Blue CrossВ® Local HMO Silver Saver

Health Insurance Plan Details (2024 Plan)

by Blue Care Network of Michigan

Monthly Premium

HMO
$ubsidy
Silver
Deductible
$5,450 /yr
Max Out-of-Pocket
$8,000 /yr

Details

Deductible (per individual) $5,450 /yr
Deductible (per family) $10,900 /yr
Max Out-of-Pocket (per individual) $8,000 /yr
Max Out-of-Pocket (per family) $16,000 /yr
Drug Deductible (per individual) Included in Medical
Drug Deductible (per family) Included in Medical
Drug Max Out-of-Pocket (per individual) Included in Medical
Drug Max Out-of-Pocket (per family) Included in Medical
Plan Type HMO
Includes Child Dental? No
Includes Adult Dental? No
Medical Services
Preventive Care No Charge
Primary Care Visit $45 Copay
Specialist Visit $90 Copay
Emergency Room $250 Copay after deductible and 20% Coinsurance after deductible
Inpatient Facility 20% Coinsurance after deductible
Inpatient Physician 20% Coinsurance after deductible
Drug Costs
Generic Drugs $4 Copay after deductible
Preferred Brand Drugs $100 Copay after deductible
Non-preferred Brand Drugs $150 Copay after deductible
Specialty Drugs 40% Coinsurance after deductible

Plan Documents

Summary of Benefits and Coverage SBC doc
Provider Directory Doctor lookup
Drug Formulary List drug list

* Figures shown are only for in-network medical costs

** Please check with insurance company if Copay and Coinsurance rates are before or after the deductible


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