Blue Cross® Premier PPO Gold Extra - 15560MI1130002 Health Insurance Plan
Blue Cross Blue Shield of Michigan Mutual Insurance Company health insurance plan with the Plan ID 15560MI1130002. The plan is called Blue Cross® Premier PPO Gold Extra.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.02% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 21.98% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.
| Health Insurance Plan ID | 15560MI1130002 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Michigan | ||||||||||||||||||
| Health Insurance Issuer | Blue Cross Blue Shield of Michigan Mutual Insurance Company | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 15560MI1130002-03 | ||||||||||||||||||
| Provider Network(s) | NULL | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 22 Oct 2024 06:47 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 15560MI1130002-00 Standard On Exchange Plan - 15560MI1130002-01 |
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| Last Plan Update Date | Wed, 16 Aug 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 22 Oct 2024 06:47 GMT |
Benefits of Blue Cross® Premier PPO Gold Extra Health Insurance Plan, 15560MI1130002-03
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
Accidental injury and emergency only. |
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | 25.00% Coinsurance after deductible |
45.00% Coinsurance after deductible |
| Bariatric Surgery
Limit: 1.0 Procedure(s) per Lifetime Subject to BCBSM medical criteria. |
YES | 50.00% Coinsurance after deductible |
70.00% Coinsurance after deductible |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
Prior authorization is required. |
YES | 25.00% Coinsurance after deductible |
45.00% Coinsurance after deductible |
| Chiropractic Care
Limit: 30.0 Visit(s) per Year Chiropractic, osteopathic manipulative, physical and occupational therapy limited to a combined maximum of 30 visits per member per calendar year. |
YES | 25.00% Coinsurance after deductible |
45.00% Coinsurance after deductible |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
BCBSM-participating hospitals only. These services require prior authorization. The penalty for not having prior authorization is denial of payment. |
YES | 25.00% Coinsurance after deductible |
45.00% Coinsurance after deductible |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
Follows Medicare guidelines. |
YES | 25.00% Coinsurance after deductible |
45.00% Coinsurance after deductible |
| Dialysis
|
YES | 25.00% Coinsurance after deductible |
45.00% Coinsurance after deductible |
| Durable Medical Equipment
Exclusions: Bath, exercise and deluxe equipment and comfort and convenience items. Prescription is required. Rental and purchase limited to basic equipment. |
YES | 50.00% Coinsurance after deductible |
70.00% Coinsurance after deductible |
| Emergency Room Services
|
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
Exclusions: Transportation for convenience. Includes air and ground transportation. |
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year A child is defined as a member up to the age of 19. Out of network is paid up to the allowed amount. |
YES | No Charge |
No Charge |
| Gender Affirming Care
Exclusions: Cosmetic surgery, investigational and experimental procedures. These services may require prior authorization. The penalty for not having prior authorization is denial of payment. |
YES | 25.00% Coinsurance after deductible |
45.00% Coinsurance after deductible |
| Generic Drugs
Exclusions: Quantity limits per fill may apply for 30-day retail, 90-day retail and up to 90 day mail order. Opioid-containing medications are limited to no more than a 30-day supply per fill and first fills of select opioid containing medications will be limited to a 5-day supply. Prior authorization, step therapy and quantity limits may apply to select drugs. The penalty for not having prior authorization is denial of payment. Any coupon, rebate, or other credits received directly or indirectly from the drug manufacturer may not be applied to a consumer?s?deductible,?cost-sharing?or out of pocket maximum. For out-of-network providers, member must pay the full cost of the drug and submit to BCBSM for reimbursement. |
YES | $15.00 |
100.00% |
| Habilitation Services
Limit: 30.0 Visit(s) per Year Physical and occupational therapy limited to a combined maximum of 30 visits per member per calendar year. Speech therapy limited to a maximum of 30 visits per member per calendar year. |
YES | $30.00 |
45.00% Coinsurance after deductible |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Exclusions: Housekeeping and custodial services. BCBSM-participating agencies only. |
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Hospice Services
Exclusions: Housekeeping services. BCBSM approved hospice programs only. Coverage includes inpatient and outpatient hospice care. |
YES | No Charge after deductible |
No Charge after deductible |
| Imaging (CT/PET Scans, MRIs)
