| Health care benefit | Priority Health
888 446-5674 | BCBSM
800 422-9146 |
|---|
| Annual deductible |
None |
$500 individual* |
| Office calls |
- $15 copay for PCP
- $30 copay for specialists, no referral required
|
10% coinsurance, in-network, after deductible |
| Routine physical exams |
$15 copay for PCP |
Not covered |
| Routine Pap smears |
Covered in full |
- Covered in full at office visit and Quest Labs
- 10% coinsurance, outpatient, after deductible
|
| Routine mammograms |
Covered in full |
10% coinsurance, in-network, after deductible |
| Allergy testing and treatment |
Included in office visit |
10% coinsurance, in-network after deductible |
| Chiropractic visits |
- Covered as part of rehabilitation therapy benefit
- $15 copay
- Max benefit 30 visits per year - combined with physical and occupational therapy
|
- 10% coinsurance, in-network, after deductible
- 26 visits per year
|
| Hospital - inpatient care |
10% coinsurance |
10% coinsurance, in-network, after deductible, up to 365 days |
| Hospital - outpatient care (including diagnostic services) |
10% coinsurance |
10% coinsurance, in-network, after deductible |
| Medical/surgical care (including surgery, anesthesia, technical surgical assistance) |
10% coinsurance |
10% coinsurance, in-network, after deductible |
| Emergency medical care |
- $65 copay (waived if admitted)
- Worldwide coverage
|
- 10% coinsurance after deductible
- $50 copay once deductible and coinsurance max are met
|
| Urgent medical care |
- $45 copay
- Worldwide coverage
|
10% coinsurance, in-network, after deductible |
| Care outside Michigan |
- Covered for urgent care and emergencies, same as in Michigan
- Most other services covered at 70% after $300 deductible up to $500 maximum
|
- Same in U.S. through Blue Card
- Outside U.S., hospital coverage through Blue Card worldwide
|
| Care outside the network in Michigan |
- Covered for urgent care and emergency care
|
Additional 20% out-of-network fee; waived if member has a referral from a Blue Preferred PPO physician |
| Home health care |
Covered in full |
Deductible applies |
| Skilled nursing facility |
No copay. 100 days (can be renewed). |
10% coinsurance after deductible; up to 100 days |
| Hospice |
Covered in full |
Deductible applies |
| Outpatient mental health services |
$15 copay |
10% coinsurance after deductible |
| Prescription drugs |
- Generic: $10 copay
- Preferred brand: $40 copay
- Non-preferred brand: $70 copay
- Specialty medications: 20% coinsurance, maximum $100 per prescription
- Up to 3-month supply available for 2 copays through mail pharmacy service. Use of mail pharmacy service is not required.
|
- 20% copay
- $7 min/$36 max retail pharmacy (1-month supply); $17.50 min/$90 max (3-month supply); additional charge on maintenance drug on or after the 4th refill if not purchased at most cost-effective venue
- $1,000* individual drug copay max for prescriptions on the formulary; 40% out-of-pocket for non-formulary drugs
|
| Durable medical equipment supplier |
20% coinsurance |
- SUPPORT Network supplier in MI - full coverage
- 20% coinsurance plus difference in cost for non-network supplier in MI
- Deductible and 10% coinsurance outside Michigan from a Blue participant
- Deductible and 10% coinsurance plus difference in cost from non-Blue participant
|
| Hearing benefits |
- Hearing and audiometric exams covered in full every 36 months
- Hearing aid covered in full up to $1,000 per aid every three years
|
- 10% coinsurance after deductible
- 2 hearing aids (purchased same day)
- Includes exams every 36 months
|
| Out-of-pocket maximum |
- $500 in-network
- $500 travel benefit
|
$800 individual* |
