This is intended as an easy-to-read summary

Benefits-at-a-Glance
WmHIP
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 BAAG 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 Preventive Services
Annual Health Maintenance Exam – beginning age 16, includes related X-rays, EKG, lab procedures, and routine screening tests performed as part of the physical exam Annual Well Woman Exam – one per calendar year Pap Smear Screening – one per calendar year Well-Baby and Child Care – through age 15 6 visits birth through age 1, 2 visits per year age 2 through 3, 1 visit per year age 4 through 15 Immunizations – child and adult Prostate Specific Antigen (PSA) exam - one per calendar year. Fecal Occult Blood Test – one per calendar year Endoscopic Exam – one per calendar year Routine Mammogram and related reading – one per member per Note: Subsequent medically necessary mammograms performed during the same calendar
year are subject to your deductible and percent copay.
Colonoscopy--Routine or Medically Necessary—one routine colonoscopy per member per calendar year Note: Subsequent medically necessary colonoscopies performed during the same calendar
year are subject to your deductible and percent copay.
Physician Office Services
All services performed during the office visit (e.g., lab, x-rays, etc.) are covered Emergency Medical Care
Qualified Medical Emergency & First Aid Services Ambulance Services – any medically necessary transport Diagnostic Services
Maternity Services Provided by a Physician
WmHIP Basic Premier – HCR Effective 010111 wsu 111710 Hospital Care
Semi-Private Room, Inpatient Physician Care, General Nursing Care, Hospital Services and Supplies Inpatient Consultations Alternatives to Hospital Care
Skilled Nursing Care – Unlimited visits Hospice care – must be provided through a participating
100% (no deductible or copay), up to 28 pre-hospice counseling visits before electing hospice services; when elected, four 90-day periods – provided through a participating
hospice program only; limited to dollar maximum that is reviewed and adjusted
periodically (after reaching dollar maximum, member transitions into individual case
management)
Surgical Services
Surgery – includes related surgical services Dental surgery and related anesthesia for the removal of wisdom Voluntary Sterilization – excludes reverse sterilizations Human Organ Transplants
Specified Organ Transplants – in designated facilities only, when coordinated through the BCBSM Human Organ Transplant Unlimited dollar maximum per transplant type Program (1-800-242-3504) Kidney, Cornea and Skin Mental Health Care and Substance Abuse Treatment
Inpatient Mental Health and Substance Abuse Care Other Services
Acupuncture – performed by a MD, DO and other select Covered – 90% after deductible Unlimited spinal manipulation visits Outpatient Physical, Speech and Occupational Therapy Unlimited visits. Services are covered when performed in the outpatient department of the hospital, approved freestanding facility or independent therapist’s office. Durable Medical Equipment/Medical Supplies (including Massage Therapy rendered by MD, DO or Chiropractor Hot & Cold packs rendered by a Chiropractor Covered – 100% of approved amount. Hearing aid must be purchased from an approved hearing aid provider. WmHIP Basic Premier – HCR Effective 010111 wsu 111710 Deductible, Copays/Coinsurance and Dollar Maximums
Deductible – per calendar year

Copays/Coinsurance
Out-of-Pocket Maximum – per calendar year
• Fixed Dollar Copays • Percent Coinsurance – Does not include deductible Lifetime Maximum
Prescription
Retail – 34 day supply
$ 0 copay – OTC drugs (Only – Zyrtec, Zyrtec D, Prilosec, Claritin, Children’s Claritin, Claritin RediTabs and Claritin-D) $ 10 copay – Generic drugs $40 copay – 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) $ 20 copay – Generic drugs $80 copay – Brand name drugs Additional Services:
Covered – limited to 12 doses per month This is intended as an easy-to-read guide. It is not a contract. An official description of benefits is contained in
applicable Blue Cross Blue Shield of Michigan coverage documents.
WmHIP Basic Premier – HCR Effective 010111 wsu 111710

Source: http://www.vbisd.org/cms/lib6/MI01000711/Centricity/Domain/10/WMHIP%20Basic%20Premier%2010.40%20Rx--HCR%20010111.pdf