Schedule of Benefits - BCBSM

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Find your plan's Schedule of Benefits here.

 

 

 

 

 

 

 

 

 

 

Find your plan document(s) below.

 

ENHANCED PPO Plans

ENHANCED HSA Plans

VALUE PPO Plans

VALUE HSA Plans

ENHANCED 0 009
ENHANCED 0 010
ENHANCED 0 011
ENHANCED 0 012
ENHANCED 0 013
ENHANCED 0 097
ENHANCED 0 113
ENHANCED 0 124
ENHANCED 1000 029
ENHANCED 1000 049
ENHANCED 1000 089
ENHANCED 1000 100
ENHANCED 1000 112
ENHANCED 1000 117
ENHANCED 1000 143
ENHANCED 1000 171
ENHANCED 1000 173
ENHANCED 1000 179
ENHANCED 250 001
ENHANCED 250 002
ENHANCED 250 003
ENHANCED 250 005
ENHANCED 250 006
ENHANCED 250 007
ENHANCED 250 014
ENHANCED 250 015
ENHANCED 250 018
ENHANCED 250 019
ENHANCED 250 024
ENHANCED 250 025
ENHANCED 250 027
ENHANCED 250 028
ENHANCED 250 051
ENHANCED 250 052
ENHANCED 250 053
ENHANCED 250 055
ENHANCED 250 061
ENHANCED 250 063
ENHANCED 250 105
ENHANCED 250 123
ENHANCED 250 125
ENHANCED 250 144
ENHANCED 250 148
ENHANCED 250 177
ENHANCED 3000 186/187
ENHANCED 500 004
ENHANCED 500 008
ENHANCED 500 016
ENHANCED 500 017
ENHANCED 500 020
ENHANCED 500 021
ENHANCED 500 030
ENHANCED 500 054
ENHANCED 500 056
ENHANCED 500 062
ENHANCED 500 065
ENHANCED 500 068
ENHANCED 500 101
ENHANCED 500 111
ENHANCED 500 118
ENHANCED 500 147
ENHANCED 500 151
ENHANCED 500 159
ENHANCED 500 160
ENHANCED 500 174
ENHANCED 500 178

ENHANCED HSA 2000 040/041
ENHANCED HSA 2000 042/043
ENHANCED HSA 2000 044/045
ENHANCED HSA 2000 121/122
ENHANCED HSA 2000 175/176
ENHANCED HSA LEVEL 034/035
ENHANCED HSA LEVEL 036/037
ENHANCED HSA LEVEL 038/039
ENHANCED HSA LEVEL 057/058
ENHANCED HSA LEVEL 119/120
ENHANCED HSA LEVEL 126/127
ENHANCED HSA LEVEL 131/132
ENHANCED HSA LEVEL 137/138
ENHANCED HSA LEVEL 141/142
ENHANCED HSA LEVEL 149/150
ENHANCED LEVEL 163/164

VALUE 0 090
VALUE 1000 096
VALUE 1000 104
VALUE 1000 165
VALUE 2000 182
VALUE 250 091
VALUE 250 092
VALUE 250 093
VALUE 250 094
VALUE 250 110
VALUE 250 145
VALUE 250 152
VALUE 500 095
VALUE 500 114
VALUE 500 128
VALUE 500 146
VALUE 500 172
VALUE 3000 186/187

 

VALUE HSA 2000 102/103
VALUE HSA 2000 115/116
VALUE HSA 2000 153/154
VALUE HSA 2000 161/162
VALUE HSA 3000 046/047
VALUE HSA 3000 059/060
VALUE HSA 3000 066/067
VALUE HSA 3000 106/107
VALUE HSA 3000 183/184
VALUE HSA 3500 155
VALUE HSA 3500 170
VALUE HSA 6350 157
VALUE HSA LEVEL 098/099
VALUE HSA LEVEL 108/109
VALUE HSA LEVEL 129/130
VALUE HSA LEVEL 133/134
VALUE HSA LEVEL 135/136
VALUE HSA LEVEL 139/140
VALUE HSA LEVEL 166/167
VALUE HSA LEVEL 168/169
VALUE HSA LEVEL 180/181