Prior authorization is required. The penalty for not having prior authorization is denial of payment. |
YES | 25.00% Coinsurance after deductible |
45.00% Coinsurance after deductible |
| Infertility Treatment
Exclusions: In vitro fertilization and artificial insemination. Underlying causes only. These services require prior authorization. The penalty for not having prior authorization is denial of payment. |
YES | 50.00% Coinsurance after deductible |
70.00% Coinsurance after deductible |
| Infusion Therapy
BCBSM approved providers only. |
YES | 25.00% Coinsurance after deductible |
45.00% Coinsurance after deductible |
| Inpatient Hospital Services (e.g., Hospital Stay)
BCBSM participating hospitals only. These services require prior authorization. The penalty for not having prior authorization is denial of payment. |
YES | 25.00% Coinsurance after deductible |
45.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services
BCBSM participating hospitals only. These services require prior authorization. The penalty for not having prior authorization is denial of payment. |
YES | 25.00% Coinsurance after deductible |
45.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services
|
YES | 25.00% Coinsurance after deductible |
45.00% Coinsurance after deductible |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
BCBSM approved facilities only. These services require prior authorization. The penalty for not having prior authorization is denial of payment. |
YES | 25.00% Coinsurance after deductible |
45.00% Coinsurance after deductible |
| Mental/Behavioral Health Outpatient Services
Copayment?applies to?provider?s?office, virtual visit?by participating BCBSM provider and virtual care visit from BCBSM selected vendor app only. Additional services are subject to the plan?s deductible and coinsurance, if applicable. BCBSM approved facilities only. |
YES | $30.00 |
45.00% Coinsurance after deductible |
| Non-Preferred Brand Drugs
Exclusions: Quantity limits per fill may apply for 30-day retail, 90-day retail and up to 90 day mail order. Opioid-containing medications are limited to no more than a 30-day supply per fill and first fills of select opioid containing medications will be limited to a 5-day supply. Prior authorization, step therapy and quantity limits may apply to select drugs. The penalty for not having prior authorization is denial of payment. Any coupon, rebate, or other credits received directly or indirectly from the drug manufacturer may not be applied to a consumer?s?deductible,?cost-sharing?or out of pocket maximum. For out-of-network providers, member must pay the full cost of the drug and submit to BCBSM for reimbursement. |
YES | $60.00 |
100.00% |
| Nutritional Counseling
Limit: 26.0 Visit(s) per Year Dietician Services. |
YES | 0.00% |
45.00% Coinsurance after deductible |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
Includes virtual and retail health clinic visits. No charge for 24/7 medical virtual visits when performed through the BCBSM selected vendor app. Diagnostic and laboratory services are not included in the office visit?copayment. These services are subject to the?plan's?deductible?and?coinsurance, if applicable. |
YES | $30.00 |
45.00% Coinsurance after deductible |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Exclusions: Cosmetic surgery, corrective eye surgery, investigational and experimental procedures. These services may require prior authorization. The penalty for not having prior authorization is denial of payment. |
YES | 25.00% Coinsurance after deductible |
45.00% Coinsurance after deductible |
| Outpatient Rehabilitation Services
Limit: 30.0 Visit(s) per Year Plan's coinsurance and deductible apply to chiropractic, osteopathic manipulative therapy and cardiac/pulmonary visits. Physical, occupational, chiropractic and osteopathic manipulative therapy limited to a combined maximum of 30 visits per member per calendar year. Speech therapy limited to a maximum of 30 visits per member per calendar year. Cardiac/pulmonary visits limited to a maximum of 30 visits per member per calendar year. |
YES | $30.00 |
45.00% Coinsurance after deductible |
| Outpatient Surgery Physician/Surgical Services
Exclusions: Cosmetic surgery, corrective eye surgery, investigational and experimental procedures. These services may require prior authorization. The penalty for not having prior authorization is denial of payment. |
YES | 25.00% Coinsurance after deductible |
45.00% Coinsurance after deductible |
| Preferred Brand Drugs
Exclusions: Quantity limits per fill may apply for 30-day retail, 90-day retail and up to 90 day mail order. Opioid-containing medications are limited to no more than a 30-day supply per fill and first fills of select opioid containing medications will be limited to a 5-day supply. Prior authorization, step therapy and quantity limits may apply to select drugs. The penalty for not having prior authorization is denial of payment. Any coupon, rebate, or other credits received directly or indirectly from the drug manufacturer may not be applied to a consumer?s?deductible,?cost-sharing?or out of pocket maximum. For out-of-network providers, member must pay the full cost of the drug and submit to BCBSM for reimbursement. |
