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Health Plan Coverage Comparison Charts

Updates to this webpage are currently in progress.

Compare coverage for the following employee health care plans:

This comparison is for benefits-eligible faculty and academic staff (FAS) and support staff (SS). Plan eligibility is determined by employee type, union affiliation (if any), and where you live. Use individual health plan links above to determine your eligibility.

Disclaimer: This comparison reviews the plan features in general terms, but is not a full description of coverage. This page may be updated periodically to ensure we provide the clearest and most accurate information. Some services may be subject to deductibles, coinsurance, and out-of-pocket maximums. We encourage you to review your plan provider's benefit and coverage summary for more detail.

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Deductibles and Out-of-Pocket Maximums

Benefit	Blue Care Network HMO		BlueCard Out-of-State PPO		CDHP PPO with HSA		Community Blue PPO		Cigna Global Health Advantage Plan PPO
Benefit	In-Network	Out-of-Network	In-Network	Out-of-Network	In-Network	Out-of- Network	In-Network	Out-of-Network	International (Outside U.S.)	In-Network (U.S.)	Out-of-Network (U.S.)
Deductibles per calendar year	Individual: $175 Family: $350	Individual: $500 Family: $1,000	Individual: $175 Family: $350	Individual: $500 Family: $1,000	Individual: $2,000 ¹ Family: $4,000 ¹	Individual: $4,000 Family: $8,000	FAS: Individual: $100 Family: $200 SS: None	Individual: $250² Family: $500²	Individual: $100 Family: $200	Individual: $100 Family: $200	Individual: $500 Family: $1,000
Health Care Out-of-Pocket Maximum ³	Individual: $3,000 ⁴ Family: $6,000 ⁴	Individual: $3,000 ⁵ Family: $6,000 ⁵	Individual: $3,000 ⁴ Family: $6,000 ⁴	Individual: $3,000 ⁵ Family: $6,000 ⁵	Individual: $3,000 ⁶ Family: $6,000 ⁶	Individual: $6,000 Family: $12,000	Individual: $2,000 Family: $4,000	Individual: $2,250 ⁷ Family: $4,500 ⁷	Individual: $3,000 Family: $6,000	Individual: $3,000 Family: $6,000	Individual: $3,000 Family: $6,000
Prescription Drug Benefit Out-of-Pocket Maximum	Individual: $1,000 Family: $2,000	Individual: $1,000 Family: $2,000	Individual: $1,000 Family: $2,000	Individual: $1,000 Family: $2,000	subject to deductible, co-insurance, and out-of-pocket maximum	subject t,o deductible, co-insurance, and out-of-pocket maximum	Individual: $1,000 Family: $2,000	Individual: $1,000 Family: $2,000	TBD	TBD	TBD

Footnotes:

Deductible is combined for medical and prescription coverage. The full family deductible must be met under a two-person or family contract before benefits are paid for any person on the contract.
Services where no network exists are covered at the in-network level.
Per calendar year. Amount includes deductible, coinsurance, and copays, where applicable. Note: The Cigna plan excludes the deductible.
For medical services only.
For co-insurance only, plus out-of-network deductible.
For medical and prescription services only.
For co-insurance, out-of-network cost-sharing amounts also count towards the in-network out-of-pocket maximum.

Prescriptions

Prescription Drug Tier	Blue Care Network HMO, BlueCard Out-of-State PPO, and Community Blue PPO	CDHP PPO with HSA	Cigna Global Health Advantage Plan PPO
Prescription Drug Tier		CDHP PPO with HSA	International (Outside U.S.)	In-Network (U.S.)	Out-of-Network (U.S.)
Tier 1 - Generic	34-Day Supply: $15 90-Day Supply: $30¹	Please see footnote².	No Charge	30-Day Supply: $10 90-Day Supply: $30	30-Day Supply: You pay 20% after plan deductible. 90-Day Supply: In-Network Coverage Only
Tier 2 - Preferred Brand Name	34-Day Supply: $30 90-Day Supply: $60¹	Please see footnote².	No Charge	30-Day Supply: $30 90-Day Supply: $90	30-Day Supply: You pay 20% after plan deductible. 90-Day Supply: In-Network Coverage Only
Tier 3 - Non-Preferred Brand Name	34-Day Supply: $75 90-Day Supply: $150¹	Please see footnote².	No Charge	30-Day Supply: $60 90-Day Supply: $180	30-Day Supply: You pay 20% after plan deductible. 90-Day Supply: In-Network Coverage Only

