Blue Cross® Premier PPO Gold Extra
15560MI1130002
Gold
PPO
Blue Cross® Premier PPO Gold Extra is a Gold PPO plan by Blue Cross Blue Shield of Michigan.
IMPORTANT: You are viewing the 2023 version of Blue Cross® Premier PPO Gold Extra 15560MI1130002. You can enroll in this plan if you qualify for special enrollment until the end of 2023.
Locations
Blue Cross® Premier PPO Gold Extra is offered in the following counties.
Plan Overview
This is a plan overview for 2023 version of Blue Cross® Premier PPO Gold Extra 15560MI1130002.
| Insurer: | Blue Cross Blue Shield of Michigan |
| Network Type: | PPO |
| Metal Type: | Gold |
| HSA Eligible?: | No |
| Plan ID: | 15560MI1130002 |
Cost-Sharing Overview
Blue Cross® Premier PPO Gold Extra offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for Blue Cross® Premier PPO Gold Extra includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | $8,700.00 | $8700 per person | $17400 per group |
| Deductible: | $2,000.00 | $2000 per person | $4000 per group |
| Coinsurance: | 25.00% | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for Blue Cross® Premier PPO Gold Extra will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | $17,400.00 | $17400 per person | $34800 per group |
| Out-of-Network Deductible: | $4,000.00 | $4000 per person | $8000 per group |
Cost-Sharing Examples
The cost-sharing for the sample Summary of Benefits & Coverage (SBC) scenarios of having a baby, having diabetes, and having a simple fracture.
| Deductible: | $2,000.00 |
| Copayment: | $10.00 |
| Coinsurance: | $2,600.00 |
| Limit: | $60.00 |
| Deductible: | $900.00 |
| Copayment: | $700.00 |
| Coinsurance: | $0.00 |
| Limit: | $20.00 |
| Deductible: | $200.00 |
| Copayment: | $300.00 |
| Coinsurance: | $20.00 |
| Limit: | $0.00 |
Notes:
- Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
- You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Blue Cross® Premier PPO Gold Extra?
Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904
Plan Features
Blue Cross® Premier PPO Gold Extra offers the following features and referral requirements.
| Wellness Program: | No |
| Disease Program: | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs |
| Notice Pregnancy: | No |
| Referral Specialist: | No |
| Specialist Requiring Referral: | |
| Plan Exclusions: | |
| Child Only Option?: | Allows Adult and Child-Only |
Network Details
The following network details will help you understand what Blue Cross® Premier PPO Gold Extra covers when you are out of the service area or out of the country.
| 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 |
| National Network: | Yes |
Additional Benefits and Cost-Sharing
Blue Cross® Premier PPO Gold Extra includes the following benefits at the cost sharing rates listed below.
| Service | In-Network Copay / Coinsurance | Out-of-Network Copay / Coinsurance | Limits and Explanation |
|---|---|---|---|
| Primary Care Visit to Treat an Injury or Illness Covered | $30.00 | 45.00% Coinsurance after deductible | Includes virtual and retail health clinic visits. Medical online visits are covered 100% before deductible on all plans, when performed by a BCBSM selected vendor. 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. |
| Specialist Visit Covered | $60.00 | 45.00% Coinsurance after deductible | Medical online visits are covered 100% before deductible on all plans, when performed by a BCBSM selected vendor. 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. |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | $30.00 | 45.00% Coinsurance after deductible | Includes virtual and retail health clinic visits. Medical online visits are covered 100% before deductible on all plans, when performed by a BCBSM selected vendor. 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. |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | 25.00% Coinsurance after deductible | 45.00% Coinsurance after deductible | 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. |
| Outpatient Surgery Physician/Surgical Services Covered | 25.00% Coinsurance after deductible | 45.00% Coinsurance after deductible | 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. |
| Hospice Services Covered | No Charge after deductible | No Charge after deductible | Housekeeping services. BCBSM approved hospice programs only. Coverage includes inpatient and outpatient hospice care. |
| Routine Dental Services (Adult) Not Covered | |||
| Infertility Treatment Covered | 50.00% Coinsurance after deductible | 70.00% Coinsurance after deductible | 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. |
| Long-Term/Custodial Nursing Home Care Not Covered | |||
