Irregular Employee Medical Plan Comparison
BCBSM Plans
Effective 7/1/15 - 6/30/16
In Network Plan Features
PLAN 1
PLAN 2
PLAN 3
PPO - CONVENTIONAL
PPO - HIGH DEDUCTIBLE
HSA ELIGIBLE
PPO - HIGH DEDUCTIBLE
HSA ELIGIBLE
$1,300
$1,300
$2,600
$2,600
20%
0%
20%
Deductible
A
Deductible - Single
$500
B
Deductible - 2 Person/Family
A
$1000
Additional Cost After Deductible
C
Coinsurance % after Deductible
D
Co-Insurance Max after Ded - Single
$1,500
$0
$950
E
Co-Insurance Max after Ded - 2 Person/Family
$3,000
$0
$1,900
Maximum Out of Pocket Cost
F
Max Out of Pocket - Single
$6,350
$2,250
$2,250
G
Max Out of Pocket - 2 Person/Family
$12,700
$4,500
$4,500
Copayments
H
Office Visit Copay
$20
B
$0 after Ded.
20% After Ded.
I
Specialist Copay
$40B
$0 after Ded.
20% After Ded.
J
Urgent Care Copay
$60B
$0 after Ded.
20% After Ded.
K
ER Copay
$150
$0 after Ded.
20% After Ded.
L
Chiropractic Benefit
$30/12 VisitsB
$0 after Ded/12 Visits
20% after Ded/12 Visits
M
Generic Rx Copay
$10
B
$10 after Ded.
$15 After Ded.
N
Preferred Brand Name Rx Copay
$40
B
$60 after Ded.
$50 After Ded.
O
Non-preferred Brand Name Rx Copay
$80B
$60 after Ded.
50% - $70 min/$100 max After Ded.
B
Monthly Rates**
P
One Person Rate per Month
$543.14
$502.08
$455.72
Q
Two Person Rate per Month
$1,302.02
$1,203.45
$1,092.26
R
Full Family Rate per Month
$1,633.28
$1,508.93
$1,371.07
A
for 2 Person/Family coverage, once a single member meets the "individual" deductible amount of $500, BCBSM will begin paying 80% of the cost of most approved
services for that member. See benefit summary for details.
B
Copay does not apply to deductible or coinsurance.
*Because the Single Coverage rate is less than the Hard Cap limitations, this plan will automatically come with an HSA partially funded by MCC. The difference
between the hard cap limitation and the premium amount will be placed in an HSA for the employee. The employee can opt to contribute their own dollars as well.
** Your bi-weekly premium deduction amount is based on your Benefit Eligibility Factor (BEF). See the Irregular Employee Medical Premium Deduction Calculator
on the HR Health & Wellness Website to determine your bi-weekly premium deduction.
DISCLAIMER: This document is a summary of certain plan features. It should not be interpreted as a complete comparison of the products represented.
For more information see the Summary of Benefits on the HR website.