Blue Cross® Premier PPO Gold

Blue Cross Blue Shield of Michigan Mutual Insurance Company

Gold

Ind. deductible: $1,450
Family deductible: $1,450
Ind. OOP max: $9,000
Family OOP max: $9,000

Other cost-sharing reduction variants for this plan:

Limited Cost Sharing Plan Variation Standard Gold 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 Bronze Secure Blue Cross® Premier PPO Silver Saver HSA Blue Cross® Premier PPO Bronze Extra

Monthly premiums by age

Age	Individual	Individual + tobacco
21	$748	—
30	$849	—
40	$956	—
50	$1,337	—
60	$2,031	—

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	$250.00 Copay after deductible
Inpatient Hospital Services (e.g., Hospital Stay)	20.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services	20.00% Coinsurance after deductible
Urgent Care Centers or Facilities	$75.00

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	0.00%
Chiropractic Care	0.00%
Cosmetic Surgery	Not covered
Delivery and All Inpatient Services for Maternity Care	20.00% Coinsurance after deductible
Dental Check-Up for Children	Not covered
Diabetes Education	20.00% Coinsurance after deductible
Dialysis	20.00% Coinsurance after deductible
Durable Medical Equipment	0.00%
Emergency Transportation/Ambulance	20.00% Coinsurance after deductible
Eye Glasses for Children	No charge
Habilitation Services	0.00%
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	0.00%
Inpatient Physician and Surgical Services	0.00%
Laboratory Outpatient and Professional Services	0.00%
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	20.00% Coinsurance after deductible
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	20.00% Coinsurance after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy	0.00%
Rehabilitative Speech Therapy	0.00%
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	0.00%
Specified Sex-Trait Modification Procedures(SSTMP)	20.00% Coinsurance after deductible
Substance Abuse Disorder Inpatient Services	20.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services	$0.00
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	20.00% Coinsurance after deductible

Plan rules

Service area

This plan covers 1 geographic area.