Key Benefits
• Vaccinations, annual visit, wellness visits for kids
• 24/7 medical virtual visits through selected vendor app (medical urgent care visits)
• Diabetes test strips, lancets and connected devices with diabetes, pre-diabetes and hypertension management programs
• Maternity and menopause programs
• App - access to cost and transparency tools
• Mental health coaching self-guided content in the Teladoc app
• Urgent care
Discounts:
• Access to more than 20,000 gyms
• Blue 365 on vitamins, food, retailers, etc.
Availability
Plan Type
Health Savings Account
Related Documents
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.
Agent Compensation
Key Benefits
• Vaccinations, annual visit, wellness visits for kids
• 24/7 medical virtual visits through selected vendor app (medical urgent care visits)
• Diabetes test strips, lancets and connected devices with diabetes, pre-diabetes and hypertension management programs
• Maternity and menopause programs
• App - access to cost and transparency tools
• Mental health coaching self-guided content in the Teladoc app
• Urgent care
Discounts:
• Access to more than 20,000 gyms
• Blue 365 on vitamins, food, retailers, etc.
Availability
Plan Type
Health Savings Account
Related Documents
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.
Agent Compensation
Need medical coverage?
Open enrollment is closed but you can get or change coverage for the remainder of 2025 if you've had one of these qualifying life events.
Plan details
Monthly Premiums
To give you an accurate price, we'll need some information. Find a plan to get a quote.
Deductible
Any coupon, rebate or other credits received directly or indirectly from an assistance program or the drug manufacturer may not be applied to a consumer's deductible, cost-sharing or out-of-pocket maximum.
In network
Individual: $3,800
Family: $7,600
Out of network
Individual: $7,600
Family: $15,200
Coinsurance
In network
You pay 20% after deductible for most services.
You pay 50% after deductible for bariatric, temporomandibular joint, infertility, prosthetic and orthotic, and durable medical equipment services.
Out of network
You pay 40% after deductible for most services.
You pay 70% after deductible for bariatric, temporomandibular joint, infertility, prosthetic and orthotic, and durable medical equipment services.
Out-of Pocket Maximum
Any coupon, rebate or other credits received directly or indirectly from an assistance program or the drug manufacturer may not be applied to a consumer's deductible, cost-sharing or out-of-pocket maximum.
In network
Individual: $9,000
Family: $18,000
Out of network
Individual: $18,000
Family: $36,000
Office Visits
Primary Care
Specialist
Urgent care center
Emergency Room
Prescriptions
Dental
This plan doesn't include dental coverage. View our Dental plans.
Vision
This plan only includes vision coverage for children. View our Vision plans.
In-Network Benefits
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 and prescription drugs have nationwide coverage with in-network cost-sharing.
Preventive Care
Medical Exams, Prescription Drugs and Immunizations
In network
You pay $0.
Out of network
You pay 40% after deductible.
Office Visits
In network
Primary care: You pay $30 after deductible including virtual and retail health visits and medical evaluations at an affiliated immunization pharmacy.
Specialist: You pay $50 after deductible.
Out of network
You pay 40% after deductible.
Virtual Visits (available nationwide)
In network
You pay $0 for 24/7 medical virtual visits through selected vendor app.
You pay $30 after deductible for mental health virtual visits through selected vendor app.
You pay $30 after deductible for virtual primary care visits through selected vendor app nationwide.
Out of network
You pay 40% after deductible.
Emergency Services
Emergency Room Visit
Transportation by Ambulance
Urgent Care Center Visits
In network
You pay $75.
Out of network
You pay 40% after deductible.
Hospitalization and Other Services
Inpatient Hospital Care, Maternity, Delivery & Newborn Care, Surgery, Chemotherapy
In network
You pay 20% after deductible.
Out of network
You pay 40% after deductible.
Rehabilitative Services
Outpatient Physical and Occupational Therapy
In network
You pay 20% after deductible.
Out of network
You pay 40% after deductible.
Chiropractic Spinal Manipulation and Osteopathic Manipulative Therapy
In network
You pay 20% after deductible.
Out of network
You pay 40% after deductible.
Speech Therapy
In network
You pay 20% after deductible.
Out of network
You pay 40% after deductible.
