|
Exhibits A, B, and C
Your Health Care Plan
The benefit chart(s) in Your Benefits Guide are designed to
provide you with a summary of the services covered under your health
plan. You will need to reference the actual certificate(s) or
rider(s) for detailed information about a benefit including any
exclusions or limitations.
When you need to reference a certificate or rider, simply match
the form number from the benefit chart (located to the left of the
benefit) to the same form number on the navigation bar. Then double
click on the form number in the navigation bar.
Dependent Continuation
4656 - DC
Dependents between the
ages of 19 and 25 provided they meet all of the requirements of this
rider.
Sponsored Dependents
3326 - SD
Dependent coverage for
those individuals who are financially dependent on the subscriber if
they meet all of the requirements of this rider.
Community Blue PPO Benefit Chart
Deductible, Copays and Dollar Maximums - $1 million lifetime per
covered specified organ transplant type and a separate $5 million
lifetime per member for all other covered services and as noted
below for individual services.
| Benefits |
Form |
In-Network |
Form |
Out-of-Network |
| Deductible |
5775 |
$100 per person or $200 for the
family per calendar year |
6225 |
$250 per person or $500 for the
family per calendar year
Note: Your out-of-network deductible amount will also be
applied to your in-network requirement. |
| Fixed Dollar Copays |
6225
6225 |
$10 copay for specific office
services $50 copay for emergency services, waived if
admitted or for an accidental injury |
6225
6225 |
Not applicable $50 copay for
emergency services, waived if admitted or for an accidental
injury |
| Percent Copays |
577501 |
10 percent copay after
Deductible |
5769 |
30 percent copay after
Deductible |
| Mental Health Percent Copay |
6225 |
50 percent copay
afterdeductible |
6225 |
30 percent copay after
deductible |
| Private Duty Nursing Percent
Copay |
6225 |
50 percent copay after
deductible |
6225 |
30 percent copay after
deductible |
| Copay Dollar Maximums |
5815 |
$500 per member, $1,000 for the
family per calendar year |
5857 |
$1,500 per member, $3,000 for
the family per calendar year |
Preventive Care Service - $500 annual maximum for covered
preventive care services. (Form Number - 3742)
| Benefits |
Form |
In-Network |
Form |
Out-of-Network |
| Health Maintenance Exam -
includes chest X-ray, EKG and select lab procedures, one per
member, per calendar year |
6225 |
Covered - 100 percent of
approved amount |
6225 |
Not Covered |
| Gynecological Exam - one per
member, per calendar year |
6225 |
Covered - 100 percent of
approved amount |
6225 |
Not Covered |
| Pap Smear Screening, laboratory
and pathology services, one per member, per calendar year |
6225 |
Covered - 100 percent of
approved amount |
6225 |
Not Covered |
|
Well-Baby and
Child Care
- 6 visits, birth
through 12 months
- 6 visits, 13
months through 23 months
- 2 visits, 24
months through 35 months
- 2 visits, 36
months through 47 months
- 1 visit per
birth year, 48 months through age 15 |
6225 |
Covered - 100 percent of
approved amount |
6225 |
Not Covered |
| Immunizations, up through age
16 |
6225 |
Covered - 100 percent of
approved amount |
6225 |
Not Covered |
| Fecal Occult Blood Screening,
one per member, per calendar year |
6225 |
Covered - 100 percent of
approved amount |
6225 |
Not Covered |
| Flexible Sigmoidoscopy Exam,
one per member, per calendar year |
6225 |
Covered - 100 percent
ofapproved amount |
6225 |
Not Covered |
| Prostate Specific Antigen (PSA)
Screening, one per member, per calendar year |
6225 |
Covered - 100 percent of
approved amount |
6225 |
Not Covered |
Mammography
| Benefits |
Form |
In-Network |
Form |
Out-of-Network |
| Mammography Screening, one per
contract year, no age restrictions |
577501 |
Covered - 90 percent of
approved amount after deductible |
5769 |
Covered - 70 percent of
approved amount after deductible |
Physician Office Services
| Benefits |
Form |
In-Network |
Form |
Out-of-Network |
| Office Visits |
6225 |
Covered - $10 copay for
specific office services |
5769 |
Covered - 70 percent of
approved amount after deductible, must be medically
necessary |
| Outpatient and Home Visits |
6225 |
Covered - 90 percent of
approved amount after deductible |
