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Plan Type PPO
Office Visit for Primary Doctor
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$40 copay deductible waived; 2 office visits per memeber per calendar yr. After out-of-pocket max is met, up to 5 additional office visits per member per calender yr.
Office Visit for Specialist $40 copay deductible waived; 2 office visits per memeber per calendar yr. After out-of-pocket max is met, up to 5 additional office visits per member per calender yr.
Office Visit for Other Practitioner (Nurse, Physician Assistant) N/A
Annual Deductible Individual: $1,500
1500 inpatient/ 5000 outpatient
Separate Prescription Drugs Deductible $1000 Individual
$2000 Family
Coinsurance Inpatient- 30% / Outpatient- none
Retail Prescription Drugs N/A
Annual Out-of-Pocket Limit Individual: $5,000
Includes deductible
OOP Limit can be met by one of 3 ways: Satisfy inpatient deductible & annual coinsurance max, satisfy outpatient deductible, or satisfy combination of inpatient & outpatient deductibles & annual coinsurance max
Lifetime Maximum Unlimited
Health Savings Account (HSA) Eligible No
Out-of-Network Coverage Yes  (Details in plan brochure below)
Out-of-Country Coverage Yes. Paid as in-network benefits if through a WorldWide BlueCard Provider 
Office Visit
Primary Care Physician Required No
Specialist Referrals Required No
Preventive Care Coverage
Periodic Health Exam No Charge
Periodic OB-GYN Exam No Charge
Well Baby Care No Charge
Emergency and Urgent Care
Emergency Room 0% coinsurance after outpatient deductible plus $250 copay (copay waived if admitted)
Emergency Ambulance Services N/A
Urgent Care Facility N/A
Prescription Drug Coverage
Retail Prescription Drugs N/A
Separate Prescription Drugs Deductible $1000 Individual
$2000 Family
Mail Order Prescription Drugs N/A
Mail Order Supply N/A
Outpatient Coverage
Outpatient Surgery 30% coinsurance after inpatient deductible, 0% coinsurance after outpatient deductible
Outpatient Lab/X-Ray 30% after inpatient deductible, 0% coinsurance after outpatient deductible
Imaging (CT and PET scans, MRIs) N/A
Outpatient Mental Health N/A
Outpatient Substance Abuse N/A
Outpatient Rehabilitation Services (PT, OT, ST) N/A
Inpatient Coverage
Hospitalization 30% coinsurance after inpatient deductible, up to 180 days combined, per member per calendar year (semi-private room in BCBSM approved facility)
Skilled Nursing Facility N/A
Inpatient Mental Health N/A
Inpatient Substance Abuse N/A
Home Healthcare N/A
Maternity Coverage
Pre & Postnatal Office Visit Not Covered
Labor & Delivery Hospital Stay Not Covered
Pediatric Services
Dental Checkup for Children N/A
Vision Screening for Children N/A
Eye Glasses for Children N/A
Major Dental Coverage (Pediatric) N/A
Additional Coverage
Chiropractic Coverage Not Covered
Durable Medical Equipment N/A
Hospice N/A
Major Dental Coverage (Adult) N/A
Vision Coverage (Adult) N/A
Out-of-Network Coverage
Out-of-Network Authorization Required No
Out-of-Network Annual Deductible (Details in plan brochure below)
Out-of-Network Annual Coinsurance (Details in plan brochure below)
Out-of-Network Annual Out-of-Pocket Limit (Details in plan brochure below)
Additional Information
A.M. Best Rating A- as of 08/07/2013
Electronic Signature for Application Available Yes
Details and documents about this plan
View Plan Brochure Exclusions and Limitations

Summary of Benefits & Coverage (Not available)

The Summary of Benefits & Coverage can be found at healthcare.gov. A paper copy of this Summary of Benefits & Coverage is available upon request by calling our toll free number. Click here to view the Uniform Glossary of Coverage and Medical Terms.

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Important notices and disclaimers

  • The benefits matrix is a summary for informational purposes only. Review the evidence of coverage and insurance policy (plan contract) for a detailed description of coverage benefits, limitations, and exclusions. Only the terms and conditions of coverage benefits listed in the policy are binding.
  • The benefits listed may be contingent on your use of physicians, hospitals, and services within the specific insurance company's provider network.
  • The Copayment, Deductible, and Coinsurance amounts are your share of the costs for covered benefits. These amounts are subject to change.
  • Each insurance carrier may have unique Notices, Disclaimers, and Fees. Please check below for information regarding the plans and carriers you selected.
  • The quotes or rates shown above are estimates only. Your premium is subject to change based on the optional benefits you selected, if any, and other relevant factors, such as changes in rates that take effect before your coverage start date. The insurance company always determines your actual premium. Insurance companies reserve the right to change the terms of a policy upon proper notification.
  • The Summary of Benefits & Coverage can be found at healthcare.gov. A paper copy of this Summary of Benefits & Coverage is available upon request by calling our toll free number. Click here to view the Uniform Glossary of Coverage and Medical Terms.