Habilitative Services
Outpatient Physical and Occupational Therapy
In network
You pay 20% after deductible.
Out of network
You pay 40% after deductible.
Speech Therapy
In network
You pay 20% after deductible.
Out of network
You pay 40% after deductible.
Applied Behavior Analysis for Specified Autism Spectrum Disorder
In network
You pay $30 after deductible.
Out of network
You pay 40% after deductible.
Mental Health/Substance Use
Inpatient and Residential Mental Health
In network
You pay 20% after deductible.
Out of network
You pay 40% after deductible.
Outpatient Mental Health Services
In network
You pay $30 after deductible.
Out of network
You pay 40% after deductible.
Residential Substance Use Disorder Treatment
You pay 20% after deductible.
Outpatient Substance Use Disorder Treatment
In network
You pay $30 after deductible.
Out of network
You pay 40% after deductible.
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. You can get 60-day prescriptions from mail-order pharmacies only. 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 an assistance program or the drug manufacturer may not be applied to a consumer's deductible, cost sharing or out-of-pocket maximum.
Out-of-Network Benefits
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 the type of drug. Certain drugs may need prior authorization. Look on this list to find a drug (PDF).
Generic
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
Commonly prescribed, generic versions of brand-name medications available for the lowest copay.
Preferred Brand
30-day supply:You pay up to $100 after deductible.
60-day supply (mail order only): You pay up to $200 after deductible.
90-day supply: You pay up to $300 after deductible.
Brand-name drugs not yet available as a generic.
Nonpreferred Brand
30-day supply: You pay up to $150 after deductible.
60-day supply (mail order only): You pay up to $300 after deductible.
90-day supply: You pay up to $450 after deductible.
Brand-name drugs that have generic or preferred brand alternatives.
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 Walgreens Specialty Pharmacy to fill these types of prescriptions.
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 Nonpreferred Speciality drugs, you'll pay more for them at the pharmacy. You'll need to use Walgreens Specialty Pharmacy to fill these types of prescriptions.
Discounts
- Weight management programs, organic groceries and fresh produce.
- Yoga classes, workout gear and gym memberships.
- Discounted admission to Michigan attractions.
Doctor Visits
Well-Being
- 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 Well-Being.SM
- Take part in our Tobacco Coaching program®.
Monthly Premiums
To give you an accurate price, we'll need some information. Find a plan to get a quote.
Deductible
Any coupon, rebate or other credits received directly or indirectly from an assistance program or the drug manufacturer may not be applied to a consumer's deductible, cost-sharing or out-of-pocket maximum.
In network
Individual: $3,800
Family: $7,600
Out of network
Individual: $7,600
Family: $15,200
Coinsurance
In network
You pay 20% after deductible for most services.
You pay 50% after deductible for bariatric, temporomandibular joint, infertility, prosthetic and orthotic, and durable medical equipment services.
Out of network
You pay 40% after deductible for most services.
You pay 70% after deductible for bariatric, temporomandibular joint, infertility, prosthetic and orthotic, and durable medical equipment services.
Out-of Pocket Maximum
Any coupon, rebate or other credits received directly or indirectly from an assistance program or the drug manufacturer may not be applied to a consumer's deductible, cost-sharing or out-of-pocket maximum.
In network
Individual: $9,000
Family: $18,000
Out of network
Individual: $18,000
Family: $36,000
Office Visits
Primary Care
Specialist
Urgent care center
Emergency Room
Prescriptions
Dental
This plan doesn't include dental coverage. View our Dental plans.
Vision
This plan only includes vision coverage for children. View our Vision plans.
In-Network Benefits
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 and prescription drugs have nationwide coverage with in-network cost-sharing.
Preventive Care
Medical Exams, Prescription Drugs and Immunizations
In network
You pay $0.
Out of network
You pay 40% after deductible.
Office Visits
In network
Primary care: You pay $30 after deductible including virtual and retail health visits and medical evaluations at an affiliated immunization pharmacy.
Specialist: You pay $50 after deductible.
Out of network
You pay 40% after deductible.
Virtual Visits (available nationwide)
In network
You pay $0 for 24/7 medical virtual visits through selected vendor app.
