Accidental injury and emergency only.

Limit: 1.0 Procedure(s) per Lifetime

Subject to BCBSM medical criteria.

Prior authorization is required.

Limit: 30.0 Visit(s) per Year

Chiropractic, osteopathic manipulative, physical and occupational therapy limited to a combined maximum of 30 visits per member per calendar year.

BCBSM-participating hospitals only. These services require prior authorization. The penalty for not having prior authorization is denial of payment.

Follows Medicare guidelines.

Exclusions: Bath, exercise and deluxe equipment and comfort and convenience items.

Prescription is required. Rental and purchase limited to basic equipment.

Exclusions: Transportation for convenience.

Includes air and ground transportation.

Limit: 1.0 Item(s) per Year

A child is defined as a member up to the age of 19. Out of network is paid up to the allowed amount.

Exclusions: Cosmetic surgery, investigational and experimental procedures.

These services may require prior authorization. The penalty for not having prior authorization is denial of payment.

Exclusions: Quantity limits per fill may apply for 30-day retail, 90-day retail and up to 90 day mail order. Opioid-containing medications are limited to no more than a 30-day supply per fill and first fills of select opioid containing medications will be limited to a 5-day supply.

Prior authorization, step therapy and quantity limits may apply to select drugs. The penalty for not having prior authorization is denial of payment. Any coupon, rebate, or other credits received directly or indirectly from the drug manufacturer may not be applied to a consumer?s?deductible,?cost-sharing?or out of pocket maximum. For out-of-network providers, member must pay the full cost of the drug and submit to BCBSM for reimbursement.

Limit: 30.0 Visit(s) per Year

Physical and occupational therapy limited to a combined maximum of 30 visits per member per calendar year. Speech therapy limited to a maximum of 30 visits per member per calendar year.

Exclusions: Housekeeping and custodial services.

BCBSM-participating agencies only.

Exclusions: Housekeeping services.

BCBSM approved hospice programs only. Coverage includes inpatient and outpatient hospice care.

Prior authorization is required. The penalty for not having prior authorization is denial of payment.

Exclusions: In vitro fertilization and artificial insemination.

Underlying causes only. These services require prior authorization. The penalty for not having prior authorization is denial of payment.

BCBSM approved providers only.

BCBSM participating hospitals only. These services require prior authorization. The penalty for not having prior authorization is denial of payment.

BCBSM participating hospitals only. These services require prior authorization. The penalty for not having prior authorization is denial of payment.

BCBSM approved facilities only. These services require prior authorization. The penalty for not having prior authorization is denial of payment.

Copayment?applies to?provider?s?office, virtual visit?by participating BCBSM provider and virtual care visit from BCBSM selected vendor app only. Additional services are subject to the plan?s deductible and coinsurance, if applicable. BCBSM approved facilities only.

Exclusions: Quantity limits per fill may apply for 30-day retail, 90-day retail and up to 90 day mail order. Opioid-containing medications are limited to no more than a 30-day supply per fill and first fills of select opioid containing medications will be limited to a 5-day supply.

Prior authorization, step therapy and quantity limits may apply to select drugs. The penalty for not having prior authorization is denial of payment. Any coupon, rebate, or other credits received directly or indirectly from the drug manufacturer may not be applied to a consumer?s?deductible,?cost-sharing?or out of pocket maximum. For out-of-network providers, member must pay the full cost of the drug and submit to BCBSM for reimbursement.

Exclusions: Specialty drugs are limited to a 30-day supply per fill, however some may be limited to a 15-day supply fill, depending on the medication.

BCBSM has contracted with an exclusive pharmacy?network?for?specialty drugs. Call the customer service phone number on the back of your ID card for the pharmacy?s phone number or location nearest to you. If you obtain your?specialty drugs?from any other pharmacy, you are responsible for the total cost. Prior authorization, step therapy and quantity limits may apply to select drugs. The penalty for not having prior authorization is denial of payment. Any coupon, rebate, or other credits received directly or indirectly from the drug manufacturer may not be applied to a consumer?s?deductible,?cost-sharing?or out of pocket maximum.

Limit: 26.0 Visit(s) per Year

Dietician Services.

Includes virtual and retail health clinic visits. No charge for 24/7 medical virtual visits when performed through the BCBSM selected vendor app, except HSA eligible plans have no charge after deductible. Diagnostic and laboratory services are not included in the office visit?copayment. These services are subject to the?plan's?deductible?and?coinsurance, if applicable.

