Page 5 - Michigan Fitness Foundation 2021 Booklet

Michigan Fitness Foundation

January 2021 BCN Platinum Renewal

Current Renewal Option 1
Blue Care Network Blue Care Network Blue Care Network
Platinum $500 0% Platinum $500 0% Gold $500 20%
Plan Type HMO HMO HMO
Plan Year 2020 2021 2021
In-Network In-Network In-Network
Deductible
Individual $500 $500 $500
Family $1000 $1000 $1000
Coinsurance 0% 0% 20%
Coinsurance Max
Individual Not Applicable Not Applicable $5000
Couple/Family Not Applicable Not Applicable $10000
Annual Out of Pocket Max
Individual $1500 $1500 $8150
Couple/Family $3000 $3000 $16300
Physician Copays
Preventive Care No Charge No Charge No Charge
Office Visit $20 $20 $30
Specialty Office Visit $30 $30 $50
Virtual Visits $20 $0 $0
Hospital Services
Urgent Care $35 $35 $35
Emergency Room $150 Copay after deductible $150 Copay after deductible $250 Copay after deductible
Inpatient Hospital 0% after deductible 0% after deductible 20% after deductible
Outpatient Hospital 0% after deductible 0% after deductible 20% after deductible
Diagnostic Services
Imaging/CT/PET/MRI $150 Copay after deductible $150 Copay after deductible $150 Copay after deductible
Labs No Charge No Charge No Charge
X-Rays 0% after deductible 0% after deductible 20% after deductible
Mental Health - Outpatient $20 $20 $30
Rehabilitative Care
Chiropractic $30 $30 $50
Speech Therapy $30 Copay after deductible $30 Copay after deductible $50 Copay after deductible
Occupational and Physical Therapy $30 Copay after deductible $30 Copay after deductible $50 Copay after deductible
Durable Medical Equipment 50% 50% 50%
Prescription Drugs
Generic $4/$15 $4/$15 $15/$40
Preferred Brand $40 $40 $80
Non-Preferred Brand $80 $80 $100
Preferred Specialty 20%/$200 max 20%/$200 max 20%/$200 max
Non-Preferred Specialty 20%/$300 max 20%/$300 max 20%/$300 max
Effective Date 1/1/2020 1/1/2021 1/1/2021
Total Number of Employees 18 18 18
Monthly Total Medical Premium $20,523.09 $21,542.32 $18,080.08
Annual Total Medical Premium $246,277.08 $258,507.84 $216,960.96
Percentage Change From Current 4.97% -11.90%
Annual Dollar Change From Current $12,230.76 ($29,316.12)