Schedule H HMO Benefits Summary and Claims Paid Data.xlsx

XLSX spreadsheet 35 KB Posted Nov 1, 2023

Attached to: HMO Services for MPSERS
Solicitation number: RFP 171 230000003226 2
Issued by: Michigan

About this file

Written by GovTribe AI · Mar 13, 2026

This file contains Medicare and Non-Medicare HMO benefits summaries and claims paid data for RFP No. 230000003226, Schedule H, covering historical enrollment and financial performance data from March 2021 through March 2023 for two HMO plans. The document provides detailed benefit information for both Medicare and Non-Medicare populations, including coverage details for hospital care, emergency services, surgical services, office visits, preventive services, mental health services, durable medical equipment, hearing benefits, prescription drugs, and out-of-area care. The data encompasses enrollee counts, medical claims paid, and prescription drug claims paid on a monthly basis, with HMO 1 maintaining approximately 5,200 to 5,800 Medicare enrollees and 3,400 to 3,700 Non-Medicare enrollees, while HMO 2 maintained significantly larger enrollment of approximately 22,200 to 23,300 Medicare enrollees and 3,000 to 4,100 Non-Medicare enrollees during the review period.

The benefits summary explicitly states that bidders are not required to replicate the benefits shown but must provide actuarially equivalent benefits as specified in Schedules I2, I4, I1, and I3, with reference to Schedule A, Section 1.2.1. Medicare medical deductibles ranged from $300 to $525 individual depending on the plan and year, while Non-Medicare deductibles ranged from $400 to $1,500 individual or $800 to $3,000 family. Out-of-pocket maximums for Medicare plans ranged from $2,100 to $3,200 individual, while Non-Medicare plans ranged from $750 to $20,000 depending on network status. Prescription drug benefits included tiered copay structures with generic drugs ranging from $5 to $20, preferred brands from $40 to $75, and non-preferred drugs from $70 to $100, with specialty drugs subject to 20% coinsurance and varying maximum copays. The document notes this information is for informational purposes only and serves as baseline data for proposal evaluation.

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Other files

File	Type	Posted
Schedule J Dependent Coverage.pdf	PDF	Nov 1, 2023
Schedule P TRR Report Template.xlsx	XLSX spreadsheet	Nov 1, 2023
Schedule L Benefit Comparison and Actuarial Attestation.xlsx	XLSX spreadsheet	Nov 1, 2023
Schedule K 834 Use Case and Example.docx	DOCX document	Nov 1, 2023
Schedule M HMO Census Data REVISED.xlsx	XLSX spreadsheet	Nov 1, 2023
Schedule B Pricing.xlsx	XLSX spreadsheet	Nov 1, 2023
Schedule I2 PPO Medicare Summary of Benefits.pdf	PDF	Nov 1, 2023
Schedule I4 Medicare Prescription Drug Summary of Benefits.pdf	PDF	Nov 1, 2023
Schedule F Definitions.docx	DOCX document	Nov 1, 2023
Schedule G - Contractor Performance Evaluation Survey.doc	DOC document	Nov 1, 2023
Schedule I1 PPO Non Medicare Summary of Benefits.pdf	PDF	Nov 1, 2023
Schedule I3 Non-Medicare Prescription Drug Summary of Benefits.pdf	PDF	Nov 1, 2023
230000003226 HMO Services RFP.docx	DOCX document	Nov 1, 2023
Schedule N Section 2 Solutions Table.xlsx	XLSX spreadsheet	Nov 1, 2023
230000003226 Questions Answers.pdf	PDF	Nov 1, 2023
Schedule Q RFI Report Template.xlsx	XLSX spreadsheet	Nov 1, 2023
Schedule R Payment Discrepancy Report Template.xlsx	XLSX spreadsheet	Nov 1, 2023