| Private-Duty Nursing Not Covered | |||
| Routine Eye Exam (Adult) Not Covered | |||
| Urgent Care Centers or Facilities Covered | $45.00 | 45.00% Coinsurance after deductible | When the urgent care visit is for an emergency or accidental injury, in-network cost-sharing applies. |
| Home Health Care Services Covered | 25.00% Coinsurance after deductible | 25.00% Coinsurance after deductible | Housekeeping and custodial services. BCBSM-participating agencies only. |
| Emergency Room Services Covered | 25.00% Coinsurance after deductible | 25.00% Coinsurance after deductible | |
| Emergency Transportation/Ambulance Covered | 25.00% Coinsurance after deductible | 25.00% Coinsurance after deductible | Transportation for convenience. Includes air and ground transportation. |
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | 25.00% Coinsurance after deductible | 45.00% Coinsurance after deductible | BCBSM participating hospitals only. These services require prior authorization. The penalty for not having prior authorization is denial of payment. |
| Inpatient Physician and Surgical Services Covered | 25.00% Coinsurance after deductible | 45.00% Coinsurance after deductible | BCBSM participating hospitals only. These services require prior authorization. The penalty for not having prior authorization is denial of payment. |
| Bariatric Surgery Covered | 50.00% Coinsurance after deductible | 70.00% Coinsurance after deductible | 1 Procedure(s) per Lifetime Subject to BCBSM medical criteria. |
| Cosmetic Surgery Not Covered | |||
| Skilled Nursing Facility Covered | 25.00% Coinsurance after deductible | 45.00% Coinsurance after deductible | 45 Days per Year Custodial care. BCBSM-participating facilities only. These services require prior authorization. The penalty for not having prior authorization is denial of payment. |
| Prenatal and Postnatal Care Covered | No Charge | 45.00% Coinsurance after deductible | Cost sharing does not apply for preventive services. Depending on the type of services, a copayment, coinsurance or deductible may apply. |
| Delivery and All Inpatient Services for Maternity Care Covered | 25.00% Coinsurance after deductible | 45.00% Coinsurance after deductible | BCBSM-participating hospitals only. These services require prior authorization. The penalty for not having prior authorization is denial of payment. |
| Mental/Behavioral Health Outpatient Services Covered | $30.00 | 45.00% Coinsurance after deductible | Copayment?applies to?provider?s?office, virtual visit?by participating BCBSM provider and Blue Cross online visit from BCBSM selected vendor only. Additional services are subject to the plan?s deductible and coinsurance, if applicable. BCBSM approved facilities only. |
| Mental/Behavioral Health Inpatient Services Covered | 25.00% Coinsurance after deductible | 45.00% Coinsurance after deductible | BCBSM approved facilities only. These services require prior authorization. The penalty for not having prior authorization is denial of payment. |
| Substance Abuse Disorder Outpatient Services Covered | $30.00 | 45.00% Coinsurance after deductible | Copayment?applies to?provider?s?office, virtual visit?by participating BCBSM provider and Blue Cross online visit from BCBSM selected vendor only. Additional services are subject to the plan?s deductible and coinsurance, if applicable. BCBSM approved facilities only. |
| Substance Abuse Disorder Inpatient Services Covered | 25.00% Coinsurance after deductible | 25.00% Coinsurance after deductible | BCBSM approved facilities only. These services require prior authorization. The penalty for not having prior authorization is denial of payment. |
| Generic Drugs Covered | $15.00 | 100.00% | 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. |
| Preferred Brand Drugs Covered | $30.00 | 100.00% | 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. |
| Non-Preferred Brand Drugs Covered | $60.00 | 100.00% | 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. |
| Specialty Drugs Covered | $250.00 | 100.00% | 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. |
| Outpatient Rehabilitation Services Covered | $30.00 | 45.00% Coinsurance after deductible | 30 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. |
| Habilitation Services Covered | $30.00 | 45.00% Coinsurance after deductible | 30 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. |
| Chiropractic Care Covered | 25.00% Coinsurance after deductible | 45.00% Coinsurance after deductible | 30 Visit(s) per Year Chiropractic, osteopathic manipulative, physical and occupational therapy limited to a combined maximum of 30 visits per member per calendar year. |
