PPO – Retiree HuskyCare 1
Benefits-at-a-Glance
Michigan Technological University
Group Number: 71571
Package Code(s): 020
Section Code(s): 1100 1200
In-Network
Out-of-Network
Deductible, Copays/Coinsurance and Dollar Maximums
Copays/Coinsurance
• Fixed Dollar Copays
$500 per member
$1,000 per family
$75 copay for:
•
Emergency Room
$1,000 per member
$2,000 per family
$75 copay for:
•
Emergency Room
• Percent Coinsurance
10% unless otherwise noted
Out-of-Pocket Maximum
• Percent Coinsurance
Includes Deductible
Lifetime Maximum
$1,500 per member
$3,000 per family
30% unless otherwise noted
Note: Services without a network are
covered at the in-network level.
$3,000 per member
$6,000 per family
Deductible - per calendar year
Unlimited
Preventive Services
Health Maintenance Exam - one per calendar year
Routine Physical Related Test - X-Rays, EKG and lab
procedures performed as part of the health maintenance
exam
Annual Gynecological Exam - one per calendar year, in
addition to health maintenance exam
Pap Smear Screening - one per calendar year
Mammography Screening - one per calendar year
Contraceptive Methods and Counseling
Prostate Specific Antigen (PSA) Screening - one per
calendar year beginning age 40
Endoscopic Exams - one per calendar year beginning age
50
Well Child Care
− 6 visits, birth through 12 months
− 6 visits, 13 months through 23 months
− 6 visits, 24 months through 35 months
− 2 visits, 36 months through 47 months
− Visits beyond 47 months are limited to one per
member per calendar year under the health
maintenance exam benefit.
Immunizations – pediatric and adult
Covered - 100%
Covered - 100%
Not Covered
Not Covered
Covered - 100%
Not Covered
Covered - 100%
Covered - 100%
Covered - 100%
Covered - 100%
Not Covered
Not Covered
Covered - 65% after deductible
Not Covered
Covered - 100%
Not Covered
Covered - 100%
Not Covered
Covered - 100%
Not Covered
Covered - 65%
Covered - 65% after deductible
Physician Office Services
Office Visits
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In-Network
Out-of-Network
Emergency Medical Care
Hospital Emergency Room
Qualified medical emergency
Non-Emergency use of the Emergency Room
Urgent Care Services
Ambulance Services - Medically Necessary Transport
Covered - 100% after $75 copay; copay
waived if admitted
Covered - 65% after deductible
Covered - 100% after $50 copay
Covered - 90% after deductible
Covered - 100% after $75 copay; copay
waived if admitted
Covered - 65% after deductible
Covered - 70% after deductible
Covered - 90% after deductible
Covered - 90%
Covered - 90%
Covered - 90% after deductible
Covered - 70% after deductible
Covered - 70% after deductible
Covered - 70% after deductible
Covered - 65%
Covered - 90% after deductible
Covered - 65% after deductible
Covered - 70% after deductible
Covered - 90% after deductible
Covered - 70% after deductible
Covered - 90% after deductible
Covered - 70% after deductible
Covered - 90% after deductible
Covered - 70% after deductible
Covered - 90% after deductible
Covered - 90% after deductible
Covered - 70% after deductible
Covered - 70% after deductible
Covered - 90% after deductible
Covered - 90% after deductible
Covered - 70% after deductible
Covered - 70% after deductible
Covered - 100%
Covered - 70% after deductible
Covered - 100%
Not covered except in designated facilities
Covered - 90% after deductible
Covered - 70% after deductible
Covered - 90% after deductible
Covered - 65%
Covered - 70% after deductible
Covered - 65% after deductible
Covered - 90% after deductible
Covered - 65%
Covered - 70% after deductible
Covered - 60% after deductible
Covered - 65%
Covered - 65%
Covered - 90% after deductible
Covered - 65%
Covered - 65% after deductible
Covered - 65% after deductible
Covered - 70% after deductible
Covered - 65% after deductible
Covered - 65%
Covered - 60% after deductible
Covered - 65%
Covered - 65%
