ÿþ<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd"> <html xmlns="http://www.w3.org/1999/xhtml"> <head> <title>MyBlue Plans: Individual Care Blue Health Insurance Plan</title> <meta name="Description" content="MyBlue Plans offers low cost Individual Care Blue Insurance Plan from Blue Cross Blue Shield of Michigan. Low cost health Insurance deductibles, copays & prescription drug coverage." /> <meta name="keywords" content="Individual Care Blue, Health Insurance,Michigan,Blue Cross Blue Shield" /> <meta name="Robots" content="INDEX,FOLLOW"> <meta name="Revisit-after" content="1 Day"> <link type="text/css" href="include/StyleSheet.css" rel="Stylesheet" /> <script src="include/validate.js" type="text/javascript"></script> <script src="include/RightClickDisable.js" type="text/javascript"></script> </head> <body onload="return ChangeSubmenu('sm2')"> <table cellpadding="0" cellspacing="0" width="870px" border="0" style="background-color: #2E4B9B; padding: 10px" align="center"> <tr> <td valign="top"> <table cellpadding="0" cellspacing="0" width="850" border="0"> <tr style="height: 10px"> <td valign="top" style="background-image: url(images/top.jpg); background-repeat: no-repeat"> </td> </tr> <tr> <td valign="top" style="background-color: White"> <table cellpadding="0" cellspacing="0" width="100%" border="0"> <tr> <td> <!-- header --> <script src="include/header.js" type="text/javascript"></script> </td> </tr> <tr> <td colspan="5"> <table cellpadding="0" cellspacing="0" width="100%" border="0" style="padding-right: 0px; padding-left: 0px;"> <tr style="height: auto; vertical-align: top"> <td style="width: 10px"> </td> <td colspan="" style="width: 626px; border: 0px solid #000000;" class="myblueheader"> <!-- content --> <table cellpadding="0" cellspacing="0" border="0" width="99.5%"> <tr> <td class="fontwelcome"> <a id="top"></a>Individual Care Blue Plus<sup>SM</sup></td> </tr> <tr> <td> &nbsp; </td> </tr> <!-------------------------- menu table start -----------------------> <tr> <td> <script type="text/javascript" src="include/Menu.js"></script> </td> </tr> <tr> <td> &nbsp; <input id="hidmenuflag" type="hidden" value="1" /> <input id="hidpagename" type="hidden" value="ICB" /> </td> </tr> <tr> <td> <img src="images/arrow.gif" alt="" style="" />&nbsp;&nbsp;<a href="#icbpb">Individual Care Blue Plus Benefits</a>&nbsp;&nbsp;&nbsp;&nbsp;<img src="images/arrow.gif" alt="" style="" />&nbsp;&nbsp;<a href="#dental">Dental (optional)</a> </td> </tr> <tr> <td> &nbsp; </td> </tr> <tr> <td class="fontwelcome"> <a id="icbpb"></a>Individual Care Blue Plus Benefits-at-a-Glance </td> </tr> <tr> <td> &nbsp; </td> </tr> <tr> <td> <a href="docs/ic_blue_baag.pdf" target="_blank" title="Portable Document Format">Download Individual Care Blue Plus Benefits (86K PDF) </a> </td> </tr> <tr> <td> &nbsp;<br /> </td> </tr> <tr> <td> <table cellpadding="0" cellspacing="0" border="1" width="100%" style="text-align: justify; border-collapse: collapse; border-color: #D6D3CE"> <tr> <td style="width: 40%"> &nbsp;&nbsp;&nbsp;&nbsp;</td> <td class="Benefitbg2" style="width: 30%"> In-Network</td> <td class="Benefitbg3" style="width: 30%"> Out-of-Network</td> </tr> <tr> <td colspan="3" class="ICBbg"> Benefit HighLights </td> </tr> <tr> <td class="Benefitfleft"> Annual deductible</td> <td class="Benefitbg2"> $1,000 individual/$2,000 family</td> <td class="Benefitbg3"> $2,000 individual/$4,000 family</td> </tr> <tr> <td valign="top" class="Benefitfleft"> Copays</td> <td class="Benefitbg2"> 30% of the <acronym title="Blue Cross Blue Shield of Michigan">BCBSM</acronym>-approved amount</td> <td class="Benefitbg3"> 50% of the <acronym title="Blue Cross Blue Shield of Michigan">BCBSM</acronym>-approved amount</td> </tr> <tr> <td valign="top" class="Benefitfleft"> Annual out-of-pocket maximum: The annual out-of-pocket maximum limits the amount you will be responsible for paying each year. Once the annual out-of-pocket maximum is met, most services are payable at 100% of the <acronym title="Blue Cross Blue Shield of Michigan"> BCBSM</acronym>-approved amount.