Footnotes:

90-day supply (except biotech/specialty drugs) may only be filled at the MSU Health Care Pharmacy or through CVS Caremark mail order.
Those enrolled in the CDHP with HSA have different prescription benefits. Prescription drug costs are subject to plan deductible and coinsurance, and then the total cost is covered after you reach the out-of-pocket maximum. This means that you pay 100% of prescription costs until you reach the deductible. Once the deductible is met, the plan covers 80% of the costs while you pay 20% coinsurance. Once the out-of-pocket maximum is reached, prescriptions are 100% covered for the remainder of the plan year. Certain preventative generic prescription drugs for chronic conditions (asthma, cholesterol, diabetes, and anti-hypertensives) are 100% covered without a deductible or coinsurance.

Preventative Services

Benefit	Blue Care Network HMO		BlueCard Out-of-State PPO		CDHP PPO with HSA		Community Blue PPO		Cigna Global Health Advantage Plan PPO
Benefit	In-Network	Out-of-Network	In-Network	Out-of-Network	In-Network	Out-of-Network	In-Network	Out-of-Network	International (Outside U.S.)	In-Network (U.S.)	Out-of-Network (U.S.)
Health Maintenance Exam ¹	Covered 100% ²	Not Covered	Covered 100% ²	Not Covered	Covered 100% ²	Not Covered	Covered 100% ²	Not Covered	Covered 100%	Covered 100%	Not Covered
Annual Gynecological Exam ¹	Covered 100%	Not Covered	Covered 100%	Not Covered	Covered 100%	Not Covered	Covered 100%	Not Covered	Covered 100%	Covered 100%	Covered 80%³
Pap Smear Screening ¹ Lab services only	Covered 100%	Not Covered	Covered 100%	Not Covered	Covered 100%	Not Covered	Covered 100%	Not Covered	Covered 100%	Covered 100%	Covered 80%³
Mammography Screening ¹	Covered 100%	Covered 80%^{4, 5, 6}	Covered 100%	Covered 80%^{4, 5, 6}	Covered 100%	Covered 60%³	Covered 100%	Covered 80%³	Covered 100%	Covered 100%	Covered 80%³
Contraceptive Devices IUD, Diaphragm, Norplant	Covered 100%	Not Covered	Covered 100%	Covered 100%³	Covered 100%	Covered 60%³	Covered 100%	Covered 100%³	Not Covered	Covered 100% ⁷	Not Covered
Contraceptive Injections	Covered 100%	Not Covered	Covered 100%	Covered 80%³	Covered 100%	Covered 60%³	Covered 100%	Covered 80%³	TBD	TBD	TBD
Well-Baby and Child Care Exams	Covered 100%	Not Covered	Covered 100%	Not Covered	Covered 100%	Not Covered	Covered 100%	Not Covered	Covered 100%	Covered 100%	Covered 80%³
Immunizations ⁸	Covered 100%	Not Covered	Covered 100%	Not Covered	Covered 100%	Not Covered	Covered 100%	Not Covered	Covered 100%	Covered 100%	Not Covered
Flu Shots	Covered 100%	Covered 100%	Covered 100%	Covered 100%	Covered 100%	Not Covered	Covered 100%	Not Covered	TBD	TBD	TBD
Fecal Occult Blood Screening ¹	Covered 100%	Not Covered	Covered 100%	Not Covered	Covered 100%	Not Covered	Covered 100%	Not Covered	Covered 100%	Covered 100%	Covered 80%³
Preventative Colonoscopy^{1, 9}	Covered 100%	Covered 80% ^{4 ,} ⁵ ^{, 6}	Covered 100%	Covered 80% ^{4 ,} ⁵ ^{, 6}	Covered 100%	Covered 60%³	Covered 100%	Covered 80%³	Covered 100%	Covered 100%	Covered 80%³
Flexible Sigmoidoscopy Exam ¹	Covered 100%	Not Covered	Covered 100%	Not Covered	Covered 100%	Not Covered	Covered 100%	Not Covered	TBD	TBD	TBD
Prostate Exam and Specific Antigen Screen^{1, 9}	Covered 100%	Not Covered	Covered 100%	Not Covered	Covered 100%	Not Covered	Covered 100%	Not Covered	Covered 100%	Covered 100%	Covered 80%³