You pay $30 after deductible for mental health virtual visits through selected vendor app.
You pay $30 after deductible for virtual primary care visits through selected vendor app nationwide.
Out of network
You pay 40% after deductible.
Emergency Services
Emergency Room Visit
Transportation by Ambulance
Urgent Care Center Visits
In network
You pay $75.
Out of network
You pay 40% after deductible.
Hospitalization and Other Services
Inpatient Hospital Care, Maternity, Delivery & Newborn Care, Surgery, Chemotherapy
In network
You pay 20% after deductible.
Out of network
You pay 40% after deductible.
Rehabilitative Services
Outpatient Physical and Occupational Therapy
In network
You pay 20% after deductible.
Out of network
You pay 40% after deductible.
Chiropractic Spinal Manipulation and Osteopathic Manipulative Therapy
In network
You pay 20% after deductible.
Out of network
You pay 40% after deductible.
Speech Therapy
In network
You pay 20% after deductible.
Out of network
You pay 40% after deductible.
Habilitative Services
Outpatient Physical and Occupational Therapy
In network
You pay 20% after deductible.
Out of network
You pay 40% after deductible.
Speech Therapy
In network
You pay 20% after deductible.
Out of network
You pay 40% after deductible.
Applied Behavior Analysis for Specified Autism Spectrum Disorder
In network
You pay $30 after deductible.
Out of network
You pay 40% after deductible.
Mental Health/Substance Use
Inpatient and Residential Mental Health
In network
You pay 20% after deductible.
Out of network
You pay 40% after deductible.
Outpatient Mental Health Services
In network
You pay $30 after deductible.
Out of network
You pay 40% after deductible.
Residential Substance Use Disorder Treatment
You pay 20% after deductible.
Outpatient Substance Use Disorder Treatment
In network
You pay $30 after deductible.
Out of network
You pay 40% after deductible.
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. You can get 60-day prescriptions from mail-order pharmacies only. 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 an assistance program or the drug manufacturer may not be applied to a consumer's deductible, cost sharing or out-of-pocket maximum.
Out-of-Network Benefits
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 the type of drug. Certain drugs may need prior authorization. Look on this list to find a drug (PDF).
Generic
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
Commonly prescribed, generic versions of brand-name medications available for the lowest copay.
Preferred Brand
30-day supply:You pay up to $100 after deductible.
60-day supply (mail order only): You pay up to $200 after deductible.
90-day supply: You pay up to $300 after deductible.
Brand-name drugs not yet available as a generic.
Nonpreferred Brand
30-day supply: You pay up to $150 after deductible.
60-day supply (mail order only): You pay up to $300 after deductible.
90-day supply: You pay up to $450 after deductible.
Brand-name drugs that have generic or preferred brand alternatives.
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 Walgreens Specialty Pharmacy to fill these types of prescriptions.
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 Nonpreferred Speciality drugs, you'll pay more for them at the pharmacy. You'll need to use Walgreens Specialty Pharmacy to fill these types of prescriptions.
Discounts
- Weight management programs, organic groceries and fresh produce.
- Yoga classes, workout gear and gym memberships.
- Discounted admission to Michigan attractions.
Doctor Visits
Well-Being
- 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 Well-Being.SM
- Take part in our Tobacco Coaching program®.
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 BCBSM ID card and providing the procedure code. Your provider can also provide this information upon request.
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, admissions and hospitalizations; dental care, dental implants or treatment to the teeth except as specifically stated in your benefit plan; hearing aids; infertility-related drugs; private duty nursing; telephone, fax machine or any other type of electronic consultation; educational services, except as specifically provided or arranged by BCBSM or specifically stated in your benefit plan; 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; voluntary abortions or vasectomy reversals; RK, PRRK, or Lasik; 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 approved by the Food and Drug Administration, unless required by law; vitamins, dietary products and any other nonprescription supplements except as specifically stated in your benefit plan; dental services, except for dental injury; appliances, supplies or services as a result of 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; 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 Shiled of Michigan certificate and riders. In the event of a conflict between this document and the applicable certificate and riders, the certificate and riders will rule. Payment amounts are based on the BCBSM-approved amount, less any applicable deductible, copay and/or coinsurance amounts required by the plan. 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.
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