Medical Insurance
PPO 3000 Simply Blue
Blue Cross Blue Shield of Michigan PPO medical plan
PPO 3000 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 | $365.33 | $85.33 |
| Two Person | $918.77 | $162.82 |
| Family | $1,058.25 | $293.73 |
Single
- Company
- $365.33
- Associate
- $85.33
Two Person
- Company
- $918.77
- Associate
- $162.82
Family
- Company
- $1,058.25
- Associate
- $293.73
- *Additional surcharges (working spouse, preventive exam, tobacco user) may be applied to associates enrolled in medical.
Coverage Details
| Feature | In-Network |
|---|---|
| Office Visit | $40 copay |
| Specialist Visit | $60 copay |
| Emergency Room | $250 |
| Urgent Care | $60 |
| Chiropractic Care | 12 visits per year |
| Annual Deductible - Single | $3,000 |
| Annual Deductible - Two Person/Family | $6,000 |
| Coinsurance After Deductible | 20% |
| Annual Coinsurance Maximum - Single | $2,500 |
| Annual Coinsurance Maximum - Two Person/Family | $5,000 |
| Annual Out-of-Pocket Maximum - Single | $8,150 |
| Annual Out-of-Pocket Maximum - Two Person/Family | $16,300 |
Office Visit
- In-Network
- $40 copay
Specialist Visit
- In-Network
- $60 copay
Emergency Room
- In-Network
- $250
Urgent Care
- In-Network
- $60
Chiropractic Care
- In-Network
- 12 visits per year
Annual Deductible - Single
- In-Network
- $3,000
Annual Deductible - Two Person/Family
- In-Network
- $6,000
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
- $8,150
Annual Out-of-Pocket Maximum - Two Person/Family
- In-Network
- $16,300
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.