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Medicare Paid Claims

RFP No. 230000003226
Schedule: H
Month	Enrollee Count (#) HMO 1	Medical Paid ($) HMO 1	Prescription Drug Paid ($) HMO 1	Enrollee Count (#) HMO 2	Medical Paid ($) HMO 2	Prescription Drug Paid ($) HMO 2
Mar-23	5,815	$ 3,355,393	$ 2,202,767	23,216	$13,660,345.78	$8,100,730.78
Feb-23	5,787	$ 3,424,590	$ 1,975,021	23,166	$13,175,839.33	$6,757,016.13
Jan-23	5,743	$ 3,971,967	$ 2,521,608	23,183	$15,796,136.12	$7,509,301.38
Dec-22	5,717	$ 3,928,024	$ 1,710,960	23,303	$15,116,578.35	$8,204,613.54
Nov-22	5,696	$ 3,793,910	$ 1,570,271	23,275	$14,874,876.64	$7,697,727.58
Oct-22	5,651	$ 4,172,675	$ 1,616,153	23,248	$17,821,250.21	$7,707,101.72
Sep-22	5,622	$ 3,036,258	$ 2,359,273	23,229	$12,890,313.37	$7,825,469.80
Aug-22	5,569	$ 3,634,314	$ 1,574,722	23,151	$13,223,031.48	$7,713,319.90
Jul-22	5,522	$ 3,430,789	$ 1,491,245	23,103	$15,632,532.78	$7,188,554.87
Jun-22	5,447	$ 3,039,705	$ 1,457,265	22,990	$12,660,936.90	$7,669,435.61
May-22	5,402	$ 3,839,669	$ 1,508,793	22,974	$17,012,479.72	$6,678,925.82
Apr-22	5,366	$ 2,790,859	$ 2,467,914	22,925	$12,910,090.89	$7,448,786.64
Mar-22	5,338	$ 2,901,456	$ 1,522,080	22,890	$12,434,268.90	$7,555,269.90
Feb-22	5,297	$ 2,962,372	$ 1,409,125	22,834	$13,689,042.68	$6,343,420.11
Jan-22	5,269	$ 3,424,002	$ 1,398,237	22,799	$15,797,375.61	$6,627,007.19
Dec-21	5,317	$ 3,488,762	$ 1,443,269	22,851	$14,008,475.41	$7,233,359.94
Nov-21	5,283	$ 4,235,047	$ 1,391,398	22,809	$14,379,605.55	$6,396,874.43
Oct-21	5,250	$ 2,928,787	$ 2,052,668	22,793	$17,297,949.78	$6,983,689.12
Sep-21	5,231	$ 3,337,499	$ 1,186,864	22,752	$13,000,592.09	$6,722,206.99
Aug-21	5,185	$ 3,501,231	$ 1,218,233	22,689	$15,483,813.68	$6,248,847.23
Jul-21	5,136	$ 2,584,798	$ 1,199,579	22,602	$12,344,200.90	$6,441,088.63
Jun-21	5,053	$ 4,082,799	$ 1,214,373	22,404	$12,229,391.07	$6,222,430.75
May-21	5,014	$ 2,513,823	$ 1,156,222	22,362	$17,457,831.00	$5,964,991.84
Apr-21	4,983	$ 2,963,922	$ 1,792,390	22,311	$10,528,856.84	$6,370,976.30
Mar-21	4,954	$ 3,375,029	$ 1,131,956	22,225	$11,627,366.96	$6,278,337.70

