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PPO Select 2, RX2, Hearing
Western Michigan Health Insurance Pool
Group Number: 71565
Package Code(s):051
Section Code(s):1000, 1100

Deductible, Copays/Coinsurance and Dollar Maximums
Deductible - per calendar year
Note: Services without a network are
covered at the in-network level.
Out-of-Pocket Maximum
Lifetime Maximum
Preventive Services
Health Maintenance Exam - one per calendar year Routine Physical Related Test - X-Rays, EKG and lab procedures performed as part of the health maintenance exam Annual Gynecological Exam - one per calendar year, in addition to health maintenance exam Pap Smear Screening - one per calendar year Mammography Screening - one per calendar year Prostate Specific Antigen (PSA) Screening - one per calendar year Endoscopic Exams - one per calendar year Visits beyond 47 months are limited to one per member per calendar year under the health maintenance exam benefit. Physician Office Services
Emergency Medical Care
Qualified medical emergency Non-Emergency use of the Emergency Room Ambulance Services - Medically Necessary Transport Diagnostic and Therapeutic Services
MRI,MRA, PET and CAT Scans and Nuclear Medicine 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 Inpatient Medical Care Alternatives to Hospital Care
Surgical Services
Surgery (includes related surgical services) excludes reversal sterilization Sterilization - females only; Human Organ Transplants
Specified Organ Transplants in designated facilities Not covered except in designated facilities only, when coordinated through BCBSM Human Organ Transplant Program (800-242-3504) Kidney, Cornea, Bone Marrow and Skin Behavioral Health and Substance Abuse Services
Other Services
24 visit maximum per calendar year Durable Medical Equipment Therapy Services
Physical, Occupational and Speech Therapy Note: The following services require preapproval: Inpatient Care, select Radiology Services, Inpatient Behavioral Health and Substance Abuse Care, and Skilled Nursing. Hearing
To be payable, hearing care benefits must be received from a participating provider and in the order listed.
Frequency Limitation
Audiometric Exam
Hearing Aid Evaluation
Hearing Aid
Hearing Aid Conformity Test
Prescription Drugs
Retail- 30 day supply
$ 0 copay – OTC drugs (Only – Zyrtec, Zyrtec D, Prilosec, Claritin, Children’s Claritin, Claritin RediTabs and Claritin-D) $5 - generic copay drugs $30 copay for brand name drugs Mail Order- 90 day supply
$ 0 copay – OTC drugs (Only – Zyrtec, Zyrtec D, Prilosec, Claritin, Children’s Claritin, Claritin RediTabs and Claritin-D) $10 copay for generic drugs $60 copay for brand name drugs Oral and Injectable Contraceptives
Covered - 100% for generic drugs; brand name drugs are subject to the applicable Additional Services
Covered – limited to 12 doses per month Diabetic Supplies
The information in this document is based on BCBSM’s current interpretation of the Patient Protection and Affordable Care Act (PPACA). Interpretations of PPACA vary and the federal government continues to issue guidance on how PPACA should be interpreted and applied. Efforts will be made to update this document as more information about PPACA becomes available. This document is only an educational tool and should not be relied upon as legal or compliance advice. Additionally, some PPACA requirements may differ for particular members enrolled in certain programs, and those members should consult with their plan administrators for specific details. This is intended as an easy-to-read summary and provides only a general overview of your benefits. It is not a contract. Additional limitations and exclusions may apply. Payment amounts are based on BCBSM’s approved amount, less any applicable deductible and/or copay. For a complete description of benefits please see the applicable BCBSM certificates and riders, if your group is underwritten or any other plan documents your group uses, if your group is self-funded. If there is a discrepancy between this Benefits-At-A-Glance and any applicable plan document, the plan document will control.


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