| Durable Medical Equipment Covered | 50.00% Coinsurance after deductible | 70.00% Coinsurance after deductible | Bath, exercise and deluxe equipment and comfort and convenience items. Prescription is required. Rental and purchase limited to basic equipment. |
| Hearing Aids Not Covered | |||
| Imaging (CT/PET Scans, MRIs) Covered | 25.00% Coinsurance after deductible | 45.00% Coinsurance after deductible | Prior authorization is required. The penalty for not having prior authorization is denial of payment. |
| Preventive Care/Screening/Immunization Covered | 0.00% | 45.00% Coinsurance after deductible | 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. |
| Routine Foot Care Not Covered | |||
| Acupuncture Not Covered | |||
| Weight Loss Programs Covered | 0.00% | 45.00% Coinsurance after deductible | Morbid obesity weight management and nutritional counseling. |
| Routine Eye Exam for Children Covered | No Charge | No Charge | 1 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. |
| Eye Glasses for Children Covered | No Charge | No Charge | 1 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. |
| Dental Check-Up for Children Not Covered | |||
| Rehabilitative Speech Therapy Covered | $30.00 | 45.00% Coinsurance after deductible | 30 Visit(s) per Year |
| Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | $30.00 | 45.00% Coinsurance after deductible | 30 Visit(s) per Year Physical, occupational, chiropractic and osteopathic manipulative therapy limited to a combined maximum of 30 visits per member per calendar year. |
| Well Baby Visits and Care Covered | 0.00% | 45.00% Coinsurance after deductible | Quantity limits based on PPACA. |
| Laboratory Outpatient and Professional Services Covered | 25.00% Coinsurance after deductible | 45.00% Coinsurance after deductible | |
| X-rays and Diagnostic Imaging Covered | 25.00% Coinsurance after deductible | 45.00% Coinsurance after deductible | |
| Basic Dental Care – Child Not Covered | |||
| Orthodontia – Child Not Covered | |||
| Major Dental Care – Child Not Covered | |||
| Basic Dental Care – Adult Not Covered | |||
| Orthodontia – Adult Not Covered | |||
| Major Dental Care – Adult Not Covered | |||
| Abortion for Which Public Funding is Prohibited Not Covered | |||
| Transplant Covered | 25.00% Coinsurance after deductible | 45.00% Coinsurance after deductible | BCBSM designated facilities only. Subject to BCBSM medical criteria. |
| Accidental Dental Covered | 25.00% Coinsurance after deductible | 25.00% Coinsurance after deductible | Accidental injury and emergency only. |
| Dialysis Covered | 25.00% Coinsurance after deductible | 45.00% Coinsurance after deductible | |
| Allergy Testing Covered | 25.00% Coinsurance after deductible | 45.00% Coinsurance after deductible | |
| Chemotherapy Covered | 25.00% Coinsurance after deductible | 45.00% Coinsurance after deductible | Prior authorization is required. |
| Radiation Covered | 25.00% Coinsurance after deductible | 45.00% Coinsurance after deductible | Prior authorization is required. |
| Diabetes Education Covered | 25.00% Coinsurance after deductible | 45.00% Coinsurance after deductible | Follows Medicare guidelines. |
| Prosthetic Devices Covered | 50.00% Coinsurance after deductible | 70.00% Coinsurance after deductible | |
| Infusion Therapy Covered | 25.00% Coinsurance after deductible | 45.00% Coinsurance after deductible | BCBSM approved providers only. |
| Treatment for Temporomandibular Joint Disorders Covered | 50.00% Coinsurance after deductible | 70.00% Coinsurance after deductible | 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. |
| Nutritional Counseling Covered | 0.00% | 45.00% Coinsurance after deductible | 26 Visit(s) per Year Dietician Services. |
| Reconstructive Surgery Covered | 25.00% Coinsurance after deductible | 45.00% Coinsurance after deductible | Medically necessary only. |
| Gender Affirming Care Covered | 25.00% Coinsurance after deductible | 45.00% Coinsurance after deductible | Cosmetic surgery, investigational and experimental procedures. These services may require prior authorization. The penalty for not having prior authorization is denial of payment. |
| Non Preferred Specialty Drugs Covered | $250.00 | 100.00% | 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. |
Free Preventive Services
There is no copayment or coinsurance for any of the following Blue Cross® Premier PPO Gold Extra preventive services. This is true even if you haven’t met your yearly deductible.
Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.