Non-Medicare Paid Claims

RFP No. 230000003226
Schedule H:
Month	Enrollee Count (#) HMO 1	Medical Paid ($) HMO 1	Prescription Drug Paid ($) HMO 1	Enrollee Count (#) HMO 2	Medical Paid ($) HMO 2	Prescription Drug Paid HMO 2
Mar-23	3,479	$ 1,467,664	$ 846,090	4,057	$1,632,454.96	$708,355.31
Feb-23	3,485	$ 1,834,276	$ 657,060	3,962	$1,842,085.21	$664,493.83
Jan-23	3,505	$ 1,855,856	$ 737,875	3,926	$2,390,835.28	$685,017.37
Dec-22	3,624	$ 1,789,887	$ 732,779	3,879	$1,568,902.27	$626,702.21
Nov-22	3,648	$ 1,526,335	$ 789,974	4,033	$1,691,150.56	$671,995.63
Oct-22	3,691	$ 1,643,976	$ 884,532	4,013	$2,129,593.73	$695,985.25
Sep-22	3,711	$ 1,744,847	$ 840,024	4,059	$1,605,079.90	$778,414.61
Aug-22	3,683	$ 2,140,144	$ 807,113	4,023	$2,529,943.52	$725,332.85
Jul-22	3,706	$ 1,444,204	$ 759,961	3,970	$2,130,622.89	$689,306.35
Jun-22	3,535	$ 1,835,249	$ 796,764	3,903	$1,502,082.90	$745,250.19
May-22	3,574	$ 2,300,436	$ 700,424	3,764	$1,992,310.12	$686,771.02
Apr-22	3,596	$ 1,841,315	$ 812,968	3,664	$2,022,578.92	$572,383.46
Mar-22	3,624	$ 1,698,036	$ 806,801	3,583	$1,984,920.29	$755,940.11
Feb-22	3,632	$ 1,645,093	$ 611,770	3,519	$1,344,723.45	$745,597.43
Jan-22	3,614	$ 2,040,249	$ 873,100	3,447	$2,369,048.45	$569,626.05
Dec-21	3,690	$ 1,447,436	$ 671,338	3,410	$1,334,044.56	$777,258.41
Nov-21	3,736	$ 1,799,791	$ 646,755	3,487	$1,352,105.97	$614,241.30
Oct-21	3,773	$ 1,564,312	$ 1,022,492	3,428	$1,353,817.50	$628,232.38
Sep-21	3,782	$ 1,592,964	$ 591,244	3,406	$1,123,353.94	$612,908.81
Aug-21	3,704	$ 2,218,859	$ 617,263	3,350	$1,698,463.12	$583,621.31
Jul-21	3,699	$ 1,657,410	$ 584,094	3,280	$1,540,083.61	$637,859.63
Jun-21	3,445	$ 1,869,720	$ 544,921	3,212	$1,571,894.47	$542,129.31
May-21	3,481	$ 1,617,386	$ 517,801	3,101	$1,726,815.18	$600,647.21
Apr-21	3,495	$ 1,392,944	$ 884,168	3,065	$1,537,316.92	$511,209.03
Mar-21	3,509	$ 1,702,091	$ 587,311	3,015	$1,790,968.05	$683,695.48

Medicare Benefit Summary

RFP #: 230000003226

Schedule H:

FOR INFORMATIONAL PURPOSES ONLY. Bidder need not replciate the benefits stated here. Bidder proposal must include benefits that are actuarially equivalent to those in Schedule I2 and I4. See also Schedule A, Section 1.2.1.

		2021		2022		2023
		HMO 1	HMO 2	HMO 1	HMO 2	HMO 1	HMO 2
	Hospital Care
	Inpatient hospital care	10% coinsurance after deductible	10% coinsurance after deductible	10% coinsurance after deductible.	10% coinsurance after deductible	10% coinsurance, after deductible	10% coinsurance, after deductible
	Outpatient hospital care, including diagnostic services	10% coinsurance after deductible. Office visit copay may apply. $150 copay after deductible for high tech imaging services.	10% coinsurance after deductible. Diagnostic labs, pathology, x-rays, $10 copay after deductible. $150 copay, deductible does not apply for high tech imaging services.	10% coinsurance after deductible. Office visit copay may apply. $150 copay or 50% coinsurance after deductible for high tech imaging services.	10% coinsurance after deductible. Diagnostic labs, pathology, X-rays $10 copay after deductible.	10% coinsurance, after deductible. Office visit copay may apply.
$150 copay or 50% coinsurance, after deductible, for high tech imaging services.	10% coinsurance, after deductible. Diagnostic labs, pathology, X-rays $10 copay after deductible.
	Alternatives to Hospital Care
	Home healthcare	Covered in full after deductible; copay may apply for physician's visit.	Covered in full, deductible does not apply.	Covered in full.	Covered in full. Deductible does not apply.	Covered in full, after deductible	Covered in full.
	Skilled nursing facility	Covered in full after deductible for 100 days (can be renewed after 60 days)	10% coinsurance 100 days (can be renewed after 60 days) after deductible.	Covered in full after deductible up to 100 days per benefit period.	10% coinsurance after deductible for 100 days. Can be renewed after 60 days.	Covered in full up to 100 days per benefit period.	10% coinsurance, after deductible for 100 days. Can be renewed after 60 days.
	Hospice	Covered by Original Medicare	Covered by Original Medicare	Covered by Original Medicare	Covered by Original Medicare.	Covered by Original Medicare	Covered by Original Medicare
	Emergency Services
	Emergency room care	$100 copay after deductible; waived if admitted	$90 copay, waived if admitted. Deductible does not apply.	$100 copay after deductible, waived if admitted.	$120 copay, waived if admitted. Deductible does not apply.	$100 copay, waived if admitted. Deductible does not apply.	$120 copay, waived if admitted. Deductible does not apply.
	Urgent care	$50 copay	$45 copay. Deductible does not apply.	$50 copay	$45 copay. Deductible does not apply.	$50 copay	$45 copay. Deductible does not apply.
	Surgical Services
	Surgical Services	10% coinsurance after deductible	10% coinsurance after deductible	10% coinsurance after deductible	10% coinsurance after deductible.	10% coinsurance, after deductible	10% coinsurance, after deductible.
	Doctor Office Visits and Services
	Office Visits	$25 copay primary. $45 copay after deductible specialist. $40 copay outpatient therapy services.	$10 copay Primary. $35 copay specialist, deductible does not apply.	Primary: Covered - $25 copay
Specialist: Covered - $45 copay after deductible	Primary: $10 copay
Specialist: $35 copay. Deductible does not apply.	Primary doctor: $10 copay.
Specialist: $35 copay. Deductible does not apply.	Primary doctor: $10 copay.

Specialist: $35 copay. Deductible does not apply.

	Online visits	$25 copay in network	$0 copay, deductible does not apply.	Covered - $25 copay in network	$0 copay. Deductible does not apply.	Covered in full.	Covered in full.
	Allergy testing and treatment	Covered in full. Office visit copay may apply after deductible.	Covered in full. Office visit copay may apply, deductible does not apply.	Covered in full after deducible. Office visit copay may apply per member, per visit.	Covered in full. Office visit copay may apply. Deductible does not apply.	Covered in full after deductible. Office visit copay may apply per member, per visit.	Covered in full. Office visit copay may apply. Deductible does not apply.
	Chiropractic visits	$20 copay after deductible when referred	$10 copay, deductible does not apply.	Covered - $20 copay after deductible	$10 copay. Deductible does not apply.	$20 copay, after deductible.	$10 copay. Deductible does not apply.
	Physical, occupational, speech therapy	$40 copay after deductible	$35 copay. Deductible does not apply.	Covered - $40 copay after deductible	$10 copay. Deductible does not apply.	$40 copay, after deductible.	$10 copay. Deductible does not apply.
	Preventive Services
	Annual routine physical exams	Medicare Wellness Exam covered in full once annually.	Covered in full, deductible does not apply.	Covered in full	Covered in full. Deductible does not apply.	Covered in full.	Covered in full.
	Routine pap smears	Covered in full	Covered in full, deductible does not apply.	Covered in full	Covered in full. Deductible does not apply.	Covered in full.	Covered in full.
	Routine mammograms	Covered in full	Covered in full, deductible does not apply.	Covered in full	Covered in full. Deductible does not apply.	Covered in full.	Covered in full.
	Screening colonoscopy	Covered in full (screening colonoscopy or screening barium enema as an alternative) every 24 months. Not high risk of colorectal cancer: Screening colonoscopy every 10 years (120 months), but not within 48 months of a screening sigmoidoscopy.	Covered in full, deductible does not apply.	Covered in full.	Covered in full. Deductible does not apply.	Covered in full.	Covered in full.
	Vaccines (Influenza, Pneumonia, Hepatitis B)	Covered in full	Covered in full.	Covered in full	Covered in full.	Covered in full.	Covered in full.
	Mental Health
	Outpatient mental health services	Covered in full	$10 copay, deductible does not apply.	Covered in full, unlimited days	$10 copay. Deductible does not apply.	Covered in full, unlimited days.	$10 copay. Deductible does not apply.
	Substance Use Disorder Treatment
	Outpatient facility	Covered in full, unlimited days	$10 copay. Deductible does not apply.	Covered in full, unlimited days	$10 copay. Deductible does not apply.	Covered in full, unlimited days.	$10 copay. Deductible does not apply.
	Durable Medical Equipment
	Durable Medical Equipment	20% coinsurance	20% coinsurance after deductible.	20% coinsurance	20% coinsurance after deductible.	20% coinsurance.	20% coinsurance, after deductible.
	Hearing
	Routine hearing care	Hearing exam: Covered in full. One exam every 36 months. Hearing aids: Covered in full. One hearing aid per year every 36 months.	Hearing exam: Covered in full. One hearing exam, one audiometric exam every 24 months.
Hearing aids: $499 copay per hearing aid for advanced aids, $799 copay per hearing aid for premium aids. One basic hearing aid per ear every 12 months. Exclusively through Rehearing providers.	Hearing exam: One exam every 36 months.
Hearing aids: One hearing aid per ear every 36 months.	Hearing exam: Covered in full. One hearing exam, one audiometric exam every 24 months. Hearing aids: $499 copay per hearing aid for advanced aids, $799 copay per hearing aid for premium aids. One basic hearing aid per ear every 12 months. Exclusively through TruHearing providers.	Hearing exam: Covered in full. One exam every 36 months.
Hearing aids: Covered in full. One hearing aid every 36 months.	Hearing exam: Covered in full. One hearing exam, one audiometric exam every 24 months.

