|
"Bold" print
identifies plan changes effective 1/1/2003
|
|
Plan
Name
|
Health
Alliance Plan of Michigan
|
BlueCard
PPO In-Network
|
BlueCard
PPO Out-of-Network
|
|
Web Site
|
www.hapcorp.org
|
www.bluecares.com
|
www.bluecares.com
|
|
Member
Service Number
|
1-800-422-4641
|
1-800-810-BLUE
|
1-800-810-BLUE
|
|
Individual
Lifetime Maximum Benefits
|
None
|
$1 Million
|
$500,000
|
|
Annual
Deductible
|
|
|
|
|
Individual
|
None
|
None
|
$200
|
|
Family
|
None
|
None
|
$400
|
|
Coinsurance
|
None
|
None
|
25%
|
|
Annual
Out-of-Pocket Maximum
|
|
|
|
|
Individual
|
None
|
None
|
$2,000
|
|
Family
|
None
|
None
|
$4,000
|
|
Inpatient
Hospital
|
100%
covered
|
100% covered |
75%
after deductible; 90 days per calendar year |
|
Physician
Services: PCP Office Visit
|
$15 copay
|
$10 copay
|
75%
after deductible
|
|
Emergency
Care: In-area Hospital
|
Covered
|
100% after $25 copay waived if admitted |
100%
after $25 copay - waived if admitted |
|
Outpatient
X-Ray and Lab
|
Covered
|
100% covered |
75%
after deductible |
|
Durable
Medical Equipment
|
Covered
for authorized equipment
|
100% with precertification
|
75%
after deductible
|
|
Retail
Prescription Coverage
|
|
|
|
|
Generic
|
$10
copay for 30-day supply
|
15%
|
15%
|
|
Brand Name
|
$20
copay for a 30-day supply
|
25% if generic unavailable;30% if generic
available and medically necessary |
25%
if generic unavailable; 30% if generic available and medically
necessary |
|
Mail-Order
Prescription Coverage:
|
|
|
|
|
Generic
|
$25 copay for a 90-day supply |
10% generic; 20% brand if generic unavailable; 25% if generic available
and medically necessary
|
10% generic; 20% brand if generic unavailable; 25% if generic
available and medically necessary
|
|
Brand Name
|
$55 copay for
90-day supply |
See Above
|
See Above
|
|
Diabetic
Benefits
|
|
|
|
|
Insulin
|
Covered Under Pharmacy
Benefit
|
Covered Under Pharmacy Benefit |
Covered
Under Pharmacy Benefit |
|
Chem. Strips/Lancets
|
Covered Under Pharmacy
Benefit
|
Covered Under Pharmacy Benefit
|
Covered
Under Pharmacy Benefit
|
|
Home Health Care
|
Covered
for authorized services
|
100% for 100 visits per calendar year
|
75%
after deductible; 100 visits per calendar year
|
|
Mental
Health
|
|
|
|
|
Inpatient
|
Covered
for up to 30 days, renewable after 60 days
|
100% up to 30 days per calendar year
|
75%
up to 10 days per calendar year
|
|
Outpatient
|
50%
copay per visit for up to 20 visit per calendar year
|
$10 copay up to 20 visits per calendar
year
|
75%
up to 20 visits per calendar year
|
|
Substance Abuse
|
|
|
|
|
Inpatient
|
Covered for up to 30 days renewable after
60 days
|
100%; 28 days + 5 detox; 2 courses of
treatment per lifetime
|
75% 28 days + 5 detox/ 2 course of
treatment per lifetime
|
|
Outpatient
|
50% copay per visit for up to 35 visit
per calendar year
|
100%; 28 days + 5 detox;2 courses of
treatment per lifetime
|
75% = 30 visits; 7 detox - two course of
treatment per lifetime
|
|
Vision
Care
|
|
|
|
|
Routine Eye Exam |
$10
copay
|
Not Covered
|
Not Covered
|
|
Eyeglasses and Contact Lenses
|
Not Covered
|
Not Covered
|
Not Covered
|
|
Hearing
Care |
|
|
|
|
Exam |
$10
copay
|
Covered through National Ear Care Plan
|
Not
Covered
|
|
Hearing Aids |
Covered, limited to conventional hearing aids
|
Covered through National Ear Care Plan
|
Not Covered
|
|
Dental
Care |
|
|
|
|
Basic Services |
Not Covered
|
Not Covered
|
Not Covered
|
|
Major Services |
Not Covered
|
Not Covered
|
Not
Covered
|
|
Preventive Services |
Not Covered
|
Not Covered
|
$30
copay
|
|
Wellness
Benefits |
yes
|
$10 copay
|
Not Covered
|