5769 |
Covered - 70 percent of
approved amount after deductible, must be medically
necessary |
| Office Consultations |
6225 |
Covered - $10 copay for
specific office services |
5769 |
Covered - 70 percent of
approved amount after deductible, must be medically
necessary |
| Urgent Care Visits |
6225 |
Covered - $10 copay for
specific office services |
5769 |
Covered - 70 percent of
approved amount after deductible, must be medically
necessary |
Emergency Medical Care
| Benefits |
Form |
In-Network |
Form |
Out-of-Network |
| Hospital Emergency Room |
6225 |
$50 copay for emergency
services, waived if admitted or for an accidental injury |
6225 |
$50 copay for emergency
services, waived if admitted or for an accidental injury |
| Ambulance Services when
medically necessary |
577501 |
Covered - 90 percent of
approved amount after deductible |
577501 |
Covered - 90 percent of
approved amount after deductible |
Diagnostic Services
| Benefits |
Form |
In-Network |
Form |
Out-of-Network |
| Laboratory and Pathology
Services |
577501 |
Covered - 90 percent of
approved amount after deductible |
5769 |
Covered - 70 percent of
approved amount after deductible |
| Diagnostic Tests and X-rays |
577501 |
Covered - 90 percent of
approved amount after deductible |
5769 |
Covered - 70 percent of
approved amount after deductible |
| Therapeutic Radiology |
577501 |
Covered - 90 percent of
approved amount after deductible |
5769 |
Covered - 70 percent of
approved amount after deductible |
Maternity Services Provided by a Physician
| Benefits |
Form |
In-Network |
Form |
Out-of-Network |
| Prenatal and Postnatal Care |
6225 |
Covered - 100 percent of
approved amount |
5769 |
Covered - 70 percent of
approved amount after deductible |
| Delivery and Nursery Care |
577501 |
Covered - 90 percent of
approved amount after deductible |
5769 |
Covered - 70 percent of
approved amount after deductible |
Hospital Care
| Benefits |
Form |
In-Network |
Form |
Out-of-Network |
| Semiprivate Room, Inpatient
Physician Care, General Nursing Care, Hospital Services and
Supplies Note: Nonemergency services must be rendered in a
participating hospital |
577501 |
Covered - 90 percent of
approved amount after deductible |
5769 |
Covered - 70 percent of
approved amount after deductible |
| Inpatient Consultations |
577501 |
Covered - 90 percent of
approved amount after deductible |
5769 |
Covered - 70 percent of
approved amount after deductible |
| Chemotherapy |
577501 |
Covered - 90 percent of
approved amount after deductible |
5769 |
Covered - 70 percent of
approved amount after deductible |
Alternatives to Hospital Care
| Benefits |
Form |
In-Network |
Form |
Out-of-Network |
| Skilled Nursing Care - Up to
120 days per member, per calendar year |
577501 |
Covered - 90 percent of
approved amount after deductible |
577501 |
Covered - 90 percent of
approved amount after deductible |
| Hospice Care - limited to
dollar maximum which is reviewed and adjusted periodically |
6225 |
Covered - 100 percent of
approved amount |
6225 |
Covered - 100 percent of
approved amount |
| Home Health Care |
577501 |
Covered - 90 percent of
approved amount after deductible |
577501 |
Covered - 90 percent of
approved amount after deductible |
Surgical Services
| Benefits |
Form |
In-Network |
Form |
Out-of-Network |
Surgery - includes related
surgical services
- Participating Ambulatory Surgery Facility |
577501 |
Covered - 90 percent of
approved amount after deductible |
5769 |
Covered - 70 percent of
approved amount after deductible |
| Voluntary Sterilization |
577501 |
Covered - 90 percent of
approved amount after deductible |
5769 |
Covered - 70 percent of
approved amount after deductible |
Human Organ Transplants
| Benefits |
Form |
In-Network |
Form |
Out-of-Network |
| Specified Organ Transplants –
in designated facilities only, when coordinated through the
BCBSM Human Organ Transplant Program (1-800-242-3504), up to
$1 million lifetime maximum per transplant type |
6225 |
Covered - 100 percent of
approved amount |
6225 |
Covered - 100 percent of
approved amount in designated facilities only |
| Bone Marrow – when coordinated
through the BCBSM Human Organ Transplant Program
(1-800-242-3504); specific criteria applies |
577501 |
Covered - 90 percent of
approved amount after deductible |
