Medicare Plus Blue PPO Signature (PPO)

4.5 out of 5 stars* for plan year 2023
$133.00 Monthly Premium

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

Plan ID: H9572-001-006

$133.00 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$133.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$0.00
Out-of-pocket maximum$4,700.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$7,400.00
Primary care doctor visitIn-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0.00
Specialty doctor visit
Out-of-Network:

Doctor Specialty Visit:
Coinsurance for Medicare Covered Physician Specialist Office Visit 40%
Inpatient hospital care
Out-of-Network:
Coinsurance for Acute Hospital Services per Stay 40%
Urgent care
Urgent Care:
Copayment for Urgent Care $0.00 to $50.00
Copayment for Urgent Care OON: $0 to $50
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
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 $250.00
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 $250.00
Coinsurance for Medicare Covered Ambulance Services - Ground 40%
Copayment for Medicare Covered Ambulance Services - Air $250.00
Coinsurance for Medicare Covered Ambulance Services - Air 40%

Health Care Services and Medical Supplies

Medicare Plus Blue PPO Signature (PPO) covers a range of additional benefits. Learn more about Medicare Plus Blue PPO Signature (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 $35.00
  • 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)
Out-of-Network:

Durable Medical Equipment:
Coinsurance for Medicare Covered Durable Medical Equipment 0% to 40%
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 $125.00
Copayment for Medicare-covered Lab Services $0.00 to $30.00
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 $125.00
Copayment for Medicare-covered Therapeutic Radiological Services $35.00
Copayment for Medicare-covered X-Ray Services $35.00 to $125.00
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
40%
Coinsurance for Medicare Covered Lab Services
40%
Coinsurance for Medicare Covered Diagnostic Radiological Services 40%
Coinsurance for Medicare Covered Therapeutic Radiological Services 40%
Coinsurance for Medicare Covered Outpatient X-Ray Services 40%
(Please see Evidence of Coverage for details)
Home health care
Out-of-Network:

Home Health Services:
Coinsurance for Medicare Covered Home Health 40%
Mental health inpatient care
Out-of-Network:
Coinsurance for Psychiatric Hospital Services per Stay 40%
Mental health outpatient care
Out-of-Network:

Outpatient Mental Health Services:
Coinsurance for Medicare Covered Individual Sessions 40%
Coinsurance for Medicare Covered Group Sessions 40%
Outpatient services/surgeryIn-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $125.00 to $205.00
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 $100.00
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 40%
Over-the-counter itemsIn-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $25.00 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 $25.00 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 $35.00
Prior Authorization Required for Podiatry Services
Skilled Nursing Facility (SNF) care
Out-of-Network:
Coinsurance for Skilled Nursing Facility Services per Stay 40%

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 40%
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 benefitsIn-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0.00 to $35.00
Copayment for Routine Eye Exams $0.00
  • Maximum 1 Routine Eye Exam every year
Copayment for Lasik & RK $35.00

Eyewear:
Copayment for Medicare-Covered Benefits $0.00
Copayment for Contact Lenses $0.00
  • Maximum 1 Pair
Copayment for Eyeglass Lenses $0.00
  • Maximum 1 Pair
Copayment for Eyeglass Frames $0.00
  • Maximum 1 Pair
Maximum Plan Benefit of $150.00 every year for all Non-Medicare covered eyewear for in and out of network services combined

Hearing Benefits

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

Coverage Details
Hearing benefitsIn-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $0.00 to $35.00
Copayment for Routine Hearing Exams $0.00 to $35.00
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0.00
  • Maximum 1 visit every three years

Hearing Aids:
Copayment for Hearing Aids $0.00
  • Maximum 2 Hearing Aids every three years
Maximum Plan Benefit of $750.00 every three years per ear for in and out of network services combined

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 shots
  • Hepatitis B shots
  • Pneumococcal shots
  • Tobacco use cessation
    Yearly "Wellness" visit

    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

    Macomb Oakland Washtenaw Wayne
    Back to plans in Michigan

    Every 60 seconds, we help someone enroll in a Medicare Advantage plan.1

    Ready to find your plan?

    Or call a licensed insurance agent

    1-800-557-6059

    TTY 711, 24/7

    Or call a licensed insurance agent

    • secure website