Blue Cross® Select HMO Silver Saver

98185MI0180012
Silver
HMO

Blue Cross® Select HMO Silver Saver is a Silver HMO plan by Blue Care Network of Michigan.

IMPORTANT: You are viewing the 2023 version of Blue Cross® Select HMO Silver Saver 98185MI0180012. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

Blue Cross® Select HMO Silver Saver is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of Blue Cross® Select HMO Silver Saver 98185MI0180012.
Insurer: Blue Care Network of Michigan
Network Type: HMO
Metal Type: Silver
HSA Eligible?: No
Plan ID: 98185MI0180012

Cost-Sharing Overview

Blue Cross® Select HMO Silver Saver 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® Select HMO Silver Saver?

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® Select HMO Silver Saver 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: Yes
Specialist Requiring Referral: All except routine OB/GYN & pediatric visits
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what Blue Cross® Select HMO Silver Saver covers when you are out of the service area or out of the country.

Out of Country Coverage: Yes
Out of Country Coverage Description: Accidential Injury and Emergency Only
Out of Service Area Coverage: Yes
Out of Service Area Coverage Description: Accidential Injury and Emergency Only
National Network: No

Additional Benefits and Cost-Sharing

Blue Cross® Select HMO Silver Saver 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
$45.00 100.00% Includes Virtual and Retail Health Clinic visits. No charge for medical online visits when performed by a BCN selected vendor. Diagnostic 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
$90.00 100.00% Referral required. The penalty for not having a referral is denial of payment. Diagnostic services are not included in the office visit copayment. These services are subject to the plan’s deductible and coinsurance, if applicable. No charge for medical online visits when performed by a BCN selected vendor.
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$45.00 100.00% Includes Virtual and Retail Health Clinic visits. No charge for medical online visits when performed by a BCN selected vendor. Diagnostic 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
20.00% Coinsurance after deductible 100.00% Cosmetic surgery, corrective eye surgery, investigational and experimental procedures. May require prior authorization.
Outpatient Surgery Physician/Surgical Services
Covered
20.00% Coinsurance after deductible 100.00% Cosmetic surgery, corrective eye surgery, investigational and experimental procedures. May require prior authorization.
Hospice Services
Covered
No Charge after deductible 100.00% Housekeeping services. Room and board at an extended care facility or hospice facility for the purposes of delivering Custodial Care. Prior authorization required. The penalty for not having prior authorization is denial of payment. BCN participating hospice programs only. Coverage includes inpatient and outpatient hospice care.
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Covered
50.00% Coinsurance after deductible 100.00% Artificial Insemination and In-Vitro Fertilization. Prior authorization required. 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 Urgent Care visits will be covered at non-participating providers for medical emergencies and accidental injuries only.
Home Health Care Services
Covered
20.00% Coinsurance after deductible 100.00% Housekeeping Services. Services for the purposes of custodial care. BCN approved providers only.
Emergency Room Services
Covered
$250.00 Copay after deductible 20.00% Coinsurance after deductible$250.00 Copay after deductible 20.00% Coinsurance after deductible Emergency room visits will be covered at non-participating facilities for medical emergencies and accidental injuries only. Copayment waived if admitted inpatient into the hospital.
Emergency Transportation/Ambulance
Covered
20.00% Coinsurance after deductible 20.00% Coinsurance after deductible Transportation for convenience. Includes air and ground transportation.
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
20.00% Coinsurance after deductible 100.00% Prior authorization required. The penalty for not having prior authorization is denial of payment.
Inpatient Physician and Surgical Services
Covered
20.00% Coinsurance after deductible 100.00% The penalty for not having prior authorization is denial of payment.
Bariatric Surgery
Covered
50.00% Coinsurance after deductible 100.00%1 Procedure(s) per Lifetime Prior authorization required. The penalty for not having prior authorization is denial of payment.
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
20.00% Coinsurance after deductible 100.00%45 Days per Year Custodial Care. Prior authoriztion required. The penalty for not having prior authorization is denial of payment. BCN participating facilities only.
Prenatal and Postnatal Care
Covered
No Charge 100.00% 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
20.00% Coinsurance after deductible 100.00% Prior authoriztion required. The penalty for not having prior authorization is denial of payment.
Mental/Behavioral Health Outpatient Services
Covered
$45.00 100.00% Copayment?applies to?provider?s?office, virtual visit?by participating BCN provider and Blue Cross online visit from BCN selected vendor only. Additional services are subject to the plan’s deductible and coinsurance. Prior authorization is not required for outpatient, office and online visits. Prior authorization is required for other outpatient services.
Mental/Behavioral Health Inpatient Services
Covered
20.00% Coinsurance after deductible 100.00% Prior authoriztion required. The penalty for not having prior authorization is denial of payment.
Substance Abuse Disorder Outpatient Services
Covered
$45.00 100.00% Copayment?applies to?provider?s?office, virtual visit?by participating BCN provider and Blue Cross online visit from BCN selected vendor only. Additional services are subject to the plan’s deductible and coinsurance. Prior authorization is not required for outpatient, office and online visits. Prior authorization is required for other outpatient services.
Substance Abuse Disorder Inpatient Services
Covered
20.00% Coinsurance after deductible 100.00% Prior authoriztion required. The penalty for not having prior authorization is denial of payment.
Generic Drugs
Covered
$4.00 Copay after deductible 100.00% Quantity limits per fill may apply for 30-day retail, 90-day retail, and 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. Refer to drug list for quantity limits and other exclusions. May require prior authorization & step therapy. The penalty for not having prior authorization is denial of payment. No charge for Tier 1A contraceptives. 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
Preferred Brand Drugs
Covered
