Michigan Medical

Blue Cross Blue Shield	In-Network	Out-of-Network
Calendar Year Deductible: Single / Family	$1,000/ $2,000	$2,000/ $4,000
Coinsurance	20%	40%
Maximum Out of Pocket Limit: Single /Family (Includes the deductible)	$6,350 / $12,700	$12,700 / $25,400
Primary Care Office Visit	$30 copay	40% coinsurance
Specialist Office Visit	$50 copay	40% coinsurance
Preventive Care	No Charge	Not Covered
Surgical Services	20% after deductible	40% coinsurance
Complex X-Ray and Lab – CT, PET, MRI, MRA etc.	20% coinsurance	40% coinsurance
Urgent Care Centers	$60 copay/visit; deductible does not apply	40% coinsurance
Emergency Room	$150 copay/visit; deductible does not apply	$150 copay/visit; deductible does not apply
In-Patient Hospital Services	20% coinsurance	40% coinsurance
Out-Patient Hospital Services	20% coinsurance	40% coinsurance