagnostic) | Covered — 80% after deductible | Covered — 60% after deductible |
| CT scans and MRIs (BCBSM-participating facilities only) | Covered — 80% after deductible | Covered — 60% after deductible |
| Radiation therapy | Covered — 80% after deductible | Covered — 60% after deductible |
| Maternity Services | ||
| Delivery and newborn exam | Not available | |
| Pre and postnatal exams (office visits) |
Not available | |
| Inpatient Hospital Care | ||
| Semi private room: 120 days with 60-day renewal (BCBSM-approved facilities only) | Covered — 80% after deductible | Covered — 60% after deductible |
| Inpatient consultations | Covered — 80% after deductible | Covered — 60% after deductible |
| Complications of pregnancy | Covered — 80% after deductible | Covered — 60% after deductible |
| Surgical Care — Hospital or Outpatient | ||
| Inpatient surgical care | Covered — 80% after deductible | Covered — 60% after deductible |
| Outpatient surgical care | Covered — 80% after deductible | Covered — 60% after deductible |
| Physician surgical services | Covered — 80% after deductible | Covered — 60% after deductible |
| Gender reassignment surgery and services |
Not covered | |
| Bariatric surgery and services | Not covered | |
| Alternatives to Hospitalization | ||
| Home health care: up to the annual maximum (BCBSM-participating providers only) | Covered — 80% after in-network deductible | |
| Hospice care: up to the annual dollar maximum (BCBSM-participating programs only) | Covered — 100% after in-network deductible | |
| Outpatient Services | ||
| Outpatient physical, occupational and speech therapy | Not covered | |
| Chemotherapy (IV and oral) | Covered — 80% after deductible | Covered — 60% after deductible |
| Home infusion therapy (BCBSM-participating providers only) | Covered — 80% after in-network deductible | |
| Voluntary sterilization | Covered — 80% after deductible | Covered — 60% after deductible |
| Prosthetics: mandated only (BCBSM-participating providers only) |
Covered — 80% after in-network deductible | |
| Other Medical Benefits | ||
| Insulin, disposable needles and syringes dispensed with insulin, diabetic testing supplies | Covered — 80% after deductible | Covered — 60% after deductible |
| Outpatient diabetes management program |
Covered — 80% after deductible | Covered — 60% after deductible |
| Contraceptives: physician-administered, prescription drugs only, devices and contraceptive injectables (implants are not covered) |
Covered — 80% after deductible | Covered — 60% after deductible |
| Organ Transplantation | ||
| Bone marrow transplants | Covered — 80% after deductible | Covered — 60% after deductible |
| Kidney, cornea and skin transplants |
Covered — 80% after deductible | Covered — 60% after deductible |
| Specified organ transplant: $1 million lifetime maximum per transplant type, included in the $5 million lifetime maximum (BCBSM-designated facilities only) |
Covered — 100% after in-network deductible | |
| Mental Health and Substance Abuse Treatment | ||
| Inpatient mental health (BCBSM-approved facilities only) | Covered — 80% after deductible, 30 days with 60-day renewal | Covered — 60% after deductible, 30 days with 60-day renewal |
| Outpatient mental health | Not covered | |
| Substance abuse: inpatient (residential) and outpatient, up to state-mandated benefit (BCBSM-approved facilities only) | Covered — 80% after deductible | Covered — 60% after deductible |
| Network Pharmacy | Non-network Pharmacy | |
| Prescription Drugs | ||
|---|---|---|
| Prescription drug benefits are subject to a 180-day waiting period for pre-existing conditions. Covered after the in-network integrated deductible. Medical and drug expenses combine to meet the integrated deductible. Prescription drug copayments contribute to the annual copayment dollar maximum. | ||
| Annual maximum | Covered — $2,500 per member, per calendar year after in-network integrated deductible, retail and mail order combined. Members who exhaust the annual maximum may purchase prescription drugs at the BCBSM-negotiated rate for the remainder of the calendar year. These expenses will not contribute to the in-network integrated deductible or annual copay dollar maximum. | |
| Retail (1-34 day supply) | Covered — 50% of the approved amount with $10 minimum and $100 maximum copay, after in-network integrated deductible | Members must pay the pharmacist the full cost of the drug. After the in-network integrated deductible, BCBSM will reimburse 80% of the BCBSM-approved amount for covered drugs, less the copay and the difference between the non-network pharmacy's charge and the BCBSM-approved amount for the drug. |
| 90-day retail (84-90 day supply) | Covered — 50% of the approved amount with a minimum of $20 and a maximum of $200 per prescription, after in-network integrated deductible | Not covered |
| Mail order (35-90 day supply) | Covered — 50% of the approved amount with a minimum of $20 and a maximum of $200 per prescription, after in-network integrated deductible | Not covered |
Note: The 90-day benefit waiting period for preventive services will be waived with proof of creditable coverage.