Preventive Care Benefits for All Adults
Preventive Care Benefits for Women
Preventive Care Benefits for Children
Preventive Care Benefits for All Adults
Preventive care benefits for adults
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
- Alcohol misuse screening and counseling
- Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk
- Blood pressure screening
- Cholesterol screening for adults of certain ages or at higher risk
- Colorectal cancer screening for adults 45 to 75
- Depression screening
- Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese
- Diet counseling for adults at higher risk for chronic disease
- Falls prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over, living in a community setting
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults age 18 to 79 years
- HIV screening for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV through sex or injection drug use
- Immunizations for adults — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria
- Flu (influenza)
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Measles
- Meningococcal
- Mumps
- Whooping Cough (Pertussis)
- Pneumococcal
- Rubella
- Shingles
- Tetanus
- Lung cancer screening for adults 50 to 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
- Obesity screening and counseling
- Sexually transmitted infection (STI) prevention counseling for adults at higher risk
- Statin preventive medication for adults 40 to 75 at high risk
- Syphilis screening for adults at higher risk
- Tobacco use screening for all adults and cessation interventions for tobacco users
- Tuberculosis screening for certain adults without symptoms at high risk
Preventive Care Benefits for Women
Services for pregnant women or women who may become pregnant
- Breastfeeding support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
- Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
- Folic acid supplements for women who may become pregnant
- Gestational diabetes screening for women 24 weeks pregnant (or later) and those at high risk of developing gestational diabetes
- Gonorrhea screening for all women at higher risk
- Hepatitis B screening for pregnant women at their first prenatal visit
- Maternal depression screening for mothers at well-baby visits
- Preeclampsia prevention and screening for pregnant women with high blood pressure
- Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk
- Syphilis screening
- Expanded tobacco intervention and counseling for pregnant tobacco users
- Urinary tract or other infection screening
Other covered preventive services for women
- Bone density screening for all women over age 65 or women age 64 and younger that have gone through menopause
- Breast cancer genetic test counseling (BRCA) for women at higher risk
- Breast cancer mammography screenings
- Every 2 years for women 50 and over
- As recommended by a provider for women 40 to 49 or women at higher risk for breast cancer
- Breast cancer chemoprevention counseling for women at higher risk
- Cervical cancer screening
- Pap test (also called a Pap smear) for women age 21 to 65
- Chlamydia infection screening for younger women and other women at higher risk
- Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before
- Domestic and interpersonal violence screening and counseling for all women
- Gonorrhea screening for all women at higher risk
- HIV screening and counseling for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative women at high risk for getting HIV through sex or injection drug use
- Sexually transmitted infections counseling for sexually active women
- Tobacco use screening and interventions
- Urinary incontinence screening for women yearly
- Well-woman visits to get recommended services for all women
Preventive Care Benefits for Children
Coverage for children’s preventive health services
- Alcohol, tobacco, and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Behavioral assessments for children: Age 0 to 17 years
- Bilirubin concentration screening for newborns
- Blood pressure screening for children: Age 0 to 17
- Blood screening for newborns
- Depression screening for adolescents beginning routinely at age 12
- Developmental screening for children under age 3
- Dyslipidemia screening for all children once between 9 and 11 years and once between 17 and 21 years, and for children at higher risk of lipid disorders
- Fluoride supplements for children without fluoride in their water source
- Fluoride varnish for all infants and children as soon as teeth are present
- Gonorrhea preventive medication for the eyes of all newborns
- Hearing screening for all newborns; and regular screenings for children and adolescents as recommended by their provider
- Height, weight and body mass index (BMI) measurements taken regularly for all children
- Hematocrit or hemoglobin screening for all children
- Hemoglobinopathies or sickle cell screening for newborns
- Hepatitis B screening for adolescents at higher risk
- HIV screening for adolescents at higher risk
- Hypothyroidism screening for newborns
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk for getting HIV through sex or injection drug use
Immunizations for children from birth to age 18 — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria, tetanus, and pertussis (DTaP)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Inactivated Poliovirus
- Influenza (flu shot)
- Measles
- Meningococcal
- Mumps
- Pneumococcal
- Rubella
- Rotavirus
Lead screening for children at risk of exposure
Obesity screening and counseling
- Oral health risk assessment for young children from 6 months to 6 years
- Phenylketonuria (PKU) screening for newborns
- Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
- Tuberculin testing for children at higher risk of tuberculosis: Age 0 -17
- Vision screening for all children
- Well-baby and well-child visits
Additional Resources
Below are additional resources for Blue Cross® Premier PPO Gold Extra including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.
| Summary of Benefits: | Summary of Benefits Link |
| Plan Brochure: | Plan Brochure Link |
| Formulary: | Formulary Link |
| Premium Payment Website: | Premium Payment Link |
Ready to sign up for Blue Cross® Premier PPO Gold Extra?
Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904