Medical Insurance
PPO 1500 Simply Blue
Blue Cross Blue Shield of Michigan PPO medical plan
PPO 1500 Simply Blue
Video coming soon
Plan Details
- Carrier
- Blue Cross Blue Shield of Michigan (BCBSM)
- Plan type
- PPO
- Network
- BCBSM PPO Network
- Out-of-network coverage
- Yes
- HSA eligible
- No
- FSA eligible
- Yes
Premiums (Bi-Weekly)
| Coverage Tier | Company | Associate |
|---|---|---|
| Single | $404.72 | $101.54 |
| Two Person | $948.81 | $266.22 |
| Family | $1,150.47 | $368.31 |
Single
- Company
- $404.72
- Associate
- $101.54
Two Person
- Company
- $948.81
- Associate
- $266.22
Family
- Company
- $1,150.47
- Associate
- $368.31
- *Additional surcharges (working spouse, preventive exam, tobacco user) may be applied to associates enrolled in medical.
Coverage Details
| Feature | In-Network |
|---|---|
| Office Visit | $30 copay |
| Specialist Visit | $30 copay |
| Emergency Room | $150 |
| Urgent Care | $40 |
| Chiropractic Care | 12 visits per year |
| Annual Deductible - Single | $1,500 |
| Annual Deductible - Two Person/Family | $3,000 |
| Coinsurance After Deductible | 20% |
| Annual Coinsurance Maximum - Single | $2,500 |
| Annual Coinsurance Maximum - Two Person/Family | $5,000 |
| Annual Out-of-Pocket Maximum - Single | $6,350 |
| Annual Out-of-Pocket Maximum - Two Person/Family | $12,700 |
Office Visit
- In-Network
- $30 copay
Specialist Visit
- In-Network
- $30 copay
Emergency Room
- In-Network
- $150
Urgent Care
- In-Network
- $40
Chiropractic Care
- In-Network
- 12 visits per year
Annual Deductible - Single
- In-Network
- $1,500
Annual Deductible - Two Person/Family
- In-Network
- $3,000
Coinsurance After Deductible
- In-Network
- 20%
Annual Coinsurance Maximum - Single
- In-Network
- $2,500
Annual Coinsurance Maximum - Two Person/Family
- In-Network
- $5,000
Annual Out-of-Pocket Maximum - Single
- In-Network
- $6,350
Annual Out-of-Pocket Maximum - Two Person/Family
- In-Network
- $12,700
Prescription Drug Coverage
| Tier | 30-Day Supply (if available) |
|---|---|
| Tier 1: Generic | $10 copay |
| Tier 2: Preferred Brand Name | $40 copay |
| Tier 3: Non-Preferred Brand-name | $80 copay |
| Tier 4: Preferred Specialty Drugs | 15% of approved amount, but no more than $150 |
| Tier 5: Non-Preferred Specialty Drugs | 25% of approved amount, but no more than $300 |
Tier 1: Generic
- 30-Day Supply (if available)
- $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)
- 15% of approved amount, but no more than $150
Tier 5: Non-Preferred Specialty Drugs
- 30-Day Supply (if available)
- 25% of approved amount, but no more than $300
- Prescription drug copays accumulate towards the annual out-of-pocket maximum.
Plan Notes
- All medical options are preferred provider organization (PPO) plans with in-network and out-of-network benefits. Out-of-network services are paid as out-of-network, even if referred by a PPO provider.
- An office visit copayment applies to the exam. Deductibles and coinsurance apply to any visit services; services include diagnostic (including complex), surgery and therapeutic. Cost share may not apply if preventive or immunization services are provided during the office visit.
- Preventive care services are covered at 100% in network, with no deductible, copay or coinsurance required.
- Emergency room copay is not waived for accidental injury; copay is waived for admission.
- Covers physical, speech and occupational therapy up to 30 visits per calendar year. Chiropractic care has a 12 visit limit.
- Deductible and coinsurance apply to outpatient mental health and substance abuse visits.