All benefits are subject to the definitions, limitations, and exclusions set forth in the federal brochure. Before making a final decision, please read the Plan’s federal brochure (RI 71-005). This is a summary of the features of the Blue Cross and Blue Shield Service Benefit Plan. The formulary and/or pharmacy network may change at any time. Enrollment in MPDP depends on contract renewal. The FEP Medicare Prescription Drug Program is a prescription drug plan with a Medicare contract. 3 You must be the contract holder or spouse, 18 or older, on a Standard or Basic Option Plan to earn incentive rewards.2 If you have Medicare Part B primary, your costs for prescription drugs may be lower.1 Under Basic Option you pay 30% of our allowance for agents, drugs and/or supplies you receive during your care.This includes doctors, dentists, hospitals, urgent care centers, and more. BCBS members can can visit the Blue Cross Blue Shield Provider Finder to find in-network providers. ^ What you’ll pay for a 30-day supply of covered drugs. There are several places you can go for medical care: a doctor’s office, an urgent care center, a retail health clinic or the emergency room.Under Basic Option, benefits are not available for services performed by Non-preferred providers, except in certain situations such as emergency care.Ĭost sharing may not apply or may be different if Medicare is your primary coverage (it pays first). Tier 4 (Preferred specialty): $85 copay 2 Visit the Medicare page for more information.
Tier 5 (Non-preferred specialty): $110 copay 2Īvailable to members with Medicare Part B primary only. Tier 4 (Preferred specialty): $85 copay 2 Tier 3 (Non-preferred brand): 60% of our allowance ( $90 minimum) 2 $0 for first 2 visits and all nutrition visits 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.Nothing for covered preventive screenings, immunizations and services Payment amounts are based on the BCBSM-approved amount, less any applicable deductible, copay and/or coinsurance amounts required by the plan. In the event of a conflict between this document and the applicable certificate and riders, the certificate and riders will rule.
A complete description of benefits is contained in the applicable Blue Cross Blue Shiled of Michigan certificate and riders. Additional limitations and exclusions may apply to covered services. This document is intended to be an easy-to-read summary.
#Blue cross blue shield copay emergency room professional
Conditions covered by workers’ compensation or similar law services or supplies not specifically listed as covered under your benefit plan services received before your effective date or after coverage ends services you wouldn’t have to pay for if you did not have this coverage services or supplies that are not medically necessary physical exams for insurance, employment, sports or school any amounts in excess of BCBSM’s approved amount cosmetic surgery, admissions and hospitalizations dental care, dental implants or treatment to the teeth except as specifically stated in your benefit plan hearing aids infertility-related drugs private duty nursing telephone, fax machine or any other type of electronic consultation educational services, except as specifically provided or arranged by BCBSM or specifically stated in your benefit plan care or treatment furnished in a nonparticipating hospital, except as specifically stated in your benefit plan personal comfort items custodial care services or supplies supplied to any person not covered under your benefit plan services while confined in a hospital or other facility owned or operated by state or federal government, unless required by law voluntary abortions or vasectomy reversals RK, PRRK, or Lasik services provided by a professional provider to a family member services provided by any person who ordinarily resides in the covered person’s home or who is a family member any drug, medicine or device that is not approved by the Food and Drug Administration, unless required by law vitamins, dietary products and any other nonprescription supplements except as specifically stated in your benefit plan dental services, except for dental injury appliances, supplies or services as a result of war or any act of war, whether declared or not communication or travel time, lodging or transportation, except as stated in your benefit plan foot care services, except as stated in your benefit plan health clubs or health spas, aerobic and strength conditioning, work-hardening programs and related material and products for these programs hair prosthesis, hair transplants or implants experimental treatments, except as stated in your benefit plan and alternative medicines or therapies.
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