</td> <td class="Benefitbg2"> $3,500 individual/$7,000 family</td> <td class="Benefitbg3"> $7,000 individual/$14,000 family</td> </tr> <tr> <td valign="top" class="Benefitfleft"> Annual copay dollar maximum</td> <td class="Benefitbg2"> $2,500 per individual or family contract (two or more members)</td> <td class="Benefitbg3"> No out-of-pocket maximum</td> </tr> <tr> <td valign="top" class="Benefitfleft"> Lifetime maximum per member</td> <td colspan="2" style="text-align: center"> $5 million</td> </tr> <tr> <td valign="top" class="Benefitfleft"> Fourth-quarter deductible carryover</td> <td class="Benefitbg2"> Not applicable</td> <td class="Benefitbg3"> Not applicable</td> </tr> </table> </td> </tr> <tr> <td> &nbsp;<br /> </td> </tr> <tr> <td> <table cellpadding="0" cellspacing="0" border="1" width="100%" style="text-align: justify; border-collapse: collapse; border-color: #D6D3CE"> <tr> <td style="width: 40%" colspan="3" class="ICBbg"> Preventive Services </td> </tr> <tr> <td style="width: 40%;" class="Benefitfleft"> Preventive medical care: Includes health maintenance exam, routine laboratory and radiology, fecal occult blood screening, flexible sigmoidoscopy, gynecological exam, childhood immunizations (through age 15), Pap smear screening, prostate specific antigen screening, well-baby and well-child exams (6 visits per year through age 1; 2 visits per year, ages 2 through 3; 1 visit per year, ages 4 through 15).</td> <td class="Benefitbg2" style="width: 30%" valign="top"> Covered  100% with no deductible, up to a combined maximum of $500 per member, per calendar year. 90-day benefit waiting period applies.</td> <td class="Benefitbg3" style="width: 30%" valign="top"> Not covered</td> </tr> <tr> <td valign="top" style="width: 40%" class="Benefitfleft"> Mammography</td> <td class="Benefitfleft" colspan="2"> Covered  100% with no deductible. 90-day benefit waiting period applies.</td> </tr> <tr> <td valign="top" style="width: 40%" class="Benefitfleft"> Preventive dental</td> <td class="Benefitfleft" colspan="2"> Covered  100% with no deductible. One dental exam, cleaning and bitewing per member, per calendar year. 90-day benefit waiting period applies.</td> </tr> <tr> <td valign="top" style="width: 40%" class="Benefitfleft"> Preventive vision (VSP network provider only)</td> <td class="Benefitfleft" colspan="2"> Covered  100% with no deductible. One vision exam, per member, per calendar year</td> </tr> </table> </td> </tr> <tr> <td> &nbsp;<br /> </td> </tr> <tr> <td> <table cellpadding="0" cellspacing="0" border="1" width="100%" style="text-align: justify; border-collapse: collapse; border-color: #D6D3CE"> <tr> <td style="width: 40%" colspan="3" class="ICBbg"> Physician Office Services </td> </tr> <tr> <td style="width: 40%" class="Benefitfleft"> Office visits</td> <td class="Benefitbg2" style="width: 30%" valign="top"> Covered  70% with no deductible; 2 visits, per member, per calendar year</td> <td class="Benefitbg3" style="width: 30%" valign="top"> Not covered</td> </tr> <tr> <td valign="top" style="width: 40%" class="Benefitfleft"> Outpatient presurgical second opinion consultations</td> <td class="Benefitbg2" style="width: 30%"> Covered  100% after deductible</td> <td class="Benefitbg3" style="width: 30%"> Not covered</td> </tr> <tr> <td valign="top" style="width: 40%" class="Benefitfleft"> Office