YES | $30.00 |
100.00% |
| Prenatal and Postnatal Care
Cost sharing does not apply for preventive services. Depending on the type of services, a copayment, coinsurance or deductible may apply. |
YES | No Charge |
45.00% Coinsurance after deductible |
| Preventive Care/Screening/Immunization
You may have to pay for services that aren?t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. |
YES | 0.00% |
45.00% Coinsurance after deductible |
| Primary Care Visit to Treat an Injury or Illness
Includes virtual and retail health clinic visits. No charge for 24/7 medical virtual visits when performed through the BCBSM selected vendor app. Diagnostic and laboratory services are not included in the office visit?copayment. These services are subject to the?plan's?deductible?and?coinsurance, if applicable. |
YES | $30.00 |
45.00% Coinsurance after deductible |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 50.00% Coinsurance after deductible |
70.00% Coinsurance after deductible |
| Radiation
Prior authorization is required. |
YES | 25.00% Coinsurance after deductible |
45.00% Coinsurance after deductible |
| Reconstructive Surgery
Medically necessary only. |
YES | 25.00% Coinsurance after deductible |
45.00% Coinsurance after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Year Physical, occupational, chiropractic and osteopathic manipulative therapy limited to a combined maximum of 30 visits per member per calendar year. |
YES | $30.00 |
45.00% Coinsurance after deductible |
| Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Year |
YES | $30.00 |
45.00% Coinsurance after deductible |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year A child is defined as a member up to the age of 19. Out of network is paid up to the allowed amount. |
YES | No Charge |
No Charge |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 45.0 Days per Year Exclusions: Custodial care. BCBSM-participating facilities only. These services require prior authorization. The penalty for not having prior authorization is denial of payment. |
YES | 25.00% Coinsurance after deductible |
45.00% Coinsurance after deductible |
| Specialist Visit
No charge for 24/7 medical virtual visits when performed through the BCBSM selected vendor app. Diagnostic and laboratory services are not included in the office visit?copayment. These services are subject to the?plan's?deductible?and?coinsurance, if applicable. |
YES | $60.00 |
45.00% Coinsurance after deductible |
| Specialty Drugs
Exclusions: Specialty drugs are limited to a 30-day supply per fill, however some may be limited to a 15-day supply fill, depending on the medication. BCBSM has contracted with an exclusive pharmacy?network?for?specialty drugs. Call the customer service phone number on the back of your ID card for the pharmacy?s phone number or location nearest to you. If you obtain your?specialty drugs?from any other pharmacy, you are responsible for the total cost. Prior authorization, step therapy and quantity limits may apply to select drugs. The penalty for not having prior authorization is denial of payment. Any coupon, rebate, or other credits received directly or indirectly from the drug manufacturer may not be applied to a consumer?s?deductible,?cost-sharing?or out of pocket maximum. |
YES | $250.00 |
100.00% |
| Substance Abuse Disorder Inpatient Services
BCBSM approved facilities only. These services require prior authorization. The penalty for not having prior authorization is denial of payment. |
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services
Copayment?applies to?provider?s?office, virtual visit?by participating BCBSM provider and virtual care visit from BCBSM selected vendor app only. Additional services are subject to the plan?s deductible and coinsurance, if applicable. BCBSM approved facilities only. |
YES | $30.00 |
45.00% Coinsurance after deductible |
| Transplant
BCBSM designated facilities only. Subject to BCBSM medical criteria. |
YES | 25.00% Coinsurance after deductible |
45.00% Coinsurance after deductible |
| Treatment for Temporomandibular Joint Disorders
Coverage includes medical care or services to treat dysfunction or TMJ resulting from a medical cause or Injury, Office visits for medical evaluation and treatment, X-rays of the temporomandibular joint including contrast studies, but not dental x-rays, Myofunctional therapy and Surgery to the temporomandibular joint, such as condylectomy, meniscectomy, arthrotomy, and arthrocentesis. |
YES | 50.00% Coinsurance after deductible |
70.00% Coinsurance after deductible |
| Urgent Care Centers or Facilities
When the urgent care visit is for an emergency or accidental injury, in-network cost-sharing applies. |
YES | $45.00 |
45.00% Coinsurance after deductible |
| Weight Loss Programs