Exclusions: Cosmetic surgery, corrective eye surgery, investigational and experimental procedures.

These services may require prior authorization. The penalty for not having prior authorization is denial of payment.

Limit: 30.0 Visit(s) per Year

Physical, occupational, chiropractic and osteopathic manipulative therapy limited to a combined maximum of 30 visits per member per calendar year. Speech therapy limited to a maximum of 30 visits per member per calendar year. Cardiac/pulmonary visits limited to a maximum of 30 visits per member per calendar year.

Exclusions: Cosmetic surgery, corrective eye surgery, investigational and experimental procedures.

These services may require prior authorization. The penalty for not having prior authorization is denial of payment.

Exclusions: Quantity limits per fill may apply for 30-day retail, 90-day retail and up to 90 day mail order. Opioid-containing medications are limited to no more than a 30-day supply per fill and first fills of select opioid containing medications will be limited to a 5-day supply.

Prior authorization, step therapy and quantity limits may apply to select drugs. The penalty for not having prior authorization is denial of payment. Any coupon, rebate, or other credits received directly or indirectly from the drug manufacturer may not be applied to a consumer?s?deductible,?cost-sharing?or out of pocket maximum. For out-of-network providers, member must pay the full cost of the drug and submit to BCBSM for reimbursement.

Cost sharing does not apply for preventive services. Depending on the type of services, a copayment, coinsurance or deductible may apply.

You may have to pay for services that aren?t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.

Includes virtual and retail health clinic visits. No charge for 24/7 medical virtual visits when performed through the BCBSM selected vendor app, except HSA eligible plans have no charge after deductible. Diagnostic and laboratory services are not included in the office visit?copayment. These services are subject to the?plan's?deductible?and?coinsurance, if applicable.

Prior authorization is required.

Medically necessary only.

Limit: 30.0 Visit(s) per Year

Physical, occupational, chiropractic and osteopathic manipulative therapy limited to a combined maximum of 30 visits per member per calendar year.

Limit: 30.0 Visit(s) per Year

Limit: 1.0 Exam(s) per Year

A child is defined as a member up to the age of 19. Out of network is paid up to the allowed amount.

Limit: 45.0 Days per Year

Exclusions: Custodial care.

BCBSM-participating facilities only. These services require prior authorization. The penalty for not having prior authorization is denial of payment.

No charge for 24/7 medical virtual visits when performed through the BCBSM selected vendor app, except HSA eligible plans have no charge after deductible. Diagnostic and laboratory services are not included in the office visit?copayment. These services are subject to the?plan's?deductible?and?coinsurance, if applicable.

Exclusions: Specialty drugs are limited to a 30-day supply per fill, however some may be limited to a 15-day supply fill, depending on the medication.

BCBSM has contracted with an exclusive pharmacy?network?for?specialty drugs. Call the customer service phone number on the back of your ID card for the pharmacy?s phone number or location nearest to you. If you obtain your?specialty drugs?from any other pharmacy, you are responsible for the total cost. Prior authorization, step therapy and quantity limits may apply to select drugs. The penalty for not having prior authorization is denial of payment. Any coupon, rebate, or other credits received directly or indirectly from the drug manufacturer may not be applied to a consumer?s?deductible,?cost-sharing?or out of pocket maximum.

BCBSM approved facilities only. These services require prior authorization. The penalty for not having prior authorization is denial of payment.

Copayment?applies to?provider?s?office, virtual visit?by participating BCBSM provider and virtual care visit from BCBSM selected vendor app only. Additional services are subject to the plan?s deductible and coinsurance, if applicable. BCBSM approved facilities only.

BCBSM designated facilities only. Subject to BCBSM medical criteria.

Coverage includes medical care or services to treat dysfunction or TMJ resulting from a medical cause or Injury, Office visits for medical evaluation and treatment, X-rays of the temporomandibular joint including contrast studies, but not dental x-rays, Myofunctional therapy and Surgery to the temporomandibular joint, such as condylectomy, meniscectomy, arthrotomy, and arthrocentesis.

When the urgent care visit is for an emergency or accidental injury, in-network cost-sharing applies.

Morbid obesity weight management and nutritional counseling.

Quantity limits based on PPACA.