Hearing Aids: $499 copay per hearing aid for advanced aids, $799 copay per hearing aid for premium aids. One basic hearing aid per ear every 12 months. Exclusively through TruHearing providers.

Location of Care
Care in Michigan, but outside the network	Emergency and Urgent care covered. Other care not covered unless member has prior authorization on file.	Emergency and Urgent Care same as in-network. Most other covered services, travel deductible and coinsurance apply.	Emergency and urgent care covered. Other care not covered unless member has prior authorization on file.	Emergency and urgent care same as in network. Most other covered services, travel deductible, and coinsurance apply.	Emergency and urgent care covered. Other care not covered unless member has prior authorization on file.	Emergency and urgent care same as in network. Most other covered services, travel deductible, and coinsurance apply.
Care outside Michigan	Routine, urgent and follow-up care through BlueCard.	Emergency and Urgent Care same as in-network. Out of state benefit covers out of state care the same as in-network when you visit a Multiplan Medicare participating provider.	Routine, urgent, and follow-up care through BlueCard.	Emergency and urgent care same as in network. Out-of-state benefit covers out-of-state care the same as in network when you visit a Multiplan Medicare participating provider.	Routine, urgent, and follow-up care through BlueCard.	Emergency and urgent care same as in network. Out-of-state benefit covers out-of-state care the same as in network when you visit a Multiplan Medicare participating provider.
Medical Deductible
Deductible	$400 individual	$300 individual	$400 individual	$450 individual	$400 individual	In network: $525 individual

Out of network: $725 individual

Medical Maximum
Medical Coinsurance / copay Maximum	$1,700 individual	$1,800 individual	$1,700 individual	$1,650 individual	$1700 individual	In network: $1,775 individual

Out of network: $2,475 individual Total medical out of pocket maximum $2,100 individual $2,100 individual $2,100 individual $2,100 individual $2100 individual In network: $2,300 individual Out of network: $3,200 individual

Prescription Drugs
Traditional prescription drugs	Preferred Pharmacy: $12 copay Generic.

$55 copay Preferred Brand.

$80 copay Non-Preferred Drugs.

50% coinsurance sexual dysfunction drugs (31-day supply) Standard Pharmacy:

$20 copay generic $75 copay Preferred Brand $100 copay Non-Preferred Drugs Mail Order: 32 day to 90-day supply for 2 copays Deductible does not apply Preferred Pharmacy:

$9 copay Tier 1 Generic $40 copay Tier 2 Preferred Brand $70 copay Tier 3 Non Preferred Brand

Non-Preferred Pharmacy:

$15 copay Tier 1 Generic $45 copay Tier 2 Preferred Brand $75 copay Tier 3 Non-Preferred Brand

Mail Order: Up to 90-day supply for 2 copays. Tier 1 generic $0 copay. Preferred Pharmacy:

Preferred Generic and Generic: $12 copay Preferred Brand: $55 copay Non-Preferred Drugs: $80 copay 50% coinsurance sexual dysfunction drugs (31-day supply) Standard Pharmacy:

Preferred Generic and Generic: $20 copay Preferred Brand: $75 copay Non-Preferred Drugs: $100 copay

Mail Order: 32-day to 90-day supply for two copays Preferred Pharmacy:

Generic: $9 copay Preferred Brand: $40 copay Non-Preferred Brand: $70 copay Standard Retail Pharmacy:

Generic: $15 copay Preferred Brand: $45 copay Non-Preferred Brand: $75 copay Mail Order: Up to 90-day supply for two copays. Tier 1 generic $0 copay. Preferred Pharmacy:

Preferred Generic and Generic: $5 copay Preferred Brand: $40 copay Non-Preferred Brand: $70 copay.

50% coinsurance sexual dysfunction drugs (31-day supply).

Standard Pharmacy:

Preferred Generic and Generic: $10 copay Preferred Brand: $45 copay Non-Preferred Brand: $75 copay

Mail Order: 32-day to 90-day supply for two copays. Tier 1 and Tier 2 generic $0 copay Preferred pharmacy:

Preferred Generic and Generic: $9 copay.

