Page 4 - Habitat for Humanity 2020 Benefit Guide

Habitat For Humanity of Michigan

Medical Benefit Analysis- 7/1/2020

BCBSM Blue Care Network
Current Renewal Current Renewal
BCBSM BCBSM Blue Care Network Blue Care Network
SB PPO Gold $500 SB PPO Gold $500 HMO Gold $1000 HMO Gold $1000

Member level rating Member level rating Member level rating Member level rating
effective 7/01/2019 effective 7/01/2020 effective 7/01/2019 effective 7/01/2020

Deductible In-Network In-Network In-Network In-Network
Individual $500 $500 $1,000 $1,000
Family $1,000 $1,000 $2,000 $2,000
Coinsurance Maximum 80% 80% 80% 80%
Individual $3,500* $4,500* $2,500* $3,500*
Family $7,000* $9,000* $5,000* $7,000*
Out-of-Pocket Maximum
Individual $6,600** $8,150** $6,600** $8,150**
Family $13,200** $16,300** $13,200** $16,300**
Hospitalization 80% after ded 80% after ded 80% after ded 80% after ded
Emergency Room $250 $250 $150 after ded $250 after ded
Urgent Care $60* $60* $50 $50
Office Visit/Online $20* $20* $20 $20
Specialist copay $40* $40* $40 $40
Preventative Care 100% 100% 100% 100%
Prescription Drugs
Tier 1 $20 $20 $6-$25 $10-$30
Tier 2 $60 $60 $50 $60
Tier 3 50% ($80-$100) 50% ($80-$100) $80 $80
Tier 4 20% (max $200) 20% (max $200) 20% (max $200) 20% (max $200)
Tier 5 25% (max $300) 25% (max $300) 20% (max $300) 20% (max $300)

This is a summary analysis only. Please refer to certificate of coverage for all specific details. This summary is not a
contract and makes no representations or warranties as to final outcomes of claim adjudication.
Final rates are subject to underwriting approval and are subject to change. *Rates include taxes and fees.
*Applies to coinsurance amounts only; does not include flat copays, deductible or RX copays.
** OOP includes deductible, copays, coinsurance and RX copays.