Medical
CENTURY 21 Affiliated provides group health insurance through Blue Care Network. Three (3) HMO options are below with election options and premium amounts.
For more information on the health insurance and in-network providers, visit www.bcbsm.com .
OPTION
HMO OPTION 1
HMO OPTION 2
HMO OPTION 3
Network Name
BCN MI $4000 HMO
BCN MI $1000 HMO
BCN MI $500 HMO
Group Number
00624058
00624058
00624058
Benefits
In-Network
Non-Network
In-Network
Non-Network
In-Network
Non-Network
Deductible Ind/Family
$4,000 / $8,000
N/A
$1,000 / $2,000
N/A
$500 / $1,000
N/A
$10 / $30 / $60 / $80 / 20% coinsurance
$10 / $30 / $60 / $80 / 20% coinsurance
$10 / $30 / $60 / $80 / 20% coinsurance
RX Benefit
Not Covered
Not Covered
Not Covered
PCP Office Visits
$30 Copayment
Not Covered
$20 Copayment
Not Covered
$20 Copayment
Not Covered
Specialty Office Visits
$50 Copayment
Not Covered
$40 Copayment
Not Covered
$40 Copayment
Not Covered
TeleHealth Visits
$30 Copayment
Not Covered
$20 Copayment
Not Covered
$20 Copayment
Not Covered
Preventive Exams
Select Services Covered In Full
Select Services Covered In Full
Select Services Covered In Full
Not Covered
Not Covered
Not Covered
Urgent Care
$60 Copayment
Not Covered
$50 Copayment
Not Covered
$50 Copayment
No Covered
Emergency Room
$250 copay after deductible
$250 copay after deductible
$250 copay after deductible
30% coinsurance after deductible
20% coinsurance after deductible
20% coinsurance after deductible
Hospital Services
Not Covered
Not Covered
Not Covered
Annual Coinsurance
$2,500 per member / $1,000 per family
$2,500 per member / $1,000 per family
N / A
N / A
N / A
N / A
Maximum (per calendar year)
Out-of-Pocket Maximum
$8,150 / $16,300
N / A
$8,150 / $16,300
N / A
$8,150 / $16,300
N / A
Employee Monthly Premiums
Employee Only $109.38 Employee+1 $351.30 Employee+2 or More $582.64
Employee Only $206.63 Employee+1 $550.66 Employee+2 or More $913.29
Employee Only $278.67 Employee+1 $698.34 Employee+2 or More $1,158.23
Out-of-Pocket Maximum includes Deductible, Rx, Office, Urgent Care & Emergency Room Copays For detailed and specific information as it relates to the HMO plans with Blue Care Network, please ask HR for a copy of the summary plan descriptions.
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