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The State Health Plan PPO provides reimbursement for medical care and prescribed medication expenses when you need treatment for an illness, injury, or disease. The plan covers inpatient hospital care, as well as other outpatient services received at a hospital (including emergency room care). The Plan also covers most of your community-based care (office visits), as well as necessary medical equipment and supplies (crutches, hearing aids, etc.).

The State Health Plan PPO provides health benefits using providers and facilities that are in-network, meaning the providers and facilities have agreed to accept a discounted fee from BCBSM in order to be in-network. They won't charge you the difference between their normal charge and the amount paid by the State Health Plan PPO. When you see a PPO network provider for covered services, your out-of-pocket costs are limited to deductibles and co-payments.

Under the State Health Plan PPO, members choose their in-network providers from the BCBSM Community Blue/Blue Preferred PPO Network.  The network covers all 83 Michigan counties and is the largest PPO network in Michigan. It has more than 20,000 physicians, including specialists, and more than 140 all acute care hospitals in Michigan. Please refer to www.bcbsm.com for the list of providers.

You still have the freedom to go out-of-network to any physician, hospital or other provider of your choice. But if you receive services from a provider not in the PPO network, you may be responsible for paying additional out-of-pocket costs. Those costs include increased co-payment and deductible amounts. If the provider you select doesn't participate at all with BCBSM (BCBSM has several different provider arrangements), you may also be required to pay additional charges.

The deductibles for in-network services are $300 per member and $600 per family.  The deductibles for out-of-network services are $600 per member and $1,200 per family.

An important note regarding the State Health Plan PPO deductibles:

You have the freedom to go to both an in-network and out-of-network provider.  If you choose to do so, you will be responsible for both deductibles.  An example: a single person chooses an in-network hospital for surgery.  (S)he is responsible for the $300 deductible, then the hospital is reimbursed 100%.  Later in the year, that same person needs lab tests performed and chooses to use an out-of-network provider. (S)he is responsible for the out-of-network deductible of $600. After that deductible is met, out-of-network charges are paid accordingly (90% for lab tests, 100% for hospice care, etc.).

Express Scripts - Prescription medications are covered under the Participating Pharmacy ID Card Plan administered by Express Scripts. The co-pays for prescription drugs (both retail and mail order) are based on the employee's bargaining unit. To check the co-pay for drugs you may be taking, visit the Express Scripts website at http://www.express-scripts.com or contact Express Scripts at (800) 505-2324. The Preferred/Non-preferred list of drugs is updated periodically as new drugs are added.

Mental health/substance abuse treatment services under the State Health Plan PPO are managed and all claims handled by Magellan Behavioral of Michigan for all bargaining units except MSPTA. Services and claims for MSPTA members are handled through BCBSM.

Magellan has developed an Internet Website for use by the State of Michigan employees and retirees covered under the State Health Plan PPO.  Please visit this site at the following address: www.magellanassist.com. When you access this site, click on the Member button and select New or Unregistered User. Enter the Magellan toll free number (866-503-3158) and select Continue.  You then have the option to register by completing the necessary fields or you can scroll down and select Continue Unregistered to access information, tools and other resources to support you with work, home, and daily life needs.

An HMO is a managed care plan that provides medical care through its network of physicians, pharmacies, contracted hospitals, and medical care suppliers.  You can choose your own "primary care physician" who will provide direct care or make referrals from within the network.  An HMO provides necessary hospital and medical treatment when you are sick or injured, prescription medicine services, substance abuse treatment, short-term mental health care, and routine "preventive health maintenance" services such as immunizations.

There are no deductible requirements. There is a $10 co-payment for each office visit and a $50 co-payment for an emergency room visit, if the visit does not result in a hospital admission. The drug co-payments will be $5 for generic drugs and $10 for brand name drugs.

You may enroll in an authorized HMO plan serving your residential area . Refer to Section 5 for a listing of HMOs by zip code. Contact the HMO that interests you to request their benefit booklet. If you select a new HMO, that HMO may ask you to select your primary care physician.  Respond promptly to the carrier to complete the final phase of the enrollment process.

This is a hospitalization-only plan intended as an option if you are over-insured because you have coverage elsewhere (for example, through a spouse who works for another employer). This plan covers inpatient hospital expenses, as well as certain other services received at the hospital on an outpatient basis (including emergency room care). This plan does not cover prescription charges, office visit charges, medical equipment, psychiatric services, or other Major Medical services.

Benefits under this plan are payable only after you have covered those expenses equal to one month's basic salary (your deductible requirement). The maximum deductible for two or more covered persons in your family is limited to 1½ months of your basic salary. If you are covered by a spouse who works for a non-State employer, that plan will generally cover those expenses not covered by this plan (for example, the expenses you incur in meeting this plan's deductible requirement, community-based services, prescriptions, etc.)

If your spouse's (non-State) employer will not cover you under their group plan because you are enrolled in any of the State-sponsored health care options, including the Catastrophic Plan, you can "opt out" completely and still receive the $50 biweekly cash payment . (Select H4ZN, Health Waiver.) You must be in pay status to receive this payment.

*Except for bargaining unit T-01 (MSPTA) and those employees in certain bargaining units who are hired on or after 1/1/00 who have a regular work schedule of 40 hours or less per bi-weekly pay period (not permanent-intermittent positions).
**Except for bargaining unit T-01 (MSPTA).
***Except for those employees in certain bargaining units who are hired on or after 1/1/00 who have a regular work schedule of 40 hours or less per bi-weekly pay period (not permanent-intermittent positions).

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