consultations</td> <td class="Benefitbg2" style="width: 30%"> Not covered</td> <td class="Benefitbg3" style="width: 30%"> Not covered</td> </tr> </table> </td> </tr> <tr> <td> &nbsp;<br /> </td> </tr> <tr> <td> <table cellpadding="0" cellspacing="0" border="1" width="100%" style="text-align: justify; border-collapse: collapse; border-color: #D6D3CE"> <tr> <td style="width: 40%" colspan="3" class="ICBbg"> Emergency and Urgent Care Services </td> </tr> <tr> <td style="width: 40%" class="Benefitfleft"> Medical emergencies and accidental injuries</td> <td class="whtbg" colspan="2"> Covered  70% after in-network deductible for all services other than physician services. You pay $150 for physician services (waived if admitted).</td> </tr> <tr> <td valign="top" style="width: 40%" class="Benefitfleft"> Ambulance service: medically necessary, emergency ground transport and air ambulance</td> <td class="whtbg" colspan="2"> Covered  70% after in-network deductible</td> </tr> <tr> <td valign="top" style="width: 40%" class="Benefitfleft"> Urgent care</td> <td class="whtbg" colspan="2"> Covered  70% after in-network deductible for all services other than physician services. You pay $50 for physician services.</td> </tr> </table> </td> </tr> <tr> <td> &nbsp;<br /> </td> </tr> <tr> <td> <table cellpadding="0" cellspacing="0" border="1" width="100%" style="text-align: justify; border-collapse: collapse; border-color: #D6D3CE"> <tr> <td colspan="3" class="ICBbg"> Diagnostic and Radiation Services </td> </tr> <tr> <td style="width: 40%" class="Benefitfleft"> Ultrasound</td> <td class="Benefitbg2" style="width: 30%"> Covered  70% after deductible</td> <td class="Benefitbg3" style="width: 30%"> Covered  50% after deductible</td> </tr> <tr> <td valign="top" class="Benefitfleft"> Laboratory tests and pathology</td> <td class="Benefitbg2"> Covered  70% after deductible</td> <td class="Benefitbg3"> Covered  50% after deductible</td> </tr> <tr> <td valign="top" class="Benefitfleft"> EKGs</td> <td class="Benefitbg2"> Covered  70% after deductible</td> <td class="Benefitbg3"> Covered  50% after deductible</td> </tr> <tr> <td valign="top" class="Benefitfleft"> Diagnostic radiology and X-rays</td> <td class="Benefitbg2"> Covered  70% after deductible</td> <td class="Benefitbg3"> Covered  50% after deductible</td> </tr> <tr> <td valign="top" class="Benefitfleft"> Colonoscopies (diagnostic)</td> <td class="Benefitbg2"> Covered  70% after deductible</td> <td class="Benefitbg3"> Covered  50% after deductible</td> </tr> <tr> <td valign="top" class="Benefitfleft"> CT scans and MRIs (BCBSM-participating facilities </td> <td class="whtbg" colspan="2"> Covered  70% after in-network deductible</td> </tr> <tr> <td valign="top" class="Benefitfleft"> Radiation therapy</td> <td class="Benefitbg2"> Covered  70% after deductible</td> <td class="Benefitbg3"> Covered  50% after deductible</td> </tr> </table> </td> </tr> <tr> <td> &nbsp;<br /> </td> </tr> <tr> <td> <table cellpadding="0" cellspacing="0" border="1" width="100%" style="text-align: justifyl; border-collapse: collapse; border-color: #D6D3CE"> <tr> <td style="width: 40%" colspan="3" class="ICBbg"> Maternity Services </td> </tr> <tr> <td style="width: 40%" class="Benefitfleft"> Delivery and newborn exam</td> <td class="Benefitbg2" style="width: 30%" valign="top"> Covered  70% after deductible. Annual benefit maximum applies.</td> <td class="Benefitbg3" style="width: 30%" valign="top"> Covered  50% after deductible. Annual benefit maximum applies.