Community Blue PPO – Plan 3
Benefits-at-a-Glance City of Saginaw
This is intended as an easy to read summary and provides only a general overview of your benefits. It is not a contract. Additional limitations and exclusions may apply to covered services. For a complete description of benefits, please see the applicable Blue Cross Blue Shield of Michigan certificates and riders. Payment amounts are based on the Blue Cross Blue Shield of Michigan approved amount, less any applicable deductible and/or copay amounts required by your plan. This coverage is provided pursuant to a contract entered into in the state of Michigan and will be construed under the jurisdiction of and according to the laws of the state of Michigan.
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In-network |
Out-of-Network |
Member’s responsibility (deductibles, copays and dollar maximums) |
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Deductibles |
$250 for one member, $500 for the family (when two or more members are covered under your contract) each calendar year |
$1,000 for one member, $2,000 for the family (when two or more members are covered under your contract) each calendar year |
Copays
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$20 for office visits and $75 for emergency room visits |
$75 for emergency room visits |
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20% for general services (copay waived if the service is performed in a PPO physicians office) and 50% for mental health care, substance abuse treatment and private duty nursing |
50% for general and 50% for mental health care, substance abuse treatment and private duty nursing |
Copay dollar maximums
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None |
None |
$1,000 for one member, $2,000 for two or more members each calendar year |
$4,000 for one member, $8,000 for two or more members each calendar year |
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Dollar Maximums |
$1 million lifetime per covered specified human organ transplant type and a separate $5 million lifetime per member for all other covered services and as noted for individual services. |
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Preventative care services
*Payment for preventative services is limited to a combined maximum of $500 per member per calendar year
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In-network |
Out-of-Network |
Health maintenance exam – includes chest x-ray, EKG and select lab procedures |
Covered – 100%*, one per calendar year |
Not covered |
Gynecological exam |
Covered – 100%*, one per calendar year |
Not covered |
Pap smear screening – laboratory and pathology services |
Covered – 100%*, one per calendar year |
Not covered |
Well-baby and child care |
Covered – 100%*
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Not covered |
Childhood immunizations as recommended by the Advisory Committee on Immunization Practices and the American Academy of Pediatrics |
Covered – 100%*, one per calendar year |
Not covered |
Fecal occult blood screening |
Covered – 100%*, one per calendar year |
Not covered |
Flexible sigmoidoscopy exam |
Covered – 100%*, one per calendar year |
Not covered |
Prostate specific antigen (PSA) screening |
Covered – 100%*, one per calendar year |
Not covered |
Mammography |
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Mammography screening |
Covered – 100%*, one per calendar year |
Covered – 50% after deductible |
One per calendar year, no age restrictions |
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In-network |
Out-of-Network |
Physician office services |
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Office visits |
Covered - $20 copay per office visit |
Covered – 50% after deductible, must be medically necessary |
Outpatient and home medical care visits |
Covered – 80% after deductible |
Covered – 50% after deductible, must be medically necessary |
Office consultations |
Covered - $20 copay per office visit |
Covered – 50% after deductible, must be medically necessary |
Urgent care visits |
Covered - $20 copay per office visit |
Covered – 50% after deductible, must be medically necessary |
Emergency medical care |
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Hospital emergency room |
Covered - $75 copay per visit (copay waived if admitted or for an accidental injury) |
Covered - $75 copay per visit (copay waived if admitted or for an accidental injury) |
Ambulance services – must be medically necessary |
Covered – 80% after deductible |
Covered – 80% after deductible |
Diagnostic services |
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Laboratory and pathology services |
Covered – 80% after deductible |
Covered – 50% after deductible |
Diagnostic tests and x-rays |
Covered – 80% after deductible |
Covered – 50% after deductible |
Therapeutic radiology |
Covered – 80% after deductible |
Covered – 50% after deductible |
Maternity services provided by a physician |
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Prenatal and postnatal care |
