This is intended as an easy-to-read summary

Benefits-at-a-Glance
WmHIP
In-Network Out-of-Network
Deductible, Copays/Coinsurance and Dollar Maximums
Deductible - per calendar year
Copays/Coinsurance
Note: Services without a network are
covered at the in-network level.
Out-of-Pocket Maximum – per calendar year
Lifetime Maximum
Preventive Services – limited to $500 per member per calendar year maximum
Health Maintenance Exam – beginning age 16, one per calendar year; includes related X-rays, EKG, and lab procedures performed as part of the physical exam Annual Gynecological Exam - one per calendar year Does not contribute to annual dollar maximum Pap Smear Screening – one per calendar year; laboratory services only. Does not contribute to annual maximum Prostate Specific Antigen (PSA) Screening - one per calendar year. Does not contribute to annual maximum Fecal Occult Blood Test – one per calendar year, Does not contribute to annual dollar maximum Endoscopic Exams – one per calendar year Does not contribute to annual dollar maximum Well-Baby and Child Care - through age 15 6 visits birth through age 1, 2 visits per year age 2 through 3, 1 visit per year age 4 through 15 Immunizations - pediatric and adult Does not contribute to annual dollar maximum Hearing Exam – one per calendar year Mammograms
Mammography Screening – one per calendar year Does not contribute to annual dollar maximum Physician Office Services
One copay applies to the office visit exam and all services performed during the office ♦ Initial visit to determine pregnancy WmHIP PPO Premier – Effective 07/01/10 (MHP2) wsu 030110 In-Network Out-of-Network
Emergency Medical Care
Qualified Medical Emergency & First Aid Services Non-Emergency use of the Emergency Room Ambulance Services – medically necessary transport Diagnostic Services
MRI, MRA, PET and CAT Scans and Nuclear Medicine Other Diagnostic Tests, X-rays, Laboratory & Pathology Maternity Services Provided by a Physician
Hospital Care
Semi-Private Room, Inpatient Physician Care, General Nursing Care, Hospital Services and Supplies Alternatives to Hospital Care
Outpatient Surgical Services
Surgery – includes related surgical services Dental surgery and related anesthesia for the removal of Voluntary Sterilization – excludes reversal sterilization Human Organ Transplants
Specified Organ Transplants – in designated facilities only, when coordinated through the BCBSM Human Organ Unlimited dollar maximum per transplant type Transplant Program (1-800-242-3504) Kidney, Cornea, Bone Marrow and Skin Mental Health Care and Substance Abuse Treatment
WmHIP PPO Premier – Effective 07/01/10 (MHP2) wsu 030110 In-Network Out-of-Network
Other Services
Acupuncture - Performed by MD, DO, and other select provider specialties Allergy Testing and Therapy Outpatient Physical, Speech and Occupational Therapy Limited to 60 combined visits per calendar year. Services are covered when performed in the outpatient department of the hospital, or approved freestanding facility. Physical therapy is also covered in an independent therapist’s office. Massage Therapy rendered by MD, DO or Chiropractor Durable Medical Equipment/Medical Supplies Does not contribute to out-of-pocket maximum Covered – 100% of the approved amount. Hearing aid must be purchased from an approved hearing aid provider.
Prescription
Retail – 34 day supply
$ 0 copay – OTC drugs (Only – Zyrtec, Zyrtec D, Prilosec, Claritin, Children’s Claritin, Claritin RediTabs and Claritin-D) $ 10 copay – Generic drugs $40 copay – Brand name drugs Prescriptions and refills obtained from a non-network pharmacy are reimbursed at 75% of the approved amount, less the member’s copay. Mail Order - 90-day supply
$ 0 copay – OTC drugs (Only – Zyrtec, Zyrtec D, Prilosec, Claritin, Children’s Claritin, Claritin RediTabs and Claritin-D) $20 copay – Generic drugs $80 copay – Brand name drugs Additional Services:
Covered – limited to 12 doses per month This is intended as an easy-to-read guide. It is not a contract. An official description of benefits is contained in applicable
Blue Cross Blue Shield of Michigan coverage documents.
WmHIP PPO Premier – Effective 07/01/10 (MHP2) wsu 030110

Source: http://allegan.schoolwires.net/cms/lib07/MI01908021/Centricity/Domain/59/Benefit%20Summary%20PPO.pdf