Footnotes:

One per calendar year (does not apply to the Cigna plan.).
Chemical profile, complete blood count, urinalysis, cholesterol testing, chest x-ray and EKG are payable as part of the Health Maintenance Exam.
After deductible.
Of eligible expenses after deductible.
You may be responsible for the difference between BCBSM's or BCN's approved amount and the provider's charge when services are rendered by a non-participating provider, premiums and health care this plan doesn't cover, where applicable.
Prior authorization may be required.
For certain devices.
Recommended by the Advisory Committee on Immunization Practices or mandated by the Affordable Care Act (does not apply to the Cigna plan).
Age restrictions may apply.

Physician Office Services

Benefit	Blue Care Network HMO		BlueCard Out-of-State PPO		CDHP PPO with HSA		Community Blue PPO		Cigna Global Health Advantage Plan PPO
Benefit	In-Network	Out-of-Network	In-Network	Out-of-Network	In-Network	Out-of-Network	In-Network	Out-of-Network	International (Outside U.S.)	In-Network (U.S.)	Out-of-Network (U.S.)
Office Visits/Consultations ¹	$25 Copay	Covered 80% ²	$25 Copay	Covered 80% ²	Covered 80% ²	Covered 60% ²	$25 Copay	Covered 80% ²	Covered 100% ²	$20 Copay	Covered 80% ²

Footnotes:

Must be medically necessary.
After deductible.

Emergency Medical Care

Benefit	Blue Care Network HMO		BlueCard Out-of-State PPO		CDHP PPO with HSA		Community Blue PPO		Cigna Global Health Advantage Plan PPO
Benefit	In-Network	Out-of-Network	In-Network	Out-of-Network	In-Network	Out-of-Network	In-Network	Out-of-Network	International (Outside U.S.)	In-Network (U.S.)	Out-of-Network (U.S.)
Hospital Emergency Room	FAS: Covered 100%¹ OR $250 SS: $50 Copay¹ OR $250	FAS: Covered 100%¹ OR $250 SS: $50 Copay ¹ OR $250	$50 Copay¹ OR $250	$50 Copay¹ OR $250	Covered 80% ²	Covered 80% ²	FAS: Covered 100% ¹ OR $250 SS: $50 Copay¹ OR $250	FAS: Covered 100% ¹ OR $250 SS: $50 Copay¹ OR $250	Covered 100%	$250 Copay	$250 Copay
Emergency Room Physician's Services	Covered 100%	Covered 100%	Covered 100%	Covered 100%	Covered 80% ²	Covered 80% ²	$20 Copay ³	Covered 80% ²	Covered 100%	Covered 100%	Covered 80% ²
Urgent Care Center	$30 Copay	$30 Copay	$30 Copay	Covered 80% ²	Covered 80% ²	Covered 60% ²	$30 Copay	Covered 80% ²	Covered 100% ²	$20 Copay	Covered 80% ²
Ambulance Service ⁴	Covered 80% ^{2, 5}	Covered 80% ^{2, 5}	Covered 80% ^{2, 5}	Covered 80% ^{2, 5}	Covered 80% ²	Covered 80% ²	Covered 100%⁶	Covered 100%⁶	Covered 100% ²	Covered 100%	Covered 100%

Footnotes:

If emergency services provided or if admitted.
After deductible.
When medical emergency criteria not met.
Must be medically necessary.
Ground and air.
Of the approved amount.