Preferred Brand: $55 copay.

Non-Preferred Brand: $85 copay

Standard Retail Pharmacy:

Preferred Generic and Generic: $15 copay Preferred Brand: $60 copay Non-Preferred Brand: $90 copay.

Mail Order: Up to 90-day supply, for two copays. Tier 1 generic $0 copay.

Specialty Prescription Drugs	20% coinsurance ($200 maximum per prescription)	20% coinsurance ($100 maximum per prescription)	20% coinsurance with $200 maximum per prescription	Preferred and Non Preferred Specialty: 20% coinsurance with $100 maximum per prescription.	Specialty: 20% coinsurance, with $100 maximum per prescription	Preferred and Non-Preferred Specialty: 20% coinsurance, with $120 maximum per prescription.
Prescription Drug Maximum
Prescription Drug coinsurance maximum	No pharmacy out of pocket maximum	No pharmacy out of pocket maximum	No pharmacy out-of-pocket maximum.	No pharmacy out-of-pocket maximum.	No pharmacy out of pocket maximum	No pharmacy out-of-pocket maximum.

Non Medicare Benefit Summary

RFP #: 230000003226

Schedule H:

Non-Medicare Benefits Summary and Claims Paid Data

		2021		2022		2023
		HMO 1	HMO 2	HMO 1	HMO 2	HMO 1	HMO 2
	Hospital Care
	Inpatient hospital care	10% coinsurance after deductible	10% coinsurance after deductible	10% coinsurance after deductible	10% coinsurance after deductible.	10% coinsurance, after deductible	10% coinsurance, after deductible.
	Outpatient hospital care, including diagnostic services	10% coinsurance after deductible. $150 copay after deductible for high tech imaging services	10% coinsurance after deductible. $150 copay, deductible does not apply, for high tech imaging services.	10% coinsurance after deductible. $150 copay after deductible for high tech imaging services.	10% coinsurance after deductible. $150 copay, deductible does not apply, for high tech imaging services.	10% coinsurance, after deductible. $150 copay, after deductible for high tech imaging services.	10% coinsurance, after deductible. $150 copay, deductible does not apply, for high tech imaging services.
	Alternatives to Hospital Care
	Home healthcare	$35 copay after deductible	10% coinsurance after deductible.	$35 copay after deductible	10% coinsurance after deductible	$35 copay, after deductible.	10% coinsurance, after deductible.
	Skilled nursing facility	10% coinsurance after deductible up to 120 days per calendar year	10% coinsurance, 100 days (can be renewed) after deductible.	10% coinsurance after deductible up to 120 days per calendar year.	10% coinsurance, 100 days (can be renewed) after deductible.	10% coinsurance, after deductible up to 120 days per calendar year.	10% coinsurance, 100 days (can be renewed) after deductible.
	Hospice	Covered in full after deductible; inpatient hospice care requires prior authorization	10% coinsurance after deductible.	Covered in full after deductible. Inpatient hospice care requires prior authorization.	10% coinsurance after deductible.	Covered in full, after deductible, Inpatient hospice care requires prior authorization.	10% coinsurance, after deductible.
	Emergency Services
	Emergency room care	$150 copay after deductible, waived if admitted	$150 copay, waived if admitted. Deductible does not apply.	$150 copay after deductible, waived if admitted.	$150 copay, waived if admitted. Deductible does not apply.	$150 copay after deducible, waived if admitted.	$150 copay, waived if admitted. Deductible does not apply.
	Urgent care	$65 copay	$60 copay. Deductible does not apply.	$65 copay	$60 copay. Deductible does not apply.	$65 copay.	$60 copay. Deductible does not apply.
	Surgical Services
	Surgical Services	10% coinsurance after deductible	10% coinsurance after deductible	10% coinsurance after deductible.	10% coinsurance after deductible.	10% coinsurance, after deductible.	10% coinsurance, after deductible.
	Doctor Office Visits and Services
	Office Visits	$25 copay primary
$35 copay after deductible specialist	$25 copay primary
$40 copay specialist, deductible does not apply	$25 copay, primary
$35 copay after deductible, specialist	$25 copay, primary

$40 copay, specialist. Deductible does not apply.

Primary doctor: $25 copay.

Specialist: $35 copay after deductible.

Primary doctor: $25 copay.

Specialist: $40 copay. Deductible does not apply.