</td> </tr> <tr> <td valign="top" style="width: 40%" class="Benefitfleft"> Prenatal and postnatal exams (office visits)</td> <td class="Benefitbg2" style="width: 30%"> Not covered</td> <td class="Benefitbg3" style="width: 30%"> Not covered</td> </tr> <tr> <td valign="top" style="width: 40%" class="Benefitfleft"> Annual benefit maximum: This is the maximum amount BCBSM will pay for covered maternity services per calendar year. Benefits are subject to all applicable deductible and copay requirements and to the copay and lifetime maximums mentioned elsewhere in your certificate.</td> <td class="whtbg" colspan="2"> $5,000 per calendar year for vaginal deliveries and elective or non-medically necessary cesarean deliveries<br /> <br /> $7,500 per calendar year for medically necessary cesarean deliveries</td> </tr> </table> </td> </tr> <tr> <td> &nbsp;<br /> </td> </tr> <tr> <td> <table cellpadding="0" cellspacing="0" border="1" width="100%" style="text-align: justify; border-collapse: collapse; border-color: #D6D3CE"> <tr> <td style="width: 40%" colspan="3" class="ICBbg"> Inpatient Hospital Care </td> </tr> <tr> <td style="width: 40%" class="Benefitfleft"> Semi-private room: 120 days with 60-day renewal period (BCBSM-approved facilities only)</td> <td class="Benefitbg2" style="width: 30%" valign="top"> Covered  70% after deductible</td> <td class="Benefitbg3" style="width: 30%" valign="top"> Covered  50% after deductible</td> </tr> <tr> <td valign="top" style="width: 40%" class="Benefitfleft"> Inpatient consultations</td> <td class="Benefitbg2"> Covered  70% after deductible</td> <td class="Benefitbg3"> Covered  50% after deductible</td> </tr> <tr> <td valign="top" style="width: 40%" class="Benefitfleft"> Complications of pregnancy</td> <td class="Benefitbg2"> Covered  70% after deductible</td> <td class="Benefitbg3"> Covered  50% after deductible</td> </tr> <tr> <td valign="top" style="width: 40%" class="Benefitfleft"> Inpatient surgical care</td> <td class="Benefitbg2"> Covered  70% after deductible</td> <td class="Benefitbg3"> Covered  50% after deductible</td> </tr> <tr> <td valign="top" style="width: 40%" class="Benefitfleft"> Outpatient surgical care</td> <td class="Benefitbg2"> Covered  70% after deductible</td> <td class="Benefitbg3"> Covered  50% after deductible</td> </tr> <tr> <td valign="top" style="width: 40%" class="Benefitfleft"> Physician surgical services</td> <td class="Benefitbg2"> Covered  70%</td> <td class="Benefitbg3"> Covered  50%</td> </tr> <tr> <td valign="top" style="width: 40%" class="Benefitfleft"> Gender reassignment surgery and services</td> <td class="Benefitbg2"> Not covered</td> <td class="Benefitbg3"> Not covered</td> </tr> <tr> <td valign="top" style="width: 40%" class="Benefitfleft"> Bariatric surgery and services</td> <td class="Benefitbg2"> Not covered</td> <td class="Benefitbg3"> Not covered</td> </tr> </table> </td> </tr> <tr> <td> &nbsp;<br /> </td> </tr> <tr> <td> <table cellpadding="0" cellspacing="0" border="1" width="100%" style="text-align: justify; border-collapse: collapse; border-color: #D6D3CE"> <tr> <td style="background-color: #69943a; width: 40%" colspan="3" class="ICBbg"> Outpatient Services </td> </tr> <tr> <td style="width: 40%" class="Benefitfleft"> Inpatient surgical care</td> <td class="Benefitbg2" style="width: 30%" valign="top"> Covered  70%</td> <td class="Benefitbg3" style="width: 30%" valign="top"> Covered  50%</td> </tr> <tr> <td valign="top" style="width: 40%" class="Benefitfleft"> Outpatient surgical care</td> <td class="Benefitbg2" style="width: 30%"> Covered  70%</td> <td class="Benefitbg3" style="width: 30%"> Covered  50%</td> </tr> <tr> <td valign="top" style="width: 40%" class="Benefitfleft"> Physician surgical services</td> <td class="Benefitbg2" style="width: 30%"> Covered  70%</td> <td class="Benefitbg3" style="width: 30%"> Covered  50%</td> </tr> </table> </td> </tr> <tr> <td> &nbsp;<br /> </td> </tr> <tr> <td> <table cellpadding="0" cellspacing="0" border="1" width="100%" style="text-align: justify; border-collapse: collapse; border-color: #D6D3CE"> <tr> <td style="width: 40%" colspan="3" class="ICBbg"> Alternatives to Hospitalization </td> </tr> <tr> <td class="Benefitfleft" style="width: 40%"> Home health care (participating providers only)</td> <td class="whtbg" style="width: 60%"> Covered  70% after in-network deductible</td> </tr> <tr> <td class="Benefitfleft"> Hospice care: covered at a participating program up to the annual dollar maximum</td> <td class="whtbg"> Covered  100% after in-network deductible</td> </tr> </table> </td> </tr> <tr> <td> &nbsp;<br /> </td> </tr> <tr> <td> <table cellpadding="0" cellspacing="0" border="1" width="100%" style="text-align: justify; border-collapse: collapse; border-color: #D6D3CE"> <tr> <td colspan="3" class="ICBbg"> Outpatient Services </td> </tr> <tr> <td style="width: 40%" class="Benefitfleft"> Outpatient physical, occupational and speech therapy</td> <td class="Benefitbg2" style="width: 30%" valign="top"> Covered  70% after deductible; 12 visits total, all therapies combined, per member, per calendar year</td> <td class="Benefitbg3" style="width: 30%" valign="top"> Covered  50% after deductible; 12 visits total, all therapies combined, per member, per calendar year</td> </tr> <tr> <td class="Benefitfleft"> Chemotherapy (IV and oral)</td> <td class="Benefitbg2" style="width: 30%"> Covered  70% after deductible</td> <td class="Benefitbg3" style="width: 30%"> Covered  50% after deductible</td> </tr> <tr> <td valign="top" class="Benefitfleft"> Home infusion therapy (BCBSM-participating providers only)</td> <td class="whtbg" colspan="2"> Covered  70% after in-network deductible</td> </tr> <tr> <td valign="top" class="Benefitfleft"> Voluntary sterilization</td> <td class="Benefitbg2"> Covered  70% after deductible</td> <td class="Benefitbg3"> Covered  50% after deductible</td> </tr> <tr> <td valign="top" class="Benefitfleft"> Prosthetics: mandated only (BCBSM-participating providers only)</td> <td class="whtbg" colspan="2"> Covered  70% after in-network deductible</td> </tr> </table> </td> </tr> <tr> <td> &nbsp;<br /> </td> </tr> <tr> <td> <table cellpadding="0" cellspacing="0" border="1" width="100%" style="text-align: justify; border-collapse: collapse; border-color: #D6D3CE"> <tr> <td style="width: 40%" colspan="3" class="ICBbg"> Other medical benefits </td> </tr> <tr> <td style="width: 40%" class="Benefitfleft"> Insulin, disposable needles and syringes dispensed with insulin, diabetic testing supplies</td> <td class="Benefitbg2" style="width: 30%" valign="top"> Covered  70% after deductible</td> <td class="Benefitbg3" style="width: 30%" valign="top"> Covered  50% after deductible</td> </tr> <tr> <td valign="top" style="width: 40%" class="Benefitfleft"> Outpatient diabetes management program</td> <td class="Benefitbg2" style="width: 30%"> Covered  70% after deductible</td> <td class="Benefitbg3" style="width: 30%"> Covered  50% after deductible</td> </tr> <tr> <td valign="top" style="width: 40%" class="Benefitfleft"> Contraceptives: physician-administered, prescription drugs only, devices and contraceptive injectables (Implants are not covered)</td> <td class="Benefitbg2" style="width: 30%" valign="top"> Covered  70% after deductible</td> <td class="Benefitbg3" style="width: 30%" valign="top"> Covered  50% after deductible</td> </tr> </table> </td> </tr> <tr> <td> &nbsp;<br /> </td> </tr> <tr> <td> <table cellpadding="0" cellspacing="0" border="1" width="100%" style="text-align: justify; border-collapse: collapse; border-color: #D6D3CE"> <tr> <td style="width: 40%" colspan="3" class="ICBbg"> Organ Transplantation </td> </tr> <tr> <td style="width: 40%" class="Benefitfleft"> Bone marrow transplant</td> <td class="Benefitbg2" style="width: 30%" valign="top"> Covered  70% after deductible</td> <td class="Benefitbg3" style="width: 30%" valign="top"> Covered  50% after deductible</td> </tr> <tr> <td valign="top" style="width: 40%" class="Benefitfleft"> Kidney, cornea and skin transplants</td> <td class="Benefitbg2" style="width: 30%"> Covered  70% after deductible</td> <td class="Benefitbg3" style="width: 30%"> Covered  50% after deductible</td> </tr> <tr> <td valign="top" style="width: 40%" class="Benefitfleft"> Specified organ transplant: $1 million lifetime maximum per transplant type, included in the $5 million lifetime maximum (BCBSM-designated facilities only)</td> <td class="whtbg" colspan="2" style="width: 30%;"> Covered  100% after in-network deductible</td> </tr> </table> </td> </tr> <tr> <td> &nbsp;<br /> </td> </tr> <tr> <td> <table cellpadding="0" cellspacing="0" border="1" width="100%" style="text-align: justify; border-collapse: collapse; border-color: #D6D3CE"> <tr> <td style="width: 40%" colspan="3" class="ICBbg"> Mental Health and Substance Abuse Treatment </td> </tr> <tr> <td style="width: 40%" class="Benefitfleft"> Inpatient mental health (BCBSM-approved facilities only)</td> <td class="Benefitbg2" style="width: 30%" valign="top"> Covered  70% after deductible, 30 days with 60-day renewal</td> <td class="Benefitbg3" style="width: 30%" valign="top"> Covered  50% after deductible, 30 days with 60-day renewal</td> </tr> <tr> <td valign="top" style="width: 40%" class="Benefitfleft"> Outpatient mental health</td> <td class="Benefitbg2" style="width: 30%"> Not covered</td> <td class="Benefitbg3" style="width: 30%"> Not covered</td> </tr> <tr> <td valign="top" style="width: 40%" class="Benefitfleft"> Substance abuse  inpatient (residential) and outpatient: up to state-mandated benefit (BCBSM-approved facilities only)</td> <td class="Benefitbg2" valign="top" style="width: 30%"> Covered - 70% after deductible</td> <td class="Benefitbg3" style="width: 30%" valign="top"> Covered  50% after deductible</td> </tr> </table> </td> </tr> <tr> <td> &nbsp;<br /> </td> </tr> <tr> <td> <table cellpadding="0" cellspacing="0" border="1" width="100%" style="text-align: justify; border-collapse: collapse; border-color: #D6D3CE"> <tr> <td style="width: 40%"> &nbsp;&nbsp;&nbsp;&nbsp;</td> <td class="Benefitbg2"> Network Pharmacy</td> <td class="Benefitbg3"> non-network Pharmacy</td> </tr> <tr> <td colspan="3" class="ICBbg"> Prescription Drugs </td> </tr> <tr> <td colspan="3" class="whtbg"> Prescription drug benefits are subject to a 180-day waiting period for pre-existing conditions. Medical and drug expenses do not combine to meet the annual deductible. Prescription drug copays do not contribute to the annual copay dollar maximum.</td> </tr> <tr> <td class="Benefitfleft"> Annual maximum</td> <td class="whtbg" colspan="2"> Covered  $2,500 per member, per calendar year after in-network integrated deductible, retail and mail order combined. Members who exhaust the annual maximum may purchase prescription drugs at the BCBSM-negotiated rate for the remainder of the calendar year. These expenses will not contribute to the in-network integrated deductible or annual copay dollar maximum.</td> </tr> <tr> <td valign="top" class="Benefitfleft"> Retail (1  34 day supply)</td> <td class="Benefitbg2" valign="top"> Covered  50% of the approved amount with $10 minimum and $100 maximum copay, after in-network integrated deductible</td> <td class="Benefitbg3"> Members must pay the pharmacist the full cost of the drug. After the in-network integrated deductible, BCBSM will reimburse 80% of the BCBSM-approved amount for covered drugs, less the copay and the difference between the non-network pharrmacy s charge and the BCBSM-approved amount for the drug.