Wayne County/Oakland County

Benefits at a Glance for HealthChoice Small Business Program

Co-pay Package

This is intended as an easy-to-read summary. It is not a contract.  An official description of benefits is contained in applicable HealthChoice Subscriber certificates and riders.  Payment amounts are based on the HealthChoice approved amount, less any applicable co-pay amounts required by the program.  This coverage is provided pursuant to a current, signed group-operating agreement between the group and the HealthChoice Executive Director.  Services must be provided by member’s primary care physician (PCP) or receive prior approval from health plan.


Preventive Services

Preventive Physical Exam Covered – No co-pay for Preventive Health Exam (1 preventive health exam is provided per calendar year for adults, as required by federal preventive care guidelines for children), Non-preventive office visits are subject to $20.00 co-pay
Annual Gynecological Exam Covered
Annual Pap Smear Screening Covered
Annual Mammography Screening Covered
Well Baby and Child Care Covered
ACIP Required/Recommended Immunizations – pediatric and adult Covered
Prostate Specific Antigen (PSA) screening Covered
Hearing Screening Covered


Physician Office Visits

Office Visits Covered – $20.00 co-pay
Specialist Visits Covered – $30.00 co-pay


Prescription Drugs

Generic Drugs Covered – $10.00 co-pay per prescription
Brand Name Drugs Covered – $20.00co-pay per prescription
Psychotherapeutics Covered – 50% of each prescription drug


Emergency Care

Hospital Emergency Visit Covered –$100.00 co-pay if not admitted; No co-pay if admitted. Provider is only responsible for 110% of Michigan Medicaid DRG rate for Emergency Services. Members are liable for any and all charges that exceed 110% of Michigan Medicaid rates.
Urgent Care Center (24 hour access) Covered – $25.00 co-pay per visit
Ambulance Services – medically necessary Covered if admitted – $50.00 co-pay if not admitted


Mental Health and Substance Abuse Services

Inpatient Mental Health and/or Substance Abuse Services* Covered – $200.00 co-pay per admission. Subject to limitations indicated in the Subscriber’s Certificate


Outpatient Mental Health and Substance Abuse /Professional Services Covered – $20.00 co-pay

*- Requires Prior Authorization

Diagnostic and Therapeutic Services

Radiology Covered – No co-pay
Diagnostic Laboratory Covered – No co-pay
Physical Therapy Covered – $20.00 co-pay (30 visits/year limit)
Durable Medical Equipment Covered – 50% per prescribed equipment


Maternity Services Provided by a Physician

Pre-Natal and Post-Natal Care Covered – $20.00 co-pay
Delivery and Nursery Care Covered –$200.00 co-pay per admission


Hospital Care

Inpatient physician care, general nursing care,

Hospital Services and Supplies

Covered – $200.00 co-pay per admission.

Subject to limitations indicated in the Subscriber’s Certificate


Outpatient Hospital Services Covered – $50.00 co-pay

Alternatives to Hospital Care

Home Health Care Covered – $20.00 per visit

Surgical Services

Surgery – includes all related services and anesthesia. See member certificate for specifics Covered – (see hospital care co-pay above)


Other Rider Services

Vision Exam & Glasses Covered subject to Co-payments set forth on Appendix I and exclusions set forth on Appendix J.
Dental Covered subject to co-payments set forth on Appendix D and exclusions set forth on Appendix E.