Diagnostic Services

Benefit	Blue Care Network HMO		BlueCard Out-of-State PPO		CDHP PPO with HSA		Community Blue PPO		Cigna Global Health Advantage Plan PPO
Benefit	In-Network	Out-of-Network	In-Network	Out-of-Network	In-Network	Out-of-Network	In-Network	Out-of-Network	International (Outside U.S.)	In-Network (U.S.)	Out-of-Network (U.S.)
Laboratory and Pathology Tests	Covered 100% ¹	Not Covered	Covered 100%	Covered 100%	Covered 80% ²	Covered 80% ²	Covered 100%	Covered 80% ²	Covered 100% ²	Covered 100% ²	Covered 80% ²
Diagnostic Tests and X-Rays	Covered 100% ^2, ³	Covered 80% ² ^{, 3, 4}	Covered 100% ^{2, 3}	Covered 80% ^2, ^{3, 4}	Covered 80% ²	Covered 60% ²	Covered 100%	Covered 80% ²	Covered 100% ²	Covered 100% ²	Covered 80% ²
Radiation Therapy	Covered 100% ²	Covered 80% ²	Covered 100% ²	Covered 80% ²	Covered 80% ²	Covered 60% ²	Covered 100%	Covered 80% ²	TBD	TBD	TBD

Footnotes:

Service must be through JVHL, BCN's preferred provider.
After deductible.
Prior authorization may be required.
You may be responsible for the difference between BCBSM's or BCN's approved amount and the provider's charge when services are rendered by a non-participating provider, premiums and health care this plan doesn't cover, where applicable.

Maternity Services

Benefit	Blue Care Network HMO		BlueCard Out-of-State PPO		CDHP PPO with HSA		Community Blue PPO		Cigna Global Health Advantage Plan PPO
Benefit	In-Network	Out-of-Network	In-Network	Out-of-Network	In-Network	Out-of-Network	In-Network	Out-of-Network	International (Outside U.S.)	In-Network (U.S.)	Out-of-Network (U.S.)
Pre-Natal and Post-Natal Care ¹	Covered 100%	Covered 80%² ^{, 3}	Covered 100%	Covered 80%² ^{, 3}	Covered 100%	Covered 60%²	Covered 100%	Covered 80%²	Covered 100%²	Covered 100%²	Covered 80%²
Delivery and Nursery Care ¹	Covered 100%² ^{, 3}	Covered 80%² ^{, 3, 4}	Covered 100%² ^{, 3}	Covered 80%² ^{, 3, 4}	Covered 80%²	Covered 60%²	Covered 100%	Covered 80%²	Covered 100%²	Covered 100%²	Covered 80%²

Footnotes:

Provided by a physician.
After deductible.
Prior authorization may be required.
You may be responsible for the difference between BCBSM's or BCN's approved amount and the provider's charge when services are rendered by a non-participating provider, premiums and health care this plan doesn't cover, where applicable.

Hospital Care

Benefit	Blue Care Network HMO		BlueCard Out-of-State PPO		CDHP PPO with HSA		Community Blue PPO		Cigna Global Health Advantage Plan PPO
Benefit	In-Network	Out-of-Network	In-Network	Out-of-Network	In-Network	Out-of-Network	In-Network	Out-of-Network	International (Outside U.S.)	In-Network (U.S.)	Out-of-Network (U.S.)
Semi-Private Room, General Nursing Care, Hospital Services and Supplies	Covered 100% ^{1, 2, 3}	Covered 80% ^{1, 2, 3, 4}	Covered 100% ^{1, 2, 3}	Covered 80% ^{1, 2, 3,} ⁴	Covered 80% ^{1, 2, 3}	Covered 60% ^{1, 2, 3,} ⁴	Covered 100% ^{1, 2, 3,} ⁴	Covered 80% ^{1, 2, 3,} ⁴	Covered 100% ¹	Covered 100% ¹	Covered 80% ¹
Inpatient Consultations	Covered 100% ¹	Covered 80% ¹	Covered 100% ¹	Covered 80% ¹	Covered 80% ¹	Covered 60% ¹	Covered 100%	Covered 80% ¹	Covered 100% ¹	Covered 100% ¹	Covered 80% ¹
Chemotherapy	Covered 100% ¹	Covered 80% ¹	Covered 100% ¹	Covered 80% ¹	Covered 80% ¹	Covered 60% ¹	Covered 100% ¹	Covered 80% ¹	TBD	TBD	TBD

Footnotes:

After deductible.
Unlimited days.
Prior authorization may be required.
You may be responsible for the difference between BCBSM's or BCN's approved amount and the provider's charge when services are rendered by a non-participating provider, premiums and health care this plan doesn't cover, where applicable.