Note: Out-of-network and nonparticipating providers may bill members for the difference between BCBSM's approved amount and the provider's charge, even when referred.
Note: Flexible Blue Dental PlusSM coverage may be purchased separately with this plan.
Exclusions and limitations: Conditions covered by workers' compensation or similar law; services or supplies not specifically listed as covered under your benefit plan; services received before your effective date or after coverage ends; services you wouldn't have to pay for if you did not have this coverage; services or supplies that are not medically necessary; physical exams for insurance, employment, sports or school; any amounts in excess of BCBSM's approved amount; cosmetic surgery; dental care, dental implants or treatment to the teeth except as specifically stated in your benefit plan; hearing aids; infertility services; private duty nursing; eyeglasses or contact lenses; telephone, facsimile machine or any other type of electronic consultation; educational services, except as specifically provided or arranged by BCBSM; nutritional counseling; care or treatment furnished in a nonparticipating hospital, except as specifically stated in your benefit plan; personal comfort items; custodial care; services or supplies supplied to any person not covered under your benefit plan; services while confined in a hospital or other facility owned or operated by state or federal government, unless required by law; services provided by a professional provider to a family member; services provided by any person who ordinarily resides in the covered person's home or who is a family member; any drug, medicine or device that is not FDA–approved, unless required by law; vitamins, dietary products and any other nonprescription supplements; dental services, except for dental injury; appliances or supplies; war or any act of war, whether declared or not; communication or travel time, lodging or transportation, except as stated in your benefit plan; foot care services, except as stated in your benefit plan; health clubs or health spas, aerobic and strength conditioning, work hardening programs and related material and products for these programs; hair prosthesis, hair transplants or implants; experimental treatments, except as stated in your benefit plan; weight loss programs; and alternative medicines or therapies.
This document is intended to be an easy–to–read summary. It is not a contract. Additional limitations and exclusions may apply to covered services. A complete description of benefits is contained in the applicable Blue Cross Blue Shield of Michigan certificate and riders. Payment amounts are based on the BCBSM–approved amount, less any applicable deductible and/or copay amounts required by the plan. All covered benefits are subject to a pre–existing conditions waiting period, unless noted otherwise. This coverage is provided pursuant to a contract entered into in the state of Michigan and shall be construed under the jurisdiction and according to the laws of the state of Michigan.
This document is intended to be an easy–to–read summary. It is not a contract. Additional limitations and exclusions may apply to covered services. A complete description of benefits is contained in the applicable Blue Cross Blue Shield of Michigan certificate and riders. Payment amounts are based on the BCBSM–approved amount, less any applicable deductible and/or copay amounts required by the plan. All covered benefits are subject to a pre–existing conditions waiting period, unless noted otherwise. This coverage is provided pursuant to a contract entered into in the state of Michigan and shall be construed under the jurisdiction and according to the laws of the state of Michigan.
Flexible Blue Dental PlusSM Benefits-at-a-Glance
Download Flexible Blue Dental Plus Benefits (62K PDF)| Class I — Preventive services | |
|---|---|
| Oral exams, bitewing X-rays, teeth cleanings and fluoride | Covered — 75% twice per calendar year (90-day benefit waiting period applies). |
| Class II — Restorative services | |
| Replacement fillings and onlays, crowns, extractions and root canal therapy |
Covered — 50% of the approved amount; subject to frequency limitations (90 day benefit waiting period applies) |
| Benefit maximum | |
| The benefit maximum limits the amount payable for services each calendar year. Once a member reaches the benefit maximum, services will not be paid for that member for the balance of the calendar year. We will continue to pay claims for other eligible members until each member has reached the maximum. | $800 per member, per calendar year |
Note: The 90-day benefit waiting period for Class I and II services is waived with proof of creditable coverage.
Note: Flexible Blue Dental Plus is optional coverage that may be purchased with Individual Care Blue PlusSM or Flexible Blue IISM plans. Members may choose a DenteMax network dentist. If a member chooses to receive care outside the DenteMax network, their out-of-pocket costs may be higher.
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