5769 |
Covered - 70 percent of
approved amount after deductible |
| Kidney, Cornea and Skin |
577501 |
Covered - 90 percent of
approved amount after deductible |
5769 |
Covered - 70 percent of
approved amount after deductible |
| Specified Oncology Clinical
Trials |
577501 |
Covered - 90 percent of
approved amount after deductible |
5769 |
Covered - 70 percent of
approved amount after deductible |
Mental Health Care and Substance Abuse Treatment
| Benefits |
Form |
In-Network |
Form |
Out-of-Network |
| Inpatient Mental Health Care -
limited to $15,000 annually and $30,000 lifetime. |
6225 |
Covered - 50 percent of the
approved amount after deductible |
6225 |
Covered - 50 percent of the
approved amount after deductible |
| Inpatient Substance Abuse
Treatment -limited to $15,000 annually and $30,000 lifetime. |
6225 |
Covered - 50 percent of the
approved amount after deductible |
6225 |
Covered - 50 percent of the
approved amount after deductible |
Outpatient Mental Health Care -
limited to $2,000 per member annually and $5,000 lifetime
- Facility and Clinic
- Physician´s Office |
6225 |
Covered - 50 percent of the
approved amount after deductible |
6225 |
Covered - 50 percent of the
approved amount after deductible |
| Outpatient Substance Abuse
Treatment in approved facilities, up to the state dollar
amount which is adjusted annually |
6225 |
Covered - 50 percent of the
approved amount after deductible |
6225 |
Covered - 50 percent of the
approved amount after deductible |
Other Services
| Benefits |
Form |
In-Network |
Form |
Out-of-Network |
| Outpatient Diabetes Management
Program (ODMP) |
577501 |
Covered - 90 percent of
approved amount after deductible |
5769 |
Covered - 70 percent of
approved amount after deductible |
| Allergy Testing and Therapy |
6225 |
Covered - 100 percent of
approved amount |
5769 |
Covered - 70 percent of
approved amount after deductible |
| Chiropractic Spinal
Manipulation Note: Up to 24 visits per member, per
calendar year |
6225 |
Covered - 100 percent of
approved amount |
5769 |
Covered - 70 percent of
approved amount after deductible |
| Outpatient Physical, Speech and
Occupational Therapy Note: A combined 60-visit maximum per
calendar year for physical therapy in the outpatient
department of a hospital as well as in the physician’s
office
- Facility and Clinic |
577501 |
Covered - 90 percent of
approved amount after deductible |
577501 |
Covered - 90 percent of
approved amount after deductible |
| - Physician´s Office - excludes
speech and occupational therapy |
6225 |
Covered - 100 percent of
approved amount |
5769 |
Covered - 70 percent of
approved amount after deductible |
| Durable Medical Equipment |
577501 |
Covered - 90 percent of
approved amount after deductible |
577501 |
Covered - 90 percent of
approved amount after deductible |
| Prosthetic and Orthotic
Appliances |
577501 |
Covered - 90 percent of
approved amount after deductible |
577501 |
Covered - 90 percent of
approved amount after deductible |
| Private Duty Nursing |
6225 |
Covered - 50 percent of
approved amount after deductible |
6225 |
Covered - 50 percent of
approved amount after deductible |
Note: Temporary benefits for hospital services – When a hospital
chooses to terminate its participating contract with BCBSM, your
coverage provides temporary benefits for emergency care and for
certain services for up to six months from the date the hospital
terminates its participating contract with Blue Cross Blue Shield of
Michigan. Please refer to rider Temporary Benefits for Hospital
Services (form #1700) for covered benefits under this arrangement.
Blue Preferred RX - Benefit Chart for Prescription Drug Coverage
The following benefit chart is designed to provide you with a
summary of the services covered under your plan. You will need to
reference the actual certificate(s) or rider(s) for detailed
information about a benefit including any exclusions or limitations
Choosing your pharmacy
The amount you pay in out-of-pocket costs depends on whether or
not you use a network or non-network pharmacy. You will have the
least out-of-pocket costs when you use network pharmacies.
Important: Pharmacies outside of Michigan must use the MedImpact
BIN and PC number below to verify your eligibility, not the
five-digit group number on your ID card.