Covered – 100% |
Covered – 50% after deductible |
Includes care provided by a certified nurse midwife |
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Delivery and nursery care |
Covered – 80% after deductible |
Covered – 50% after deductible |
Includes delivery provided by a certified nurse midwife |
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Hospital care |
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Semiprivate room, inpatient physician care, general nursing care, hospital services and supplies |
Covered – 80% after deductible |
Covered – 50% after deductible |
Unlimited days |
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Inpatient consultations |
Covered – 80% after deductible |
Covered – 50% after deductible |
Chemotherapy |
Covered – 80% after deductible |
Covered – 50% after deductible |
Alternatives to hospital care |
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Skilled nursing care |
Covered – 80% after deductible |
Covered – 80% after deductible |
Up to 120 days per member per calendar year |
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Hospice care |
Covered – 100% |
Covered – 100% |
Limited to dollar maximum that is reviewed and adjusted periodically |
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Home health care – must be medically necessary |
Covered – 80% after deductible |
Covered – 80% after deductible |
Home infusion therapy – must be medically necessary |
Covered – 80% after deductible |
Covered – 80% after deductible |
Surgical services |
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Surgery – includes related surgical services and medically necessary facility services by a participating ambulatory surgery facility |
Covered – 80% after deductible |
Covered – 50% after deductible |
Presurgical consultations |
Covered – 100% |
Covered – 50% after deductible |
Colonoscopy |
Covered – 80% after deductible |
Covered – 50% after deductible |
Voluntary sterilization |
Covered – 80% after deductible |
Covered – 50% after deductible |
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In-network |
Out-of-Network |
Human organ transplants |
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Specified human organ transplants – in designated facilities only, when coordinated through the BCBSM Human Organ Transplant Program (800-242-3504) |
Covered – 100% |
Covered – in designated facilities only |
Limited to $1 million lifetime maximum per member per transplant type for transplant procedure(s) and related professional, hospital and pharmacy services |
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Bone marrow transplants – when coordinated through the BCBSM Human Organ Transplant Program (800-242-3504) |
Covered – 80% after deductible |
Covered – 50% after deductible |
Specified oncology clinical trials |
Covered – 80% after deductible |
Covered – 50% after deductible |
Kidney, cornea and skin transplants |
Covered – 80% after deductible |
Covered – 50% after deductible |
Mental health care and substance abuse treatment |
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Inpatient mental health care |
Covered – 50% after deductible |
Covered – 50% after deductible |
Unlimited days |
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Inpatient substance abuse treatment |
Covered – 50% after deductible |
Covered – 50% after deductible |
Unlimited days, up to $15,000 annual, $30,000 lifetime maximum |
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Outpatient mental health care
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Covered – 50% after deductible |
Covered – 50% after deductible |
Covered – 50% |
Covered – 50% after deductible |
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Outpatient substance abuse treatment – in approved facilities only |
Covered – 50% after deductible |
Covered – 50% after deductible |
Up to the state-dollar amount that is adjusted annually |
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Other covered services |
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Outpatient Diabetes Management Program (ODMP) |
Covered – 80% after deductible |
Covered – 50% after deductible |
Allergy testing and therapy |
Covered – 100% |
Covered – 50% after deductible |
Chiropractic manipulation treatment and osteopathic manipulation treatment |
Covered – $20 copay per office visit |
Covered – 50% after deductible |
Up to a maximum of 24 visits per member per calendar year |
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Outpatient physical, speech and occupational therapy |
Covered – 80% after deductible |
Covered – 50% after deductible |
Limited to a combined maximum of 60 visits per member per calendar year |
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Durable medical equipment |
Covered – 80% after deductible |
Covered – 80% after deductible |
Prosthetic and orthotic appliances |
Covered – 80% after deductible |
Covered – 80% after deductible |
Private duty nursing |
Covered – 50% after deductible |
Covered – 50% after deductible |