2019 Blue Cross® Select HMO Silver Saver Plan Details

Insurance Type	ACA (Obamacare)
Plan Name	Blue Cross® Select HMO Silver Saver
Plan ID	qhp-98185MI0180012
Plan Year	2019
Insurance Provider	Blue Cross Blue Shield of Michigan
Metal Level	Silver
Plan Type	HMO
Deductible	$3,300
Out-of-Pocket Maximum	$7,300
Personal Score
Plan Highlights

Costs for Medical Care
Primary Care Visit to Treat an Injury or Illness	$30 Copay
Specialist Visit	$50 Copay
Laboratory Outpatient and Professional Services	Not Applicable
X-rays and Diagnostic Imaging	30.00% Coinsurance after deductible
Deductible - Family	$6600
Out-of-Pocket Maximum - Family	$14600

Prescription drug coverage
Generic Drugs	$4 Copay
Preferred Brand Drugs	25% Coinsurance after deductible
Non-Preferred Brand Drugs	50% Coinsurance after deductible
Specialty Drugs	40% Coinsurance after deductible

Access to doctors and hospitals
Provider directory URL	Coming Soon

Hospital services
Emergency Room Services	30% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)	30% Coinsurance after deductible
Inpatient Physician and Surgical Services	30% Coinsurance after deductible

Maternity
Prenatal and Postnatal Care	Not Applicable

Mental Health
Mental/Behavioral Health Outpatient Services	Not Applicable
Mental/Behavioral Health Inpatient Services	30.00% Coinsurance after deductible

Vision Coverage
Routine Eye Exam for Children	Not Applicable
Eye Glasses for Children	Not Applicable

Exclusions and Limitations
More Included Benefits	Urgent Care Centers or Facilities Home Health Care Services Inpatient Physician and Surgical Services Bariatric Surgery Skilled Nursing Facility Radiation Diabetes Education Other Practitioner Office Visit (Nurse, Physician Assistant) Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Outpatient Surgery Physician/Surgical Services Hospice Services Infertility Treatment Outpatient Rehabilitation Services Habilitation Services Chiropractic Care Durable Medical Equipment Imaging (CT/PET Scans, MRIs) Preventive Care/Screening/Immunization Weight Loss Programs Rehabilitative Speech Therapy Rehabilitative Occupational and Rehabilitative Physical Therapy Well Baby Visits and Care Transplant Accidental Dental Dialysis Allergy Testing Chemotherapy Prosthetic Devices Infusion Therapy Treatment for Temporomandibular Joint Disorders Nutritional Counseling Reconstructive Surgery Non Preferred Generic Drugs Non Preferred Specialty Drugs
More Excluded Benefits	Hearing Aids Private-Duty Nursing Cosmetic Surgery Long-Term/Custodial Nursing Home Care Routine Foot Care Acupuncture Dental Check-Up for Children Abortion for Which Public Funding is Prohibited

Exclusions and Limitations

More Included Benefits

Urgent Care Centers or Facilities
Home Health Care Services
Inpatient Physician and Surgical Services
Bariatric Surgery
Skilled Nursing Facility
Radiation
Diabetes Education
Other Practitioner Office Visit (Nurse, Physician Assistant)
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Outpatient Surgery Physician/Surgical Services
Hospice Services
Infertility Treatment
Outpatient Rehabilitation Services
Habilitation Services
Chiropractic Care
Durable Medical Equipment
Imaging (CT/PET Scans, MRIs)
Preventive Care/Screening/Immunization
Weight Loss Programs
Rehabilitative Speech Therapy
Rehabilitative Occupational and Rehabilitative Physical Therapy
Well Baby Visits and Care
Transplant
Accidental Dental
Dialysis
Allergy Testing
Chemotherapy
Prosthetic Devices
Infusion Therapy
Treatment for Temporomandibular Joint Disorders
Nutritional Counseling
Reconstructive Surgery
Non Preferred Generic Drugs
Non Preferred Specialty Drugs

More Excluded Benefits

Hearing Aids
Private-Duty Nursing
Cosmetic Surgery
Long-Term/Custodial Nursing Home Care
Routine Foot Care
Acupuncture
Dental Check-Up for Children
Abortion for Which Public Funding is Prohibited

+ See All Coverage Details

Premium

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from $260

MyPriority HMO Silver 3200 - St. John Providence Network

$3,200.00

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$3,300.00

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$3,500.00

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from $293

MyPriority HMO Silver 3200 - Spectrum Health Partners

$3,200.00

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Last Name

Location/Distance

Please select the correct zip

Prechel, William

Zip Code	48228 (edit)
Applicant	2/19/1984 Male (edit)
Coverage Start	2/20/2019 (edit)

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Benefits & Coverage

Costs for Medical Care

Prescription drug coverage

Access to doctors and hospitals

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Maternity

Mental Health

Vision Coverage

Exclusions and Limitations

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