</td> </tr> <tr> <td valign="top" class="Benefitfleft"> 90-day retail (84  90 day supply)</td> <td class="Benefitbg2"> Covered  50% of the approved amount with a minimum of $20 and a maximum of $200 per prescription, after in network integrated deductible</td> <td class="Benefitbg3"> Not covered</td> </tr> <tr> <td valign="top" class="Benefitfleft"> Mail order (35  90 day supply)</td> <td class="Benefitbg2"> Covered  50% of the approved amount with a minimum of $20 and a maximum of $200 per prescription, after in network integrated deductible</td> <td class="Benefitbg3"> Not covered</td> </tr> </table> </td> </tr> <tr> <td> &nbsp;<br /> </td> </tr> <tr> <td> <div class="Benefitfleft"> <b>Note :</b>The 90-day benefit waiting period for preventive services will be waived with proof of creditable coverage. <br /> <br /> <b>Note :</b>Out-of-network and nonparticipating providers may bill members for the difference between BCBSM s approved amount and the provider s charge, even when referred. <br /> <br /> <b>Note :</b>Flexible Blue Dental PlusSM coverage may be purchased separately with this plan. <br /> <br /> </div> <div class="Benefitfleft" style="text-align: justify"> <strong>Exclusions and Limitations:</strong> Conditions covered by workers compensation or similar law; services or supplies not specifically listed as covered under your benefit plan; services received before your effective date or after coverage ends; services you wouldn t have to pay for if you did not have this coverage; services or supplies that are not medically necessary; physical exams for insurance, employment, sports or school; any amounts in excess of BCBSM s approved amount; cosmetic surgery; dental care, dental implants or treatment to the teeth except as specifically stated in your benefit plan; hearing aids; infertility services; private duty nursing; eyeglasses or contact lenses; telephone, facsimile machine or any other type of electronic consultation; educational services, except as specifically provided or arranged by BCBSM; nutritional counseling; care or treatment furnished in a nonparticipating hospital, except as specifically stated in your benefit plan; personal comfort items; custodial care; services or supplies supplied to any person not covered under your benefit plan; services while confined in a hospital or other facility owned or operated by state or federal government, unless required by law; services provided by a professional provider to a family member; services provided by any person who ordinarily resides in the covered person s home or who is a family member; any drug, medicine or device that is not FDA approved, unless required by law; vitamins, dietary products and any other nonprescription supplements; dental services, except for dental injury; appliances or supplies; war or any act of war, whether declared or not; communication or travel time, lodging or transportation, except as stated in your benefit plan; foot care services, except as stated in your benefit plan; health clubs or health spas, aerobic and strength conditioning, work hardening programs and related material and products for these programs; hair prosthesis, hair transplants or implants; experimental treatments, except as stated in your benefit plan; weight loss programs; and alternative medicines or therapies. </div> <div class="Benefitfleft"> <b>This document is intended to be an easy to read summary.