Blue Cross® Premier PPO Silver Saver HSA

Blue Cross Blue Shield of Michigan Mutual Insurance Company

SilverHSA eligible

Ind. deductible: $3,900
Family deductible: $3,900
Ind. OOP max: $7,700
Family OOP max: $7,700

Other cost-sharing reduction variants for this plan:

73% AV Level Silver Plan 87% AV Level Silver Plan 94% AV Level Silver Plan Limited Cost Sharing Plan Variation Standard Silver Off Exchange Plan Zero Cost Sharing Plan Variation

More Blue Cross Blue Shield of Michigan Mutual Insurance Company plans in MI

Blue Cross® Premier PPO Value Blue Cross® Premier PPO Bronze Saver HSA Blue Cross® Premier PPO Gold Blue Cross® Premier PPO Bronze Secure Blue Cross® Premier PPO Bronze Extra

Monthly premiums by age

Age	Individual	Individual + tobacco
21	$663	—
30	$752	—
40	$847	—
50	$1,184	—
60	$1,799	—

Live premium estimate

Benefits & cost sharing

Primary Care

Benefit	In-network
Preventive Care/Screening/Immunization	0.00%
Primary Care Visit to Treat an Injury or Illness	$30.00 Copay after deductible

Specialist

Benefit	In-network
Specialist Visit	$50.00 Copay after deductible

Hospital

Benefit	In-network
Emergency Room Services	$100.00 Copay after deductible
Inpatient Hospital Services (e.g., Hospital Stay)	10.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services	20.00% Coinsurance after deductible
Urgent Care Centers or Facilities	$0.00

Pharmacy

Benefit	In-network
Generic Drugs	$15.00 Copay after deductible
Non Preferred Specialty Drugs	45.00% Coinsurance after deductible
Non-Preferred Brand Drugs	$150.00 Copay after deductible
Preferred Brand Drugs	$100.00 Copay after deductible
Specialty Drugs	40.00% Coinsurance after deductible

Mental Health

Benefit	In-network
Mental/Behavioral Health Inpatient Services	20.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services	$30.00 Copay after deductible

Other

Benefit	In-network
Abortion for Which Public Funding is Prohibited	Not covered
Accidental Dental	20.00% Coinsurance after deductible
Acupuncture	Not covered
Allergy Testing	20.00% Coinsurance after deductible
Bariatric Surgery	50.00% Coinsurance after deductible
Basic Dental Care - Adult	Not covered
Basic Dental Care - Child	Not covered
Chemotherapy	10.00% Coinsurance after deductible
Chiropractic Care	0.00%
Cosmetic Surgery	Not covered
Delivery and All Inpatient Services for Maternity Care	0.00%
Dental Check-Up for Children	Not covered
Diabetes Education	20.00% Coinsurance after deductible
Dialysis	20.00% Coinsurance after deductible
Durable Medical Equipment	50.00% Coinsurance after deductible
Emergency Transportation/Ambulance	20.00% Coinsurance after deductible
Eye Glasses for Children	No charge
Habilitation Services	20.00% Coinsurance after deductible
Hearing Aids	Not covered
Home Health Care Services	0.00%
Hospice Services	No Charge after deductible
Imaging (CT/PET Scans, MRIs)	20.00% Coinsurance after deductible
Infertility Treatment	50.00% Coinsurance after deductible
Infusion Therapy	10.00% Coinsurance after deductible
Inpatient Physician and Surgical Services	20.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services	20.00% Coinsurance after deductible
Long-Term/Custodial Nursing Home Care	Not covered
Major Dental Care - Adult	Not covered
Major Dental Care - Child	Not covered
Nutritional Counseling	0.00%
Orthodontia - Adult	Not covered
Orthodontia - Child	Not covered
Other Practitioner Office Visit (Nurse, Physician Assistant)	$30.00 Copay after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)	20.00% Coinsurance after deductible
Outpatient Rehabilitation Services	0.00%
Prenatal and Postnatal Care	0.00%
Private-Duty Nursing	Not covered
Prosthetic Devices	50.00% Coinsurance after deductible
Radiation	20.00% Coinsurance after deductible
Reconstructive Surgery	10.00% Coinsurance after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy	10.00% Coinsurance after deductible
Rehabilitative Speech Therapy	20.00% Coinsurance after deductible
Routine Dental Services (Adult)	Not covered
Routine Eye Exam (Adult)	Not covered
Routine Eye Exam for Children	No charge
Routine Foot Care	Not covered
Skilled Nursing Facility	10.00% Coinsurance after deductible
Specified Sex-Trait Modification Procedures(SSTMP)	20.00% Coinsurance after deductible
Substance Abuse Disorder Inpatient Services	10.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services	$30.00 Copay after deductible
Transplant	20.00% Coinsurance after deductible
Treatment for Temporomandibular Joint Disorders	50.00% Coinsurance after deductible
Weight Loss Programs	0.00%
Well Baby Visits and Care	0.00%
X-rays and Diagnostic Imaging	0.00%

Plan rules

Service area

This plan covers 1 geographic area.