Medicare Plus Blue PPO Essential (PPO)

4.5 out of 5 stars* for plan year 2023
$0.00 Monthly Premium

Medicare Plus Blue PPO Essential (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Blue Cross Blue Shield of Michigan

Plan ID: H9572-004-002

$0.00 Monthly Premium

Michigan Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.

Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.

Learn more about Michigan Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.

Basic Costs and Coverage

Coverage Details
Monthly plan premium$0.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$0.00
Out-of-pocket maximum$5,200.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$7,400.00
Primary care doctor visit
Out-of-Network:

Doctor Office Visit:
Copayment for Medicare Covered Primary Care Office Visit $25.00
Specialty doctor visitIn-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $45.00
Inpatient hospital care
Out-of-Network:
Coinsurance for Acute Hospital Services per Stay 50%
Urgent care
Urgent Care:
Copayment for Urgent Care $0.00 to $50.00

Minimum copayment amount applies to services provided in PCP office. Maximum copayment amount applies to a services provided in an urgent care facility.
Copayment for Urgent Care OON: $0 to $50

Minimum copayment applies to services provided in PCP office. Maximum copayment amount applies to services provided in an urgent care facility.
Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $50.00
Maximum Plan Benefit of $50,000
Emergency room visit
Emergency Care:
Copayment for Emergency Care $90.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 3 days

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $90.00
Copayment for Worldwide Emergency Transportation $275.00
Maximum Plan Benefit of $50,000
Worldwide emergency, urgently needed services and emergency transportation are subject to combined $50,000 lifetime maximum benefit.
Ambulance transportation
Out-of-Network:

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $275.00
Coinsurance for Medicare Covered Ambulance Services - Ground 50%
Copayment for Medicare Covered Ambulance Services - Air $275.00
Coinsurance for Medicare Covered Ambulance Services - Air 50%

Health Care Services and Medical Supplies

Medicare Plus Blue PPO Essential (PPO) covers a range of additional benefits. Learn more about Medicare Plus Blue PPO Essential (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

Coverage Details
Chiropractic servicesIn-Network:

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $15.00
Copayment for Routine Care $45.00
  • Maximum 1 Routine Care every year
Copayment for Chiropractic X-rays $35.00
  • Maximum 1 Set every year
Diabetes supplies, training, nutrition therapy and monitoring
Out-of-Network:

Diabetic Supplies and Services:
Copayment for Medicare Covered Diabetic Supplies and Services $0.00
Durable medical equipment (DME)In-Network:

Durable Medical Equipment:
Coinsurance for Medicare-covered Durable Medical Equipment 0% to 20%
Prior Authorization Required for Durable Medical Equipment
Diagnostic tests, lab and radiology services, and X-raysIn-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00 to $150.00
Copayment for Medicare-covered Lab Services $0.00 to $40.00
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $100.00 to $150.00
Copayment for Medicare-covered Therapeutic Radiological Services $35.00
Copayment for Medicare-covered X-Ray Services $35.00 to $150.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services

Out-of-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare Covered Diagnostic Procedures/Tests
$0.00
Coinsurance for Medicare Covered Diagnostic Procedures/Tests
50%
Coinsurance for Medicare Covered Lab Services
50%
Coinsurance for Medicare Covered Diagnostic Radiological Services 50%
Coinsurance for Medicare Covered Therapeutic Radiological Services 50%
Coinsurance for Medicare Covered Outpatient X-Ray Services 50%
(Please see Evidence of Coverage for details)
Home health care
Out-of-Network:

Home Health Services:
Coinsurance for Medicare Covered Home Health 50%
Mental health inpatient care
Out-of-Network:
Coinsurance for Psychiatric Hospital Services per Stay 50%
Mental health outpatient careIn-Network:

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $20.00
Copayment for Medicare-covered Group Sessions $20.00
Outpatient services/surgery
Out-of-Network:

Outpatient Hospital and ASC Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 50%
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 50%
Outpatient substance abuse care
Out-of-Network:

Outpatient Substance Abuse Services:
Coinsurance for Medicare Covered Individual or Group Sessions 50%
Over-the-counter itemsIn-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $85.00 every three months
Nicotine Replacement Therapy (NRT) offered as a Part C OTC benefit
The unused amount is carried over but must be used within the same calendar year.
Out-of-Network:

Over-The-Counter (OTC) Items:
Copayment for Non-Medicare Covered Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $85.00 every three months
The unused amount is carried over but must be used within the same calendar year.
Podiatry servicesIn-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $45.00
Prior Authorization Required for Podiatry Services
Skilled Nursing Facility (SNF) careIn-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$188.00 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services

Dental Benefits

The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage Details
Dental care
Out-of-Network:

Medicare Covered Dental Services:
Coinsurance for Medicare Covered Comprehensive Dental 50%
Non-Medicare Covered Dental Services:
Coinsurance for Non-Medicare Covered Preventive Dental 50%
Coinsurance for Non-Medicare Covered Comprehensive Dental 50%

Vision Benefits

The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage Details
Vision benefits
Out-of-Network:

Medicare Covered Vision Services:
Coinsurance for Medicare Covered Eye Exams 50%
Coinsurance for Medicare Covered Eyewear 50%
Non-Medicare Covered Vision Services:
Coinsurance for Non-Medicare Covered Eye Exams 50%
Coinsurance for Non-Medicare Covered Eyewear 50%

Hearing Benefits

The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage Details
Hearing benefits
Out-of-Network:

Medicare Covered Hearing Services:
Coinsurance for Medicare Covered Hearing Exams 50%
Non-Medicare Covered Hearing Services:
Coinsurance for Non-Medicare Covered Hearing Exams 50%
Copayment for Non-Medicare Covered Hearing Aids $0.00

Preventive Services and Health/Wellness Education Programs

The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage Details
Preventive services and health/wellness education programsIn-Network:
$0.00 copay for Medicare Covered Preventive Services:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vaginal cancer screening
Colorectal cancer screenings
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:
  • COVID-19 shots
Flu shotsHepatitis B shotsPneumococcal shots
Tobacco use cessation
Yearly "Wellness" visit


Out-of-Network:

Medicare-covered Zero Dollar Preventive Services:
Copayment for Medicare Covered Medicare-covered Preventive Services $0.00

When reviewing Michigan Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.

You may be able to find plans in your part of Michigan that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.

Plan Documents

Links to plan documents

Michigan Counties Served

Berrien Branch Calhoun Eaton Gratiot Hillsdale Ingham Jackson Monroe Montcalm Saint Joseph Van Buren
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