MedImpact Rx BIN 003585/Rx PCN 23615
If the pharmacist needs assistance, he or she may call the
MedImpact Provider Help Desk at 1-800-239-1023.
| Benefits |
Form |
In-Network |
Form |
Out-of-Network |
| Dollar Copay |
2617 |
$10 for each generic drug $40
for each brand-name drug, even if the prescription is marked
"DAW" or there is no generic equivalent drug available |
2617 |
$10 for each generic drug $40
for each brand-name drug, even if the prescription is marked
"DAW" or there is no generic equivalent drug
available, plus 25 percent of the approve amount |
| Mail Order (Home Delivery)
Prescription Drugs Note: Specialty drugs are covered
through mail order such as cancer drugs, hormone,
antirejection and etc. |
2138 |
Covered - Copay is a separate
copay amount for covered drugs up to 34 days supply for
prescription or refill Copay is double for drugs more than a
35 up to 90 day supply for prescription or refill. |
2138 |
Not Covered |
Preferred RX Drug Plan
| Benefits |
Form |
In-Network |
Form |
Out-of-Network |
| Federal Legend Drugs |
3607 |
Covered - 100 percent of
approved amount less plan copay |
3607 |
Covered - 75 percent of
approved amount less plan copay |
| State-controlled Drugs |
3607 |
Covered - 100 percent of
approved amount less plan copay |
3607 |
Covered - 75 percent of
approved amount less plan copay |
| Disposable Needles and Syringes
– dispensed with insulin |
3607 |
Covered - 100 percent of
approved amount less plan copay |
3607 |
Covered - 75 percent of
approved amount less plan copay |
| Mail Order (Home Delivery)
Prescription Drugs Note: Specialty drugs are covered
through mail order such as cancer drugs, hormone,
antirejection and etc. |
2138 |
Covered - 100 percent of
approved amount less plan copay |
2138 |
Not Covered |
Copayment for Network and Non-Network Providers
| Class of Dental Services |
BCBSM Pays In-Network Providers |
Your Copay In-Network |
BCBSM Pays Out-of-Network
Providers |
Your Copayment Out-of-Network |
| Class I |
100% |
None |
50% |
50% |
| Class II |
75% |
25% |
50% |
50% |
| Class III |
50% |
50% |
50% |
50% |
| Class IV |
50% |
50% |
40% |
60% |
These are the codes for your Certificates and Riders and are for
internal use by BCBSM:
0507-MHP-E
1700-TBHD
2138AD-MOPD2X/10/40 65
261765-$10/40 65
360765-PREFERRED RX 65
374068-INON7 PLAN3-65
408703-RDR GPC SAT II
494365-DNTLOPT CERT65
5385-CRNA
577501-CBD$100P 90/10
5857-CBCMNP1500
6502-65 OPT 2
6603-CB-PCB
MMPD65-CATASTROPHIC 65
0738-65 OPTION 1
2138AC-MOPD2X W/$10/40
2617- $10/$40 RX
3607-PREFERRED RX
374003-IN-ON 7 PLAN 3
3742-CB-PCM-500
4943-DENTAL OPT CERT
5216-ECIP
5769-CBC 30% NP
5815-CB-CMP $500/90
6225-COMM BLUE BASIC
6600-CNM
993009-GLE-1
Tracking Number 224734
| Service Key |
Effective Date |
| C186PU |
07/01/2001 |
| S1A0MT |
07/01/2004 |
Blue Cross Blue Shield of Michigan provides administrative claims
payment services only and does not assume any financial risk or
obligation with respect to claims.
This handbook is not a contract. It is intended as a brief
description of benefits. Every effort has been made to ensure the
accuracy of the information within. However, if statements in this
description differ from the applicable coverage documents, then the
terms and conditions of those documents will prevail.
Blue Cross Blue Shield of Michigan administers the program for
your employer. Blue Cross Blue Shield of Michigan does not insure
the coverage. Benefits and future changes in benefits are the
responsibility of your employer. Information concerning members may
be reviewed by your employer and Blue Cross Blue Shield of Michigan.
The 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.
Tracking Number 224734
CompuSet44200799.txt
Group No:00426/613 Eff:11/15/59
Sales Office B:110 Pr:4/17/2007 Qty:15
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