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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: H9572-004-003
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
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.
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 | $8,000.00 |
Primary care doctor visit | Out-of-Network: Doctor Office Visit: Copayment for Medicare Covered Primary Care Office Visit $25.00 |
Specialty doctor visit | Out-of-Network: Doctor Specialty Visit: Copayment for Medicare Covered Physician Specialist Office Visit $50.00 |
Inpatient hospital care | In-Network: Acute Hospital Services: $325.00 per day for days 1 to 6 $0.00 per day for days 7 to 90 Prior Authorization Required for Acute Hospital Services |
Urgent care | Urgent Care: In Network: 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. Worldwide Coverage: Copayment for Worldwide Urgent Coverage $50.00 Maximum Plan Benefit of $50,000 Out-of-Network: Copayment for Urgent Care $0.00 to $50.00 (Please see Evidence of Coverage for details) |
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 | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $275.00 Air Ambulance: Copayment for Air Ambulance Services $275.00 Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $275.00 Coinsurance for non-emergency- Ground 50% Copayment for Medicare Covered Ambulance Services - Air $275.00 Coinsurance for non-emergency - Air 50% |
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 services | In-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $15.00 Copayment for Routine Care $45.00
Out-of-Network: Chiropractic Services: Coinsurance for Medicare Covered Chiropractic Services 50% Chiropractic Services: Coinsurance for Non-Medicare Covered Chiropractic Services 50% |
Diabetes supplies, training, nutrition therapy and monitoring | In-Network: Diabetic Supplies and Services: Copayment for Medicare-covered Diabetic Supplies $0.00 Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0.00 Prior Authorization Required for Diabetic Supplies and Services |
Durable medical equipment (DME) | Out-of-Network: Durable Medical Equipment: Coinsurance for Medicare Covered Durable Medical Equipment 0% to 50% |
Diagnostic tests, lab and radiology services, and X-rays | 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% |
Home health care | Out-of-Network: Home Health Services: Coinsurance for Medicare Covered Home Health 50% |
Mental health inpatient care | In-Network: Psychiatric Hospital Services: $300.00 per day for days 1 to 6 $0.00 per day for days 7 to 90 Prior Authorization Required for Psychiatric Hospital Services |
Mental health outpatient care | In-Network: Outpatient Mental Health Services: Copayment for Medicare-covered Individual Sessions $20.00 Copayment for Medicare-covered Group Sessions $20.00 |
Outpatient services/surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $150.00 to $275.00 Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services $0.00 Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0.00 to $125.00 Prior Authorization Required for Ambulatory Surgical Center Services |
Outpatient substance abuse care | Out-of-Network: Outpatient Substance Abuse Services: Coinsurance for Medicare Covered Individual or Group Sessions 50% |
Over-the-counter items | In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0.00 Maximum Plan Benefit of $125.00 every three months Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit Out-of-Network: Over-The-Counter (OTC) Items: Copayment for Non-Medicare Covered Over-The-Counter (OTC) Items $0.00 Maximum Plan Benefit of $125.00 The unused amount is carried over but must be used within the same calendar year. |
Podiatry services | Out-of-Network: Podiatry Services: Coinsurance for Medicare Covered Podiatry Services 50% |
Skilled Nursing Facility (SNF) care | In-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 |
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% |
The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage
Coverage | Details |
---|---|
Vision care | In-Network: Eye Exams: Copayment for Medicare Covered Benefits $0.00 to $45.00 Copayment for Routine Eye Exams $0.00
Eyewear: Copayment for Medicare-Covered Benefits $0.00 Copayment for Eyeglass Lenses $0.00
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% |
The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
Coverage | Details |
---|---|
Hearing care | 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 |
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 programs | In-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 Immunization Shots:
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.
Links to plan documents |
We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.
Every 60 seconds, we help someone enroll in a Medicare Advantage plan.1