	Online visits	$25 copay	$0 copay, deductible does not apply.	$25 copay	$0 copay. Deductible does not apply.	$25 copay.	Covered in full.
	Allergy testing and treatment	50% coinsurance after deductible
$5 copay for allergy injections	Included in office visit, deductible does not apply	50% coinsurance after deductible
$5 copay for allergy injections	Included in office visit. Deductible does not apply.	50% coinsurance, after deductible.
$5 copay for allergy injections.	Included in office visit. Deductible does not apply.
	Chiropractic visits	$35 copay after deductible	$30 copay, maximum benefit 30 visits/year with PT & OT, deductible does not apply.	$35 copay after deductible	$30 copay, maximum benefit 30 visits / year with PT and OT. Deductible does not apply.	$35 copay, after deductible.	$30 copay, maximum benefit 30 visits / year with PT and OT. Deductible does not apply.
	Physical, occupational, speech therapy	$35 copay after deductible	$30 copay, maximum benefit 30 visits / year with PT and OT. Deductible does not apply.	$35 copay after deductible, limited to 60 consecutive days per episode.	$30 copay, maximum benefit 30 visits / year with PT and OT. Deductible does not apply.	$35 copay after deductible, limited to 60 consecutive days per episode.	$30 copay, maximum benefit 30 visits / year with PT and OT. Deductible does not apply.
	Preventive Services
	Annual routine physical exams	$25 copay primary
$35 copay after deductible specialist	Covered in full, deductible does not apply.	$25 copay, primary
$35 copay after deductible, specialist	Covered in full. Deductible does not apply.	Primary doctor: $25 copay.

Specialist: $35 copay, after deductible.

Covered in full.
Routine pap smears	Covered in full.	Covered in full, deductible does not apply.	Covered in full	Covered in full. Deductible does not apply.	Covered in full	Covered in full.
Routine mammograms	Covered in full.	Covered in full, deductible does not apply.	Covered in full	Covered in full. Deductible does not apply.	Covered in full.	Covered in full.
Screening colonoscopy	Covered in full	Covered in full, deductible does not apply.	Covered in full	Covered in full. Deductible does not apply.	10% coinsurance, plus deductible.	Covered in full.
Vaccines (Influenza, Pneumonia, Hepatitis B)	Covered in full.	Influenza and Hepatitis B vaccines are covered in full.

Pneumonia vaccine is only covered in full if a member is considered high risk or with a history of asthma or smoking. Covered in full. Influenza and Hepatitis B vaccines are covered in full.

Pneumonia vaccine is only covered in full if a member is considered high risk or with a history of asthma or smoking.

	Mental Health
	Outpatient mental health services	50% coinsurance, up to 20 visits / calendar year	$25 copay, deductible does not apply	50% coinsurance, up to 20 visits / calendar year.	$25 copay. Deductible does not apply.
	50% coinsurance, up to 20 visits/calendar year.	$25 copay. Deductible does not apply.
	Substance Use Disorder Treatment
	Outpatient facility	50% coinsurance	$25 copay. Deductible does not apply.
	50% coinsurance	$25 copay. Deductible does not apply.
	50% coinsurance.	$25 copay. Deductible does not apply.
	Durable Medical Equipment
	Durable Medical Equipment	50% coinsurance of the Approved Amount when authorized and obtained from a participating provider.	20% coinsurance after deductible.	50% coinsurance of the approved amount when authorized and obtained from a participating provider.	20% coinsurance after deductible.	50% coinsurance of the approved amount when authorized and obtained from a participating provider.	20% coinsurance, after deductible.
	Hearing
	Routine hearing care	Hearing exam: Covered in full. One exam every 36 months.
Hearing aids: Covered in full. One hearing aid every 36 months.	Hearing exam: covered in full. One hearing exam, one audiometric exam every 24 months.
Hearing aids: $499 copay per hearing aid for advanced aids, $799 copay per hearing aid for premium aids. One basic hearing aid per ear every 12 months. Exclusively through TruHearing providers.	Hearing exam: Covered in full. One exam every 36 months.
Hearing aids: Covered in full. One hearing aid every 36 months.	Hearing exam: Covered in full. One hearing exam, one audiometric exam every 24 months.
Hearing aids: $499 copay per hearing aid for advanced aids, $799 copay per hearing aid for premium aids. One basic hearing aid per ear every 12 months. Exclusively through TruHearing providers.	Hearing exam: Covered in full. One exam every 36 months.
Hearing aids: Covered in full. One hearing aid every 36 months.	Hearing exam: Covered in full. One hearing exam, one audiometric exam every 24 moths.