Diagnostic and Therapeutic Services
MRI, MRA, PET and CAT Scans and Nuclear Medicine
Diagnostic Tests, X-rays, Laboratory & Pathology
Radiation Therapy and Chemotherapy
Maternity Services Provided by a Physician
Prenatal and Postnatal Care Visits
Delivery and Nursery Care
Hospital Care
Semi-Private Room, Inpatient Physician Care, General
Nursing Care, Hospital Services and Supplies
Inpatient Medical Care
Alternatives to Hospital Care
Hospice Care
Inpatient Care limited to 30 days per lifetime
Home Health Care
Skilled Nursing
Limited to 120 days per calendar year
Surgical Services
Surgery (includes related surgical services)
Sterilization – males only
excludes reversal sterilization
Sterilization – females only
excludes reversal sterilization
Human Organ Transplants
Specified Organ Transplants in designated facilities only,
when coordinated through BCBSM Human Organ
Transplant Program (800-242-3504)
Kidney, Cornea, Bone Marrow and Skin
Mental Health and Substance Abuse Services
Inpatient Mental Health and Substance Abuse Care
Outpatient Mental Health and Substance Abuse Care
Other Services
Cardiac Rehabilitation
Chiropractic Services
Limited to 24 visits per calendar year
Durable Medical Equipment
Prosthetic and Orthotic Devices
Private Duty Nursing
Allergy Therapy and Testing
Therapy Services
Physical, Occupational and Speech Therapy
Limited to 60 visits combined (includes massage therapy)
Massage Therapy
Note: The following services require preapproval: Inpatient Care, select Radiology Services, Inpatient Mental Health and Substance Abuse Care, and Skilled Nursing.
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Prescription Drugs
Retail - 34 day supply or 100-unit
doses (whichever is greater)
Mail Order- 90 day supply
Oral and Injectable Contraceptives
Retail and Mail Order
Additional Services
Smoking Cessation Drugs
Weight Loss Drugs
Impotency Drugs
Infertility Drugs
Diabetic Supplies
10% coinsurance for generic drugs ($5 minimum/$20 maximum)
25% coinsurance for brand name drugs ($10 minimum/$40 maximum)
10% coinsurance for generic drugs ($10 minimum/$40 maximum)
25% coinsurance for brand name drugs ($20 minimum/$80 maximum)
Covered - 100% for generic drugs; brand name drugs are subject to the applicable coinsurance
Covered
Not Covered
Covered
Not Covered
Includes:
Needles/Syringes and Insulin - 25% ($10 min/$40 max) at retail; 25% ($20 min/$80 max) at mail order
Test Strips - 25% ($10 min/$40 max) at retail; 25% ($20 min/$80 max) at mail order
Lancets - 25% ($10 min/$40 max) at retail; 25% ($20 min/$80 max) at mail order
The information in this document is based on BCBSM’s current interpretation of the Patient Protection and Affordable Care Act (PPACA). Interpretations of PPACA vary and the federal
government continues to issue guidance on how PPACA should be interpreted and applied. Efforts will be made to update this document as more information about PPACA becomes available.
This document is only an educational tool and should not be relied upon as legal or compliance advice. Additionally, some PPACA requirements may differ for particular members enrolled in
certain programs, and those members should consult with their plan administrators for specific details.
This is intended as an easy-to-read summary and provides only a general overview of your benefits. It is not a contract. Additional limitations and exclusions may apply. Payment amounts are
based on BCBSM’s approved amount, less any applicable deductible and/or copay. For a complete description of benefits please see the applicable BCBSM certificates and riders, if your
group is underwritten or any other plan documents your group uses, if your group is self-funded. If there is a discrepancy between this Benefits-At-A-Glance and any applicable plan
document, the plan document will control.
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