Surgical Services

Benefit	Blue Care Network HMO	BlueCard Out-of-State PPO	CDHP PPO with HSA	Community Blue PPO	Cigna Global Health Advantage Plan PPO
In-Network	Out-of-Network	In-Network	Out-of-Network	In-Network	Out-of-Network	In-Network	Out-of-Network	International (Outside U.S.)	In-Network (U.S.)	Out-of-Network (U.S.)
Surgery and Related Surgical Services	Covered 100% ¹ ^{, 2}	Covered 80% ^{1, 2} ^{, 3}	Covered 100% ¹ ^{, 2}	Covered 80% ^{1, 2} ^{, 3}	Covered 80% ^{1, 2} ^{, 3}	Covered 60% ^{1, 2} ^{, 3}	Covered 100% ^{1, 2} ^{, 3}	Covered 80% ¹ ^{, 2}	TBD	TBD	TBD
Voluntary Sterilization	Male: Covered 100% ¹ Female: Covered 100% ⁴	Not Covered	Male: Covered 100% ¹ Female: Covered 100% ⁴	Not Covered	Male: Covered 50% ¹ Female: Covered 100% ⁴	Male: Not Covered Female: Covered 60% ¹	SS: Covered 100% FAS: Male: Covered 100% ¹ Female: Covered 100%	Covered 80% ¹	Covered 100% ¹	Male: Covered 100% ¹ Female: Covered 100%	Covered 80% ¹

Benefit

Blue Care Network HMO

BlueCard
Out-of-State PPO

CDHP PPO with HSA

Community Blue PPO

Cigna Global Health Advantage Plan PPO

In-Network

Out-of-Network

In-Network

Out-of-Network

In-Network

Out-of-Network

In-Network

Out-of-Network

International
(Outside U.S.)

In-Network (U.S.)

Out-of-Network (U.S.)

Surgery and Related Surgical Services

Covered
100% ¹ ^{, 2}

Covered
80% ^{1, 2} ^{, 3}

Covered
100% ¹ ^{, 2}

Covered
80% ^{1, 2} ^{, 3}

Covered
60% ^{1, 2} ^{, 3}

Covered
100% ^{1, 2} ^{, 3}

Covered
80% ¹ ^{, 2}

TBD

Voluntary Sterilization

Male:
Covered
100% ¹

Female:
Covered
100% ⁴

Not Covered

Male:
Covered
100% ¹

Female:
Covered
100% ⁴

Not Covered

Male:
Covered
50% ¹

Female:
Covered
100% ⁴

Male:
Not Covered

Female:
Covered
60% ¹

SS:
Covered
100%

FAS:
Male:
Covered
100% ¹

Female:
Covered
100%

Covered
80% ¹

Covered
100% ¹

Male:
Covered
100% ¹

Female:
Covered
100%

Covered
80% ¹

Footnotes:

After deductible.
Prior authorization may be required.
You may be responsible for the difference between BCBSM's or BCN's approved amount and the provider's charge when services are rendered by a non-participating provider, premiums and health care this plan doesn't cover, where applicable.
Under preventative benefit.