$100.00 Copay after deductible 100.00% Quantity limits per fill may apply for 30-day retail, 90-day retail, and 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. Refer to drug list for quantity limits and other exclusions. May require prior authorization & step therapy. The penalty for not having prior authorization is denial of payment. No charge for Tier 1A contraceptives. 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
Non-Preferred Brand Drugs
Covered
$150.00 Copay after deductible 100.00% Quantity limits per fill may apply for 30-day retail, 90-day retail, and 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. Refer to drug list for quantity limits and other exclusions. May require prior authorization & step therapy. The penalty for not having prior authorization is denial of payment. No charge for Tier 1A contraceptives. 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
Specialty Drugs
Covered
40.00% Coinsurance after deductible 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 Refer to drug list for quantity limits and other exclusions. BCN 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
20.00% Coinsurance after deductible 100.00%30 Visit(s) per Year Prior authoriztion required. The penalty for not having prior authorization is denial of payment. Physical Therapy/Occupational Therapy- combined 30 visits per calendar year; 30 visits for Speech Therapy per calendar year.
Habilitation Services
Covered
20.00% Coinsurance after deductible 100.00%30 Visit(s) per Year Prior authoriztion required. The penalty for not having prior authorization is denial of payment. Physical Therapy/Occupational Therapy- combined 30 visits per calendar year; 30 visits for Speech Therapy per calendar year.
Chiropractic Care
Covered
20.00% Coinsurance after deductible 100.00%30 Visit(s) per Year Spinal manipulation limit is not combined with Occupational Therapy and Physical Therapy; limit includes services provided by an osteopathic provider.
Durable Medical Equipment
Covered
50.00% Coinsurance after deductible 100.00% Excludes bath, exercise and deluxe equipment and comfort and convenience items. Prescription is required. Rental and purchase limited to basic equipment. Prior authoriztion required. The penalty for not having prior authorization is denial of payment. Breast pumps are covered in full when preauthorized.
Hearing Aids
Not Covered
Imaging (CT/PET Scans, MRIs)
Covered
20.00% Coinsurance after deductible 100.00% Prior authoriztion required. The penalty for not having prior authorization is denial of payment.
Preventive Care/Screening/Immunization
Covered
No Charge 100.00% Care and services not defined as preventive under PPACA. May require prior authorization. The penalty for not having prior authorization is denial of payment. 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
No Charge 100.00% Obesity screening at physician’s office only.
Routine Eye Exam for Children
Covered
No Charge 100.00%1 Exam(s) per Year Out of network is paid up to the allowed amount. A child is defined as a member up to age 19.
Eye Glasses for Children
Covered
No Charge 100.00%1 Item(s) per Year Out of network is paid up to the allowed amount. A child is defined as a member up to age 19.
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
20.00% Coinsurance after deductible 100.00%30 Visit(s) per Year Prior authoriztion required. The penalty for not having prior authorization is denial of payment. Physical Therapy/Occupational Therapy- combined 30 visits per calendar year; 30 visits for Speech Therapy per calendar year.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
20.00% Coinsurance after deductible 100.00%30 Visit(s) per Year Prior authoriztion required. The penalty for not having prior authorization is denial of payment. Physical Therapy/Occupational Therapy- combined 30 visits per calendar year; 30 visits for Speech Therapy per calendar year.
Well Baby Visits and Care
Covered
No Charge 100.00% Quantity limits based on PPACA.
Laboratory Outpatient and Professional Services
Covered
No Charge 100.00% May require prior authorization. The penalty for not having prior authorization is denial of payment.
X-rays and Diagnostic Imaging
Covered
20.00% Coinsurance after deductible 100.00% May require prior authorization. The penalty for not having prior authorization is denial of payment.
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
20.00% Coinsurance after deductible 100.00% Subject to BCN medical criteria. BCN designated facility only.
Accidental Dental
Covered
20.00% Coinsurance after deductible 100.00% Accidental injury and emergency only.
Dialysis
Covered
20.00% Coinsurance after deductible 100.00%
Allergy Testing
Covered
20.00% Coinsurance after deductible 100.00% In network only if at a physican’s office.
Chemotherapy
Covered
20.00% Coinsurance after deductible 100.00%
Radiation
Covered
20.00% Coinsurance after deductible 100.00%
Diabetes Education
Covered
20.00% Coinsurance after deductible 100.00% Follow Medicare guidelines.
Prosthetic Devices
Covered
50.00% Coinsurance after deductible 100.00% BCN approved providers only. Limited to the basic items; replacement is limited to items that cannot be repaired or modified
Infusion Therapy
Covered
20.00% Coinsurance after deductible 100.00% BCN approved providers only.
Treatment for Temporomandibular Joint Disorders
Covered
50.00% Coinsurance after deductible 100.00% Dental and orthodontic services, treatment, prosthesis and appliances related to TMJ. Prior authorization required. The penalty for not having prior authorization is denial of payment. 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
No Charge 100.00% Dietician Services.
Reconstructive Surgery
Covered
20.00% Coinsurance after deductible 100.00% Covered only when medically necessary.
Gender Affirming Care
Covered
20.00% Coinsurance after deductible 100.00% Cosmetic surgery, investigational and experimental procedures. May require prior authorization.
Non-Preferred Generic Drugs
Covered
$20.00 Copay after deductible 100.00% Quantity limits per fill may apply for 30-day retail, 90-day retail, and 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. Refer to drug list for quantity limits and other exclusions. May require prior authorization & step therapy. The penalty for not having prior authorization is denial of payment. No charge for Tier 1A contraceptives. 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
Non-Preferred Specialty Drugs
Covered
45.00% Coinsurance after deductible 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 Refer to drug list for quantity limits and other exclusions. BCN 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® Select HMO Silver Saver 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® Select HMO Silver Saver 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® Select HMO Silver Saver?

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

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