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


Annual Pap Smear Screening


Annual Mammography Screening


Well Baby and Child Care


ACIP Required/Recommended Immunizations – pediatric and adult


Prostate Specific Antigen (PSA) screening


Hearing Screening



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


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


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.


Covered subject to co-payments set forth on Appendix D and exclusions set forth on Appendix E.