Human Organ Transplants

Benefit	Blue Care Network HMO		BlueCard Out-of-State PPO		CDHP PPO with HSA		Community Blue PPO		Cigna Global Health Advantage Plan PPO
Benefit	In-Network	Out-of-Network	In-Network	Out-of-Network	In-Network	Out-of-Network	In-Network	Out-of-Network	International (Outside U.S.)	In-Network (U.S.)	Out-of-Network (U.S.)
Such as: liver, heart, lung, pancreas, heart-lung, kidney, cornea, skin and bone marrow ¹	Covered 100%² ^{, 3}	Not Covered	Covered 100%² ^{, 3}	Covered 80-100%^{3, 4, 5}	Covered 80%² ^{, 3}	Covered 60-80%^{2, 3, 4} ^{, 5}	Covered 100% ^{3, 6}	Covered 80-100% ^{3, 4} ^{, 5}	Covered 100%^{2, 7}	Covered 100%^{2, 7}	Not Covered

Footnotes:

Subject to program guidelines. Must be provided at a BCBSM designated facility and may need coordination through the BCBSM Human Organ Transplant Program.
After deductible.
Prior authorization may be required.
Depending on the type of approved transplant.
You may be responsible for the difference between BCBSM's or BCN's approved amount and the provider's charge when services are rendered by a non-participating provider, premiums and health care this plan doesn't cover, where applicable.
After deductible for bone marrow.
In an approved facility.

National Cancer Institute Clinical Trials

Benefit	Blue Care Network HMO	BlueCard Out-of-State PPO	CDHP PPO with HSA	Community Blue PPO	Cigna Global Health Advantage Plan PPO
In-Network	Out-of-Network	In-Network	Out-of-Network	In-Network	Out-of-Network	In-Network	Out-of-Network	International (Outside U.S.)	In-Network (U.S.)	Out-of-Network (U.S.)
Cancer and Life-Threatening Conditions ¹	Covered 100%² ^{, 3}	Not Covered	Covered 100%² ^{, 3}	Covered 80%²	Covered 80%² ^{, 3}	Covered 60%^{2, 3} ^{, 4}	SS: Covered 100%³ FAS: Covered 100%² ^{, 3}	Covered 80%^{2, 3} ^{, 4}	TBD	TBD	TBD

Benefit

Blue Care Network HMO

BlueCard
Out-of-State PPO

CDHP PPO with HSA

Community Blue PPO

Cigna Global Health Advantage Plan PPO

In-Network

Out-of-Network

In-Network

Out-of-Network

In-Network

Out-of-Network

In-Network

Out-of-Network

International
(Outside U.S.)

In-Network (U.S.)

Out-of-Network (U.S.)

Cancer and Life-Threatening Conditions ¹

Covered
100%² ^{,
3}

Not Covered

Covered
100%² ^{,
3}

Covered
80%²

Covered
80%² ^{,
3}

Covered
60%^{2, 3} ^{,
4}

SS:
Covered
100%³

FAS:
Covered
100%² ^{,
3}

Covered
80%^{2, 3} ^{,
4}

TBD

Footnotes:

All stages, including routine care.
After deductible.
Prior authorization may be required.
You may be responsible for the difference between BCBSM's or BCN's approved amount and the provider's charge when services are rendered by a non-participating provider, premiums and health care this plan doesn't cover, where applicable.

Alternatives to Hospital Care

Benefit	Blue Care Network HMO		BlueCard Out-of-State PPO		CDHP PPO with HSA		Community Blue PPO		Cigna Global Health Advantage Plan PPO
Benefit	In-Network	Out-of-Network	In-Network	Out-of-Network	In-Network	Out-of-Network	In-Network	Out-of-Network	International (Outside U.S.)	In-Network (U.S.)	Out-of-Network (U.S.)
Skilled Nursing Care ¹	Covered 100%^{2, 3, 4,} ⁶	Covered 80%^{2, 3} ^, ⁶	Covered 100%^{2, 4, 5} ^, ⁶	Covered 100%^{2, 4, 5} ^, ⁶	Covered 80%^{2, 4, 6, 7}	Covered 80%^{2, 4, 6, 7}	Covered 100%^{2, 4, 6, 8}	Covered 100%^{2, 4, 6, 8}	TBD	TBD	TBD
Hospice Care⁹	Covered 100%^{2, 4} ^, ⁶	Covered 80%^{2, 4} ^, ⁶	Covered 100%^{4 ,} ⁶	Covered 100%^{, 4} ^{, 6}	Covered 100%^{2, 4} ^, ⁶	Covered 100%^{2, 4} ^, ⁶	Covered 100%¹⁰	Covered 100%¹⁰	TBD	TBD	TBD
Home Health Care ¹¹	Covered 100%^{2, 12}	Covered 80%^{2, 12}	Covered 100%^{2, 12}	Covered 100%^{2, 12}	Covered 80%^{2, 12}	Covered 80%^{2, 12}	FAS: Covered 100%^{2, 13} SS: Covered 100%¹³	FAS: Covered 100%^{2, 13} SS: Covered 100%¹³	TBD	TBD	TBD

