Plan Details
Costs and Other Important Information
Plan Year:
2018
Optional Supplemental Benefits
No
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
Not Applicable
Other health plan deductibles?
No
Health Plan Deductible
$0
Monthly Drug Plan Premium
$0.00
Monthly Health Plan Premium
$0.00
Benefits
Service
Cost
Inpatient hospital coverage
$0 copay
Outpatient hospital coverage
$0 copay
Doctor visits
Primary:
$0 copay
Specialist:
$0 copay
$0 copay
Specialist:
$0 copay
Preventive care
$0 copay
Emergency care/Urgent care
Emergency:
$0 copay
Urgent care:
$0 copay
$0 copay
Urgent care:
$0 copay
Diagnostic procedures/lab services/imaging
Diagnostic tests and procedures:
$0 copay
Lab services:
$0 copay
Diagnostic radiology services (e.g., MRI):
$0 copay
Outpatient x-rays:
$0 copay
$0 copay
Lab services:
$0 copay
Diagnostic radiology services (e.g., MRI):
$0 copay
Outpatient x-rays:
$0 copay
Mental health services
$0 copay
Outpatient group therapy visit with a psychiatrist:
$0 copay
Outpatient individual therapy visit with a psychiatrist:
$0 copay
Outpatient group therapy visit:
$0 copay
Outpatient individual therapy visit:
$0 copay
Outpatient group therapy visit with a psychiatrist:
$0 copay
Outpatient individual therapy visit with a psychiatrist:
$0 copay
Outpatient group therapy visit:
$0 copay
Outpatient individual therapy visit:
$0 copay
Skilled Nursing Facility
$0 copay
Rehabilitation services
Occupational therapy visit:
$0 copay
Physical therapy and speech and language therapy visit:
$0 copay
$0 copay
Physical therapy and speech and language therapy visit:
$0 copay
Ambulance
$0 copay
Transportation
$0 copay
Foot care (podiatry services)
Foot exams and treatment:
$0 copay
Routine foot care:
Not covered
$0 copay
Routine foot care:
Not covered
Medical equipment/supplies
Durable medical equipment (e.g., wheelchairs, oxygen):
$0 copay
Prosthetics (e.g., braces, artificial limbs):
$0 copay
Diabetes supplies:
$0 copay
$0 copay
Prosthetics (e.g., braces, artificial limbs):
$0 copay
Diabetes supplies:
$0 copay
Wellness programs (e.g., fitness, nursing hotline)
Covered
Medicare Part B drugs
Chemotherapy:
$0 copay
Other Part B drugs:
$0 copay
$0 copay
Other Part B drugs:
$0 copay
Coverage Area for Michigan Complete Health (Medicare-Medicaid )
| State | Michigan |
|---|---|
| County | Wayne |
Cost Sharing Information
All cost-sharing assumes in-network healthcare providers.
Prescription Drug Copay/Coninsurance Details - Initial Coverage Limit
| 30 Day Supply | Preferred Retail Pharmacies | Non-Preferred Retail Pharmacies | Mail-Order Pharmacies |
|---|---|---|---|
| Tier 1: Preferred Generic | Not offereds | 0% coinsurance | Not offered |
| Tier 2: Non-Preferred Generic | Not offered | 0% coinsurance | Not offered |
| Tier 3: Preferred Brand Name | Not offered | 0% coinsurance | Not offered |
| Tier 4: Non-Preferred Brand Name | |||
| Tier 5: Specialty Tier |
| 90 Day Supply | Preferred Retail Pharmacies | Non-Preferred Retail Pharmacies | Mail-Order Pharmacies |
|---|---|---|---|
| Tier 1: Preferred Generic | Not offered | 0% coinsurance | Not offered |
| Tier 2: Non-Preferred Generic | Not offered | 0% coinsurance | Not offered |
| Tier 3: Preferred Brand Name | Not offered | 0% coinsurance | Not offered |
| Tier 4: Non-Preferred Brand Name | |||
| Tier 5: Specialty Tier |
Physician Finder
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