</b> It is not a contract. Additional limitations and exclusions may apply to covered services. A complete description of benefits is contained in the applicable Blue Cross Blue Shield of Michigan certificate and riders. Payment amounts are based on the BCBSM approved amount, less any applicable deductible and/or copay amounts required by the plan. All covered benefits are subject to a pre existing conditions waiting period, unless noted otherwise. This coverage is provided pursuant to a contract entered into in the state of Michigan and shall be construed under the jurisdiction and according to the laws of the state of Michigan. </div> <div> <a href="#top" style="text-decoration: none"> <img src="images/iconbuttonup.gif" alt="" style="border: 0px" />&nbsp;Return to top</a> </div> </td> </tr> <tr> <td> &nbsp; </td> </tr> <tr> <td class="fontwelcome"> Flexible Blue Dental Plus Benefits-at-a-Glance <a id="dental"></a> </td> </tr> <tr> <td> &nbsp; </td> </tr> <tr> <td> <span id="downloads"><a href="docs/flex_dental_baag.pdf" target="_blank">Download Flexible Blue Dental Plus Benefits (63K PDF)</a> </span> </td> </tr> <tr> <td> &nbsp; </td> </tr> <tr> <td> <table cellpadding="0" cellspacing="0" border="1" width="100%" style="text-align: justify; border-collapse: collapse; border-color: #D6D3CE"> <tr> <td style="width: 40%" colspan="3" class="ICBbg"> Class I Preventive services </td> </tr> <tr> <td style="width: 40%" class="Benefitfleft"> Oral exams, bitewing X-rays, teeth cleanings and flouride</td> <td class="Benefitbg2" valign="top"> covered at 75% of the approved amount, twice per calendar year </td> </tr> <tr> <td style="width: 40%" colspan="3" class="ICBbg"> Class II Restorative services </td> </tr> <tr> <td valign="top" style="width: 40%" class="Benefitfleft"> Replacement fillings and onlays, crowns, extractions and root canal therapy</td> <td class="Benefitbg2"> Covered  50% of the approved amount; subject to frequency limitations (90 day benefit waiting period applies)</td> </tr> <tr> <td style="width: 40%" colspan="3" class="ICBbg"> Benefit maximum </td> </tr> <tr> <td valign="top" style="width: 40%" class="Benefitfleft"> The benefit maximum limits the amount payable for services each year. Once a member reaches the benefit maximum, services will not be paid for that member for the balance of the year. We will continue to pay claims for other eligible members until each member has reached the maximum.</td> <td class="Benefitbg2" valign="top"> $600 per member, per calendar year</td> </tr> </table> </td> </tr> <tr> <td> &nbsp; </td> </tr> <tr> <td class="Benefitfleft"> <div> <p> <strong>Note:</strong> The 90-day benefit waiting period for Class I and II services is waived with proof of creditable coverage. Flexible Blue Dental Plus is optional coverage that may be purchased with Individual Care Blue PlusSM or Flexible Blue IISM plans. Members may choose a DenteMax network dentist. If a member chooses to receive care outside the DenteMax network, their out of pocket costs may be higher. </div> <div> <a href="#top" style="text-decoration: none"> <img src="images/iconbuttonup.gif" alt="" style="border: 0px" />&nbsp;Return to top</a> </div> </td> </tr> <tr> <td> &nbsp; </td> </tr> </table> </td> <td style="width: 3px; border: 0px solid red"> </td> <td colspan="" style="width: 194px;" align="left"> <!-- right panel --> <script src="include/rightpanel.js" type="text/javascript"></script> </td> <td style="width: 8px; border: 0px solid red"> </td> </tr> </table> </td> </tr> </table> </td> </tr> <tr> <td> <script src="include/footer.js" type="text/javascript"></script> </td> </tr> <tr style="height: 10px"> <td valign="top" style="background-image: url(images/bottom.jpg); background-repeat: no-repeat"> </td> </tr> </table> </td> </tr> </table> </body> </html>