Footnotes:

Must meet medical necessity guidelines for skilled care and be within an approved facility.
After deductible.
Combined in- and out-of-network benefits up to 100 days per calendar year.
You may be responsible for the difference between BCBSM's or BCN's approved amount and the provider's charge when services are rendered by a non-participating provider, premiums and health care this plan doesn't cover, where applicable.
Combined in- and out-of-network benefits up to 120 days per calendar year.
Prior authorization may be required.
Combined in- and out-of-network benefits up to 90 days per calendar year.
In approved facilities. Up to 120 days per calendar year.
Must be an approved hospice program/facility.
With approved providers.
Must be medically necessary and use an approved home health care agency.
Combined in- and out-of-network benefits up to 60 days per calendar year.
With approved providers, unlimited visits.

Mental Health Care and Substance Abuse Treatment (in approved facilities)

Benefit	Blue Care Network HMO		BlueCard Out-of-State PPO		CDHP PPO with HSA		Community Blue PPO		Cigna Global Health Advantage Plan PPO
Benefit	In-Network	Out-of-Network	In-Network	Out-of-Network	In-Network	Out-of-Network	In-Network	Out-of-Network	International (Outside U.S.)	In-Network (U.S.)	Out-of-Network (U.S.)
Inpatient Mental Health/Substance Abuse Care	Covered 100%^{1, 2}	Covered 80%^{1, 2, 3}	Covered 100%^{1, 2}	Covered 80%^{1, 2, 3}	Covered 80%^{1, 2, 3}	Covered 60%^{1, 2, 3}	FAS: Covered 100%^{1, 2, 3} SS: Covered 100% ^{2, 3}	Covered 80%^{1, 2, 3}	Covered 100% ¹	Covered 100% ¹	Covered 80% ¹
Outpatient Mental Health/Substance Abuse Care - Office Visits	Covered 100% ^{2, 3}	Covered 80%^{1, 2, 3}	Covered 100% ^{2, 3}	Covered 80%^{1, 2, 3}	Covered 80%^{1, 2, 3}	Covered 60%¹	FAS: Covered 100%¹ SS: Covered 100%	Covered 80%¹	Covered 100% ¹	Covered 100% ¹	Covered 80% ¹
Outpatient Mental Health/Substance Abuse Care - Facility	Covered 100% ²	Covered 80%^{1, 2, 3}	Covered 100% ²	Covered 80%^{1, 2, 3}	Covered 80%^{1, 2}	Covered 80%^{2, 3, 4}	FAS: Covered 100%¹ SS: Covered 100%	Covered 80%^{2, 3, 4}	Covered 100% ¹	Covered 100% ¹	Covered 80% ¹

Footnotes:

After deductible.
Prior authorization may be required.
You may be responsible for the difference between BCBSM's or BCN's approved amount and the provider's charge when services are rendered by a non-participating provider, premiums and health care this plan doesn't cover, where applicable.
After deductible in participating facilities.

