Go Back

Medicare Plus Blue PPO Essential (PPO)

H9572 - 004 - 4
4.5 out of 5 stars (4.5 / 5)

Medicare Plus Blue PPO Essential (PPO) is a Medicare Advantage Plan by Blue Cross Blue Shield of Michigan.

This page features plan details for 2025 Medicare Plus Blue PPO Essential (PPO) H9572 – 004 – 4 available in State of Michigan.

Locations

Medicare Plus Blue PPO Essential (PPO) is offered in the following locations.

Antrim County, Michigan
Benzie County, Michigan
Cass County, Michigan

Click to see more locations

Plan Overview

Medicare Plus Blue PPO Essential (PPO) offers the following coverage and cost-sharing.

Insurer:Blue Cross Blue Shield of Michigan
Health Plan Deductible:$0
MOOP:$6,250 In and Out-of-network
$6,250 In-network
Drugs Covered:Yes

Ready to sign up for Medicare Plus Blue PPO Essential (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Medicare Part B Give Back Benefit

The Part B Premium Reduction (Medicare Part B Give Back Benefit) lowers the cost of some Medicