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Plan Description
Carrier Name > Blue Care Network HMO
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Plan Description as of 10/2/2003
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Note: This page contains a brief summary of coverage. It does not
state all provisions and limitations of the plan. The terms and provisions of
each plan, as outlined in the plan document, will determine coverage and
eligibility.
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General Plan Information
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Annual Deductible
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- Individual
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$1000
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- Family
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$2500
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Coinsurance
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100%
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Office Visit/Exam
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$10 copay
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Annual Out-of-Pocket Limit
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- Individual
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$2000
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- Family
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$3000
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Lifetime Plan Maximum
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Unlimited
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Primary Physician Election Required
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Yes
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Preventive Services
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Well-Child Care and Immunizations
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$10 copay
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Annual Pap or Prostate Exams
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$10 copay
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Mammograms
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$10 copay
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Adult Periodic Exams with Preventive Tests
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$10 copay
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Prescription Drug Benefits
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Pharmacy/Walk-in
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- Formulary Based
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Yes
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- Generic
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$5 copay
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- Brand
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$10 copay
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- Non-Formulary
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$20 copay
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- Number of Days Supply
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14 days
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Mail Order
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- Formulary Based
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Yes
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- Generic
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$7 copay
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- Brand
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$12 copay
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- Non-Formulary
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$20 copay
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- Number of Days Supply
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60 days
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Waiting Period Information
Eligible employees are eligible as of the 1st of the month following the
employee's hire date.
Termination of Coverage Information
When a plan participant is terminated from the company, the plan coverage ends on
the last day of the month following the employee's termination date.
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(per month)
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Employee
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$90.80
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Employee + Spouse
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$24.32
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Employee + Child(ren)
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$45.32
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Family
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$154.15
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Blue Cross Blue Shield of Michigan
http://www.bluesss.com
Member Services
John Carpet
600 Lafayette East
Detroit, MI 48226
(313) 225-5890
Fax (313) 225-3453
Claims Services
Jennifer Pattern
600 Lafayette East
Detroit, MI 48226
(313) 225-3445
Fax (313) 225-3435
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Enrollment Related Form)