Hearing aids: $499 copay per hearing aid for advanced aids, $799 copay per hearing aid for premium aids. One basic hearing aid per ear every 12 months. Exclusively through TruHearing providers.

	Location of Care
	Care in Michigan, but outside the network	Emergency and urgent care covered; other care not covered unless member has prior authorization on file.	Emergency and Urgent Care same as in-network.	Emergency and urgent care covered; other care not covered unless member has prior authorization on file.	Emergency and urgent care same as in network,	Emergency and urgent care covered; other care not covered unless member has prior authorization on file.	Emergency and urgent care same as in network.
	Care outside Michigan	Routine, urgent and follow-up care through BlueCard	Emergency and Urgent Care same as in-network. Most other covered services, travel deductible and coinsurance apply.	Routine, urgent, and follow-up care through BlueCard.	Emergency and urgent care same as in network. Most other covered services, travel deductible and coinsurance apply.	Routine, urgent, and follow-up care through BlueCard.	Emergency and urgent care same as in network. Most other covered services, travel deductible, and coinsurance apply.
	Medical Deductible
	Deductible	$400 individual / $800 family	In-network: $750 individual / $1,500 Family
Out-of-Network: $1,500 individual / $3000 family	$400 individual/ $800 family	In Network: $750 individual / $1,500 family
Out of Network: $1,500 individual / $3,000 family	$400 individual / $800 family.	In network: $750 individual / $1,500 family.

Out of network: $1,500 individual / $3,000 family.

	Medical Maximum
	Medical Coinsurance Maximum	$750 individual / $1,500 family	In network: $1,000 individual / $2,000 family
Out-of-network: $2,000 individual / $4,000 family	Coinsurance maximum: $750 individual / $1,500 family	Coinsurance maximum:

In network: $5,000 individual / $10,000 family Out of Network: $10,000 individual / $20,000 family $750 individual / $1,500 family. In network: $5,000 individual / $10,000 family.

Out of network: $10,000 individual / $20,000 family.

Prescription Drugs
Traditional prescription drugs	$20 copay Generic

$60 copay Preferred Brand $80 copay Non-Preferred Brand 50% coinsurance sexual dysfunction drugs (30-day supply)

Mail Order: Up to 90-day supply for 2 copays Deductible does not apply $10 copay Tier 1 $50 copay Tier 2 $80 copay Tier 3 Mail Order: 90-day supply for 2 copays Generic: $20 copay Preferred Brand: $60 copay Non-Preferred brand: $80 copay 50% coinsurance sexual dysfunction drugs (30-day supply)

Mail Oder: Up to 90-day supply for two copays. Tier 1: $10 copay Tier 2: $50 copay Tier 3: $80 copay Mail Order: 90-day supply for two copays Generic: $20 copay.

Preferred Brand: $60 copay.

Non-Preferred Brand: $80 copay.

50% coinsurance sexual dysfunction drugs (30-day supply).

Mail Order:

Up to 90-day supply for two copays. Generics: $10 copay.

Preferred brand (may include some high-cost generics): $50 copay Non-Preferred Brand (may include some high-cost generics): $80 copay Mail Order: 90-day supply for two copays.

	Specialty Prescription Drugs	20% coinsurance ($200 maximum per prescription Tier 4, $400 maximum per prescription Tier 5)	20% coinsurance ($150 maximum per prescription)	Preferred Specialty: 20% coinsurance with $200 maximum per prescription
Non-Preferred Specialty: 20% coinsurance with $400 maximum per prescription.	Specialty: 20% coinsurance with $150 maximum per prescription.	Preferred Specialty: 20% coinsurance, with $200 maximum per prescription.
Non-Preferred Specialty: 20% coinsurance, with $400 maximum per prescription.	Specialty: 20% coinsurance, with $150 maximum per prescription.
	Prescription Drug Maximum
	Prescription Drug coinsurance maximum	Specialty only: $4,800 individual pharmacy out of pocket maximum	No pharmacy out of pocket maximum	Specialty only: $4,800 individual pharmacy out-of-pocket maximum.	No pharmacy out-of-pocket maximum.	Specialty only: $4,800 individual pharmacy out-of-pocket maximum.	No pharmacy out-of-pocket maximum.

File details come from the government source that posted it. Updated Mar 12, 2026.