Blue Cross® Premier PPO Silver Extra

15560MI1130001
Silver
PPO

Blue Cross® Premier PPO Silver Extra is a Silver PPO plan by Blue Cross Blue Shield of Michigan Mutual Insurance Company.

Locations

Blue Cross® Premier PPO Silver Extra is offered in the following counties.

Plan Overview

This is a plan overview for 2025 version of Blue Cross® Premier PPO Silver Extra 15560MI1130001.
Insurer: Blue Cross Blue Shield of Michigan Mutual Insurance Company
Network Type: PPO
Metal Type: Silver
HSA Eligible?: No
Plan ID: 15560MI1130001

Cost-Sharing Overview

Blue Cross® Premier PPO Silver Extra offers the following cost-sharing.

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 Silver 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 Silver 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 Silver 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 Silver 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
$40.00 Not ApplicableNot Applicable 60.00% Coinsurance after deductible Includes virtual, retail health clinic and medical evaluation at an affiliated immunization pharmacy 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.
Specialist Visit
Covered
$80.00 Not ApplicableNot Applicable 60.00% Coinsurance after deductible 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.
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$40.00 Not ApplicableNot Applicable 60.00% Coinsurance after deductible Includes virtual, retail health clinic and medical evaluation at an affiliated immunization pharmacy 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.
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 60.00% 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
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 60.00% 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
Not Applicable No Charge after deductibleNot Applicable 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
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 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
$60.00 Not ApplicableNot Applicable 60.00% 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
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance after deductible Housekeeping and custodial services. BCBSM-participating agencies only.
Emergency Room Services
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance after deductible Transportation for convenience. Includes air and ground transportation.
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 60.00% 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
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 60.00% 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
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 70.00% Coinsurance after deductible1.0 Procedure(s) per Lifetime Subject to BCBSM medical criteria.
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 60.00% Coinsurance after deductible45.0 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 Not ApplicableNot Applicable 60.00% 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
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 60.00% 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
$40.00 Not ApplicableNot Applicable 60.00% Coinsurance after deductible Copayment applies to provider?s office, virtual visit and applied behavior analysis (ABA) treatment 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.
Mental/Behavioral Health Inpatient Services
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 60.00% 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
$40.00 Not ApplicableNot Applicable 60.00% Coinsurance after deductible Copayment applies to provider?s office and 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.
Substance Abuse Disorder Inpatient Services
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 40.00% 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
$20.00 Not ApplicableNot Applicable 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 an assistance program or 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
$40.00 Not ApplicableNot Applicable 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 an assistance program or 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
$80.00 Copay after deductible Not ApplicableNot Applicable 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 an assistance program or 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
$350.00 Copay after deductible Not ApplicableNot Applicable 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 an assistance program or the drug manufacturer may not be applied to a consumer?s deductible, cost-sharing or out of pocket maximum.
Outpatient Rehabilitation Services
Covered
$40.00 Not ApplicableNot Applicable 60.00% Coinsurance after deductible30.0 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.
Habilitation Services
Covered
$40.00 Not ApplicableNot Applicable 60.00% Coinsurance after deductible30.0 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.
Chiropractic Care
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 60.00% Coinsurance after deductible30.0 Visit(s) per Year Chiropractic, osteopathic manipulative, physical and occupational therapy limited to a combined maximum of 30 visits per member per calendar year.
Durable Medical Equipment
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 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
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 60.00% Coinsurance after deductible Prior authorization is required. The penalty for not having prior authorization is denial of payment.
Preventive Care/Screening/Immunization
Covered
Not Applicable 0.00%Not Applicable 60.00% 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
Not Applicable 0.00%Not Applicable 60.00% Coinsurance after deductible Morbid obesity weight management and nutritional counseling.
Routine Eye Exam for Children
Covered
No Charge Not ApplicableNo Charge Not Applicable1.0 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.
Eye Glasses for Children
Covered
No Charge Not ApplicableNo Charge Not Applicable1.0 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.
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
$40.00 Not ApplicableNot Applicable 60.00% Coinsurance after deductible30.0 Visit(s) per Year
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$40.00 Not ApplicableNot Applicable 60.00% Coinsurance after deductible30.0 Visit(s) per Year Physical, occupational, chiropractic and osteopathic manipulative therapy limited to a combined maximum of 30 visits per member per calendar year.
Well Baby Visits and Care
Covered
Not Applicable 0.00%Not Applicable 60.00% Coinsurance after deductible Quantity limits based on PPACA.
Laboratory Outpatient and Professional Services
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 60.00% Coinsurance after deductible
X-rays and Diagnostic Imaging
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 60.00% 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
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 60.00% Coinsurance after deductible BCBSM designated facilities only. Subject to BCBSM medical criteria.
Accidental Dental
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance after deductible Accidental injury and emergency only.
Dialysis
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 60.00% Coinsurance after deductible
Allergy Testing
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 60.00% Coinsurance after deductible
Chemotherapy
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 60.00% Coinsurance after deductible Prior authorization is required.
Radiation
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 60.00% Coinsurance after deductible Prior authorization is required.
Diabetes Education
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 60.00% Coinsurance after deductible Follows Medicare guidelines.
Prosthetic Devices
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 70.00% Coinsurance after deductible
Infusion Therapy
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 60.00% Coinsurance after deductible BCBSM approved providers only.
Treatment for Temporomandibular Joint Disorders
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 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
Not Applicable 0.00%Not Applicable 60.00% Coinsurance after deductible26.0 Visit(s) per Year Dietician Services.
Reconstructive Surgery
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 60.00% Coinsurance after deductible Medically necessary only.
Gender Affirming Care
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 60.00% 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.

Free Preventive Services

There is no copayment or coinsurance for any of the following Blue Cross® Premier PPO Silver 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.

Additional Resources

Below are additional resources for Blue Cross® Premier PPO Silver 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 Silver 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

Table of Contents