Community Blue PPO

The Community Blue PPO plan offers members the flexibility to see any provider throughout the U.S. without a referral, with lower out-of-pocket costs when you use in-network providers.   The plan is administered by Blue Cross Blue Shield of Michigan.  

Summary of Benefits

In-Network  

  • No annual deductible
  • No out-of-pocket cost to you for preventive care
  • $25 copay for office visit for injury or illness
  • $30 copay for specialist visit
  • $25 copay for urgent care
  • $100 copay for emergency care (waived if admitted)
  • $25 copay for mental health, behavioral health or substance abuse services
  • No out-of-pocket cost to you for inpatient services
  • No out-of-pocket cost to you for outpatient surgery
  • $6,350 individual/$12,700 family out-of-pocket maximum

Out-of-Network

  • No annual deductible
  • Preventive care not covered
  • You pay 50% for:
    • Office visit for injury or illness
    • Specialist visit
    • Urgent care
    • Inpatient services
    • Outpatient surgery
    • Mental health, behavioral health or substance abuse services
  • $100 copay for emergency care (waived if admitted)
  • $5,000 individual/$10,000 family out-of-pocket maximum

For complete information on benefits and coverage, please refer to the plan documents.

Using the Plan

The Community Blue PPO plan offers limited out-of-pocket costs, and access to healthcare providers throughout the U.S. Plan members can refer themselves to doctors of their choice, including specialists, inside and outside the network; however, higher out-of-pocket costs are incurred for using out-of-network providers.

Community Blue PPO members are covered at the in-network benefit level when receiving care for approved services while outside the U.S., where no network is available. The BCBSM Community Blue PPO is the only plan offering this enhanced level of coverage. To obtain in-network benefits while out of the U.S., check for participating providers at provider.bcbs.com.

Plan Documents & Forms

Plan Contact Information

bcbsm.com

877-790-BLUE

Blue Cross Blue Shield of Michigan
600 Lafayette E.
Detroit, MI 48226

Group number: 007005187