BCBSM SBC Support Staff PT 0005 2000-4000 - Kellogg ...

Common
Medical Event
Services You May Need
Physician/surgeon fee
Your cost if you use a
In-Network
Out-of-Network
Provider
Provider
No Charge after deductible 20% co-insurance after
deductible
Limitations & Exceptions
---none---
Mental/Behavioral health
outpatient services
No Charge after deductible
20% co-insurance after
deductible
Unlimited visits
If you have
mental health,
behavioral
health, or
substance abuse
needs
Mental/Behavioral health
inpatient services
Substance use disorder outpatient
services
Substance use disorder inpatient
services
No Charge after deductible
No Charge after deductible
No Charge after deductible
20% co-insurance after
deductible
20% co-insurance after
deductible
20% co-insurance after
deductible
Unlimited days
Unlimited visits
Unlimited days
If you are
pregnant
Prenatal and postnatal care
Delivery and all inpatient services
No Charge after deductible
No Charge after deductible
20% co-insurance after
deductible
20% co-insurance after
deductible
---none---
---none---
If you need help
recovering or
have other
special health
needs
Home health care
Rehabilitation services
No Charge after deductible
No Charge after deductible
No Charge after
deductible
20% co-insurance after
deductible
---none---
Habilitation services Not Covered Not Covered ---none---
Skilled nursing care
No Charge after deductible
No Charge after
deductible
Physical, Occupational, Speech therapy
is limited to a combined maximum of
60 visits per member, per calendar
year.
Limited to a maximum of 90 days per
member per calendar year.
Durable medical equipment
Hospice service
No Charge after deductible No Charge after ---none---
deductible
No Charge No Charge ---none---
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