PPO - HuskyCare HDHP
Benefits-at-a-Glance
Michigan Technological University
In-Network
Out-of-Network
Deductible, Copays, Coinsurance and Dollar Maximums
Deductible - per calendar year
$1,750 individual
$3,500 family
$3,500 individual
$7,000 family
Copays
• Fixed Dollar Copays
Coinsurance
• Percent Coinsurance
No copays
No copays
10% unless otherwise noted
30% unless otherwise noted
Note: Services without a network are
covered at the in-network level.
Out-of-Pocket Maximum
Includes Deductible, Coinsurance and Copays
$3,000 individual
$6,000 family
$6,000 individual
$12,000 family
Unlimited
Lifetime Maximum
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 - 70% after deductible
Not Covered
Covered - 100%
Not Covered
Covered - 100%
Not Covered
Covered - 100%
Not Covered
Covered - 65% after deductible
Covered - 65% after deductible
Physician Office Services
Office Visits
Michigan Technological University_010114
Group Number: 71571 Package Code(s): 040 045 Section Code(s): 4000 4200
R 10/25/13
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 - 90% after deductible
Covered - 90% after deductible
Covered - 65% after deductible
Covered - 90% after deductible
Covered - 90% after deductible
Covered - 65% after deductible
Covered - 70% after deductible
Covered - 90% after deductible
Covered - 90% after deductible
Covered - 90% after deductible
Covered - 90% after deductible
Covered - 70% after deductible
Covered - 70% after deductible
Covered - 70% after deductible
Covered - 100%
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% after deductible
Not covered except in designated facilities
Covered - 90% after deductible
Covered - 70% after deductible
Covered - 90% after deductible
Covered - 65% after deductible
Covered - 70% after deductible
Covered - 65% after deductible
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
Behavioral Health and Substance Abuse Services
Inpatient Behavioral Health and Substance Abuse Care
Outpatient Behavioral Health and Substance Abuse Care
Autism Spectrum Disorders, Diagnoses and Treatment
−
−
−
Applied Behavioral Analysis (ABA) limited to a
visit maximum of 25 hours per week
Outpatient physical therapy, speech therapy,
occupational therapy, nutritional counseling for
autism spectrum disorder – through age 18
Other covered services, including mental health
services for Autism Spectrum Disorder
Not Covered
Michigan Technological University_010114
Group Number: 71571 Package Code(s): 040 045 Section Code(s): 4000 4200
Not Covered
R 10/25/13
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
Covered - 90% after deductible
Covered - 65% after deductible
Covered - 70% after deductible
Covered - 60% after deductible
Covered - 65% after deductible
Covered - 65% after deductible
Covered - 90% after deductible
Covered - 65% after deductible
Covered - 65% after deductible
Covered - 65% after deductible
Covered - 70% after deductible
Covered - 65% after deductible
Covered - 65% after deductible
Covered - 65% after deductible
Covered - 65% after deductible
Covered - 65% after deductible
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 Behavioral Health and Substance Abuse Care, and Skilled Nursing.
Michigan Technological University_010114
Group Number: 71571 Package Code(s): 040 045 Section Code(s): 4000 4200
R 10/25/13
Prescription Drugs
Deductible
Out-of-Pocket Maximum
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
$1,750 individual
$3,500 family
$3,000 individual
$6,000 family
10% coinsurance for generic and brand name drugs
10% coinsurance for generic and brand name drugs
Covered 100% for generic, select brand name and certain over-the-counter contraceptives
Covered
Not Covered
Covered
Not Covered
Includes:
Needles/Syringes and Insulin - 10% coinsurance at retail and mail order
Test Strips - 10% coinsurance at retail and mail order
Lancets - 10% coinsurance at retail and mail order
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.
Michigan Technological University_010114
Group Number: 71571 Package Code(s): 040 045 Section Code(s): 4000 4200
R 10/25/13