Page 7 - Michigan Fitness Foundation 2021 Booklet

Michigan Fitness Foundation

January 2021 BCBSM Renewal

Current Renewal Option 1
Blue Cross Blue Shield Blue Cross Blue Shield Blue Cross Blue Shield
SB HSA Gold $2000 EA SB HSA Gold $2000 EA SB HSA Gold $2800 EA
Plan Type PPO PPO PPO
Plan Year 2020 2021 2020
In-Network In-Network In-Network
Deductible
Individual $2000 $2000 $2800
Family $4000 $4000 $5600
Coinsurance 0% 0% 0%
Coinsurance Max
Individual Not Applicable Not Applicable Not Applicable
Couple/Family Not Applicable Not Applicable Not Applicable
Annual Out of Pocket Max
Individual $3000 $3000 $5000
Couple/Family $6000 $6000 $10000
Physician Copays
Preventive Care No Charge No Charge No Charge
Office Visit No Charge after deductible No Charge after deductible No Charge after deductible
Specialty Office Visit No Charge after deductible No Charge after deductible No Charge after deductible
Virtual Visits No Charge after deductible No charge after deductible No Charge after deductible
Hospital Services
Urgent Care No Charge after deductible No Charge after deductible No Charge after deductible
Emergency Room No Charge after deductible No Charge after deductible No Charge after deductible
Inpatient Hospital No Charge after deductible No Charge after deductible No Charge after deductible
Outpatient Hospital No Charge after deductible No Charge after deductible No Charge after deductible
Diagnostic Services
Imaging/CT/PET/MRI No Charge after deductible No Charge after deductible No Charge after deductible
Labs No Charge after deductible No Charge after deductible No Charge after deductible
X-Rays No Charge after deductible No Charge after deductible No Charge after deductible
Mental Health - Outpatient No Charge after deductible No Charge after deductible No Charge after deductible
Rehabilitative Care
Chiropractic No Charge after deductible No Charge after deductible No Charge after deductible
Speech Therapy No Charge after deductible No Charge after deductible No Charge after deductible
Occupational and Physical Therapy No Charge after deductible No Charge after deductible No Charge after deductible
Durable Medical Equipment No Charge after deductible No Charge after deductible No Charge after deductible
Prescription Drugs
Generic $20 Copay after deductible $20 Copay after deductible $15 Copay after deductible
Preferred Brand $60 Copay after deductible $60 Copay after deductible $50 Copay after deductible
Non-Preferred Brand 50% after ded ($80-$100) 50% after ded ($80-$100) 50% after ded ($70-$100)
Preferred Specialty 20% after deductible/$200 max 20% after deductible/$200 max 20% after deductible $200 max
Non-Preferred Specialty 25% after deductible/$300 max 25% after deductible/$300 max 25% after deductible $300 max
Effective Date 1/1/2020 1/1/2021 10/1/2020
Total Number of Employees 3 3 3
Monthly Total Medical Premium $2,167.56 $2,229.42 $2,114.36
Annual Total Medical Premium $26,010.72 $26,753.04 $25,372.32
Percentage Change From Current 2.85% -2.45%
Annual Dollar Change From Current $742.32 ($638.40)
Employer Contribution: $500

Illustrative purposes only. Rates are subject to DIFS and Carrier approval.