$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
None
$2,000
Annual copay dollar maximum: The annual out-of-pocket maximum limits the amount
you will be responsible for paying each year. Once the annual out-of-pocket maximum
is met, most services are payable at 100% of the
BCBSM-approved amount.
$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.
Lifetime maximum per member
$5 million
Fourth-quarter deductible carryover
Not applicable
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
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,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
Covered 80% after deductible
Radiation therapy
Covered 80% after deductible
Covered 60% after deductible
Maternity Services
Delivery and newborn exam
Not covered (optional rider available)
Prenatal and postnatal exams (office visits)
Not covered (optional rider available)
Inpatient Hospital Care
Semi-private room: 120 days with 60-day renewal period (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 (BCBSMparticipating programs only)
Covered 100% after in-network deductible
Outpatient Services
Outpatient physical, occupational and speech therapy
Not covered
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 transplant
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 80% after deductible, 30 days with 60-day renewal
Covered 60% after deductible, 30 days with 60-day renewal
Outpatient mental health
Not covered
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 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.
Prescription Drugs
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 pharrmacys
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
Flexible Blue Maternity Benefits-at-a-Glance (Optional)
Note: Maternity coverage is optional and may be purchased with Flexible Blue
Individual plans. If the optional maternity coverage is not purchased at the same
time as Flexible Blue (i.e., at a later date), the 180-day waiting period for maternity
benefits begins with the effective date of the optional maternity coverage, not
the effective date of Flexible Blue.
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.
$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 out-of-pocket maximum: The annual out-of-pocket maximum limits the amount
you will be responsible for paying each 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).
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.
$10,000 per individual contract. $20,000 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.
Lifetime maximum per member
$5 million
Fourth-quarter deductible carryover
Not applicable
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
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,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
Covered 80% after deductible
Radiation therapy
Covered 80% after deductible
Covered 60% after deductible
Maternity Services
Delivery and newborn exam
Not covered (optional rider available)
Prenatal and postnatal exams (office visits)
Not covered (optional rider available)
Inpatient Hospital Care
Semi-private room: 120 days with 60-day renewal period (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
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 (BCBSMparticipating programs only)
Covered 100% after in-network deductible
Outpatient Services
Outpatient physical, occupational and speech therapy
Not covered
Not covered
Chemotherapy (IV and oral)
Covered 80% after deductible
Covered 60% after deductible
Home infusion therapy (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 transplant
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 80% after deductible, 30 days with 60-day renewal
Covered 60% after deductible, 30 days with 60-day renewal
Outpatient mental health
Not covered
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 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 a minimum of $10 and a maximum of $100
per prescription, 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 pharrmacys
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
Flexible Blue Maternity Benefits-at-a-Glance (Optional)
Note: Maternity coverage is optional and may be purchased with Flexible Blue
Individual plans. If the optional maternity coverage is not purchased at the same
time as Flexible Blue (i.e., at a later date), the 180-day waiting period for maternity
benefits begins with the effective date of the optional maternity coverage, not
the effective date of Flexible Blue.
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.
$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 out-of-pocket maximum: The annual out-of-pocket maximum limits the amount
you will be responsible for paying each 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).
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.
$11,600 per individual contract. $23,200 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.
Lifetime maximum (per member)
$5 million
Fourth-quarter deductible carryover
Not applicable
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
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,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
Covered 80% after deductible
Radiation therapy
Covered 80% after deductible
Covered 60% after deductible
Maternity Services
Delivery and newborn exam
Not covered (optional rider available)
Prenatal and postnatal exams (office visits)
Not covered (optional rider available)
Inpatient Hospital Care
Semi-private room: 120 days with 60-day renewal period (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 (BCBSMparticipating programs only)
Covered 100% after in-network deductible
Outpatient Services
Outpatient physical, occupational and speech therapy
Not covered
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 transplant
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 80% after deductible, 30 days with 60-day renewal
Covered 60% after deductible, 30 days with 60-day renewal
Outpatient mental health
Not covered
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 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.
Prescription Drugs
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 pharrmacys
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
Oral exams, bitewing X-rays, teeth cleanings and flouride
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 year. Once a member reaches the benefit maximum, services will not be paid for that member for the balance of the 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.
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.
Return to
top