Other Services

Benefit	Blue Care Network HMO		BlueCard Out-of-State PPO		CDHP PPO with HSA		Community Blue PPO		Cigna Global Health Advantage Plan PPO
Benefit	In-Network	Out-of-Network	In-Network	Out-of-Network	In-Network	Out-of-Network	In-Network	Out-of-Network	International (Outside U.S.)	In-Network (U.S.)	Out-of-Network (U.S.)
Allergy Testing and Therapy¹	Covered 100%²	Covered 80%^{3, 4, 5}	Covered 100%²	Covered 80%^{3, 4, 5}	Covered 80%³	Covered 60%³	Covered 100%	Covered 80%³	TBD	TBD	TBD
Spinal Manipulation and Osteopathic Manipulation	$25 Copay^{5, 6}	Not Covered	$25 Copay^{5, 6}	Covered 80%^{3, 7}	Covered 80%^{3, 8}	Osteopathic manipulation: Not Covered Chiropractic spinal manipulations: Covered 60%³	$25 Copay^{5, 6}	Covered 80%^{3, 8}	TBD	TBD	TBD
Outpatient Physical, Speech, and Occupational Therapy^{9, 10}	$20 Copay^{5, 11}	Covered 80%^{3, 5, 11, 12}	$20 Copay^{5, 11}	Covered 80%^{3, 5, 11, 12}	Covered 80%^{3, 5, 11}	Covered 60%^{3, 5, 11, 13}	Covered 100%¹⁴	Covered 80%^{3, 14}	TBD	TBD	TBD
Durable Medical Equipment and Medical Supplies¹⁵	Covered 80-100%^{4, 5}	Not covered	Covered 80% ^{3, 4, 5}	Covered 80%³	Covered 80-100%^{3, 5, 12}	Covered 80%^{3, 5, 12}	Covered 100%¹⁶	Covered 100%¹⁶	TBD	TBD	TBD
Private Duty Nursing	Not covered	Not covered	Covered 70%^{3, 5}	Covered 50%^{3, 5}	Covered 80%^{3, 5}	Covered 60%^{3, 5}	Covered 70%^{3, 5}	Covered 50%³	TBD	TBD	TBD
Autism Spectrum Disorder^{5, 17}	Covered 100%⁵	Covered 80%^{3, 5, 18}	Covered 100%⁵	Covered 80%^{3, 5, 18}	Covered 80%^{3, 5}	Covered 60%^{3, 5}	Covered 100%⁵	Covered 100%⁵	TBD	TBD	TBD

Footnotes:

Includes allergy injections.
Office visit copay may apply to consultations.
After deductible.
Referrals to specialists are not required.
Prior authorization may be required.
In-network only. Annual maximum of 24 visits.
Annual maximum of 24 visits.
In- and out-of-network services have an annual maximum of 24 visits.
Subject to medical criteria.
Autism Spectrum Disorder services are not subject to Outpatient Physical, Speech and Occupational Therapy visit limit.
Combined in- and out-of-network benefits up to 60 visits per calendar year.
You may be responsible for the difference between BCBSM's or BCN's approved amount and the provider's charge when services are rendered by a non-participating provider, premiums and health care this plan doesn't cover, where applicable.
Services at non-participating outpatient physical therapy facilities are not covered.
In- and out-of-network services have an annual maximum of 60 visits.
Including breastfeeding supplies.
Of the approved amount.
Applied behavioral analysis treatment must be provided by an Approved Autism Evaluation Center (AAEC).
For applied behavioral analysis.

Foreign Travel

Benefit	Blue Care Network HMO		BlueCard Out-of-State PPO		CDHP PPO with HSA		Community Blue PPO		Cigna Global Health Advantage Plan PPO
Benefit	In-Network	Out-of-Network	In-Network	Out-of-Network	In-Network	Out-of-Network	In-Network	Out-of-Network	International (Outside U.S.)	In-Network (U.S.)	Out-of-Network (U.S.)
Foreign Travel	Only covered for emergency care and accidental injuries when traveling abroad.	Only covered for emergency care and accidental injuries when traveling abroad.	Covered for non-emergency and emergency care, as well as accidental injuries.	Covered for non-emergency and emergency care, as well as accidental injuries.	Covered for non-emergency and emergency care, as well as accidental injuries.	Covered for non-emergency and emergency care, as well as accidental injuries.	Covered for non-emergency and emergency care, as well as accidental injuries.	Covered for non-emergency and emergency care, as well as accidental injuries.	TBD	TBD	TBD

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