Morbid obesity weight management and nutritional counseling. |
YES | 0.00% |
45.00% Coinsurance after deductible |
| Well Baby Visits and Care
Quantity limits based on PPACA. |
YES | 0.00% |
45.00% Coinsurance after deductible |
| X-rays and Diagnostic Imaging
|
YES | 25.00% Coinsurance after deductible |
45.00% Coinsurance after deductible |
Blue Cross® Premier PPO Gold Extra Health Insurance Plan Variant 15560MI1130002-03 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.7801851164396751 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Limited Cost Sharing Plan Variation |
| Dental Only Plan | No |
| Design Type | Design 1 |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | MIF253 |
| Formulary URL | URL |
| HIOS Product ID | 15560MI113 |
| Import Date | 2023-08-16 20:01:48 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | New |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 15560 |
| Issuer Marketplace Marketing Name | Blue Cross Blue Shield of Michigan Mutual Insurance Company |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | Yes |
| Network ID | MIN006 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Accidental injury and emergency only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Coverage outside the state of Michigan is out of network except for eligible urgent, emergency and accidental injuries services |
| Plan Brochure | URL |
| Plan Effective Date | 2024-01-01 |
| Plan Expiration Date | 2024-12-31 |
| Plan ID (Standard Component ID with Variant) | 15560MI1130002-03 |
| Plan Marketing Name | Blue Cross® Premier PPO Gold Extra |
| Plan Type | PPO |
| Plan Variant Marketing Name | Blue Cross® Premier PPO Gold Extra |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,800 |
| SBC Scenario, Having a Baby, Copayment | $10 |
| SBC Scenario, Having a Baby, Deductible | $1,500 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $700 |
| SBC Scenario, Having Diabetes, Deductible | $900 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $300 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,500 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | MIS001 |
| Source Name | SERFF |
| Plan ID | 15560MI1130002 |
| State Code | MI |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 25.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $3000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $1500 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,500 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $6000 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $3000 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $3,000 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $17400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8700 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,700 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $34800 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $17400 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $17,400 |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of Blue Cross® Premier PPO Gold Extra Health Insurance Plan, 15560MI1130002
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Blue Cross® Premier PPO Gold Extra, 15560MI1130002 Health Insurance Plan, 15560MI1130002
-
Does Blue Cross® Premier PPO Gold Extra Health Insurance Plan, 15560MI1130002 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (15560MI1130002) Health Insurance Plan, Variant (15560MI1130002-03) offer Disease Management Programs?
Does (15560MI1130002) Health Insurance Plan, Variant (15560MI1130002-03) have Out Of Country Coverage?
Does (15560MI1130002) Health Insurance Plan, Variant (15560MI1130002-03) have Out of Service Area Coverage?
Does (15560MI1130002) Health Insurance Plan, Variant (15560MI1130002-03) offer Disease Management Programs?
Does Blue Cross® Premier PPO Gold Extra Health Insurance Plan, Variant (15560MI1130002-03) offer Disease Management Programs for Asthma?
Does Blue Cross® Premier PPO Gold Extra Health Insurance Plan, Variant (15560MI1130002-03) offer Disease Management Programs for Heart disease?
Does Blue Cross® Premier PPO Gold Extra Health Insurance Plan, Variant (15560MI1130002-03) offer Disease Management Programs for Depression?
Does Blue Cross® Premier PPO Gold Extra Health Insurance Plan, Variant (15560MI1130002-03) offer Disease Management Programs for Diabetes?
Does Blue Cross® Premier PPO Gold Extra Health Insurance Plan, Variant (15560MI1130002-03) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Blue Cross® Premier PPO Gold Extra Health Insurance Plan, Variant (15560MI1130002-03) offer Disease Management Programs for Low back pain?
Does Blue Cross® Premier PPO Gold Extra Health Insurance Plan, Variant (15560MI1130002-03) offer Disease Management Programs for Pregnancy?
Does Blue Cross® Premier PPO Gold Extra Health Insurance Plan, Variant (15560MI1130002-03) offer Disease Management Programs for Weight loss programs?
Disclaimer: This is based on the import(Date: Tue, 22 Oct 2024 06:47 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API