Medical Insurance
HD 3400 Simply Blue PPO HDHP
Blue Cross Blue Shield of Michigan PPO medical plan
HD 3400 Simply Blue PPO HDHP
Video coming soon
Plan Details
- Carrier
- Blue Cross Blue Shield of Michigan (BCBSM)
- Plan type
- PPO HDHP
- Network
- BCBSM PPO Network
- Out-of-network coverage
- Yes
- HSA eligible
- Yes
- FSA eligible
- Yes
Premiums (Bi-Weekly)
| Coverage Tier | Company | Associate |
|---|---|---|
| Single | $365.51 | $17.31 |
| Two Person | $875.50 | $43.27 |
| Family | $1,058.12 | $90.35 |
Single
- Company
- $365.51
- Associate
- $17.31
Two Person
- Company
- $875.50
- Associate
- $43.27
Family
- Company
- $1,058.12
- Associate
- $90.35
- *Additional surcharges (working spouse, preventive exam, tobacco user) may be applied to associates enrolled in medical.
Coverage Details
| Feature | In-Network |
|---|---|
| Office Visit | 20% after deductible |
| Specialist Visit | 20% after deductible |
| Emergency Room | 20% after deductible |
| Urgent Care | 20% after deductible |
| Chiropractic Care | 12 visits per year |
| Annual Deductible - Single | $3,400 |
| Annual Deductible - Two Person/Family | $6,800 |
| Coinsurance After Deductible | 20% |
| Annual Coinsurance Maximum - Single | N/A |
| Annual Coinsurance Maximum - Two Person/Family | N/A |
| Annual Out-of-Pocket Maximum - Single | $6,900 |
| Annual Out-of-Pocket Maximum - Two Person/Family | $13,800 |
Office Visit
- In-Network
- 20% after deductible
Specialist Visit
- In-Network
- 20% after deductible
Emergency Room
- In-Network
- 20% after deductible
Urgent Care
- In-Network
- 20% after deductible
Chiropractic Care
- In-Network
- 12 visits per year
Annual Deductible - Single
- In-Network
- $3,400
Annual Deductible - Two Person/Family
- In-Network
- $6,800
Coinsurance After Deductible
- In-Network
- 20%
Annual Coinsurance Maximum - Single
- In-Network
- N/A
Annual Coinsurance Maximum - Two Person/Family
- In-Network
- N/A
Annual Out-of-Pocket Maximum - Single
- In-Network
- $6,900
Annual Out-of-Pocket Maximum - Two Person/Family
- In-Network
- $13,800
Prescription Drug Coverage
| Tier | 30-Day Supply (if available) |
|---|---|
| Tier 1: Generic | You pay Deductible first, then $10 copay |
| Tier 2: Preferred Brand Name | $40 copay |
| Tier 3: Non-Preferred Brand-name | $80 copay |
| Tier 4: Preferred Specialty Drugs | N/A |
| Tier 5: Non-Preferred Specialty Drugs | N/A |
Tier 1: Generic
- 30-Day Supply (if available)
- You pay Deductible first, then $10 copay
Tier 2: Preferred Brand Name
- 30-Day Supply (if available)
- $40 copay
Tier 3: Non-Preferred Brand-name
- 30-Day Supply (if available)
- $80 copay
Tier 4: Preferred Specialty Drugs
- 30-Day Supply (if available)
- N/A
Tier 5: Non-Preferred Specialty Drugs
- 30-Day Supply (if available)
- N/A
- Your prescription drug costs (other than for preventive medications) apply towards the annual deductible, and then a copay applies after the deductible is met.
- Prescription drug copays accumulate towards the annual out-of-pocket maximum.
Plan Notes
- You must satisfy the deductible before the plan begins paying for covered services. This means the cost for office visits and prescription drugs apply towards the deductible requirement. The only exception is preventive care, which is covered at 100% in network, with no deductible or coinsurance required.
- If you are enrolled as a two person or family contract and only one family member is incurring claims, that member will need to satisfy the entire family deductible for the plan to pay.
- After your annual deductible is satisfied, covered medical services (in-network) are paid at 80% and prescriptions are covered with a copay.
- Once your out-of-pocket maximum is met, the plan pays 100% of the approved amount for covered services, including office visits and prescription drug copays.
- If you enroll in the HDHP, you may be eligible to contribute to a Health Savings Account (HSA). You may use the money in an HSA to pay for current or future qualified medical expenses. You can fund your HSA with pre-tax contributions. The maximum contribution for 2026 is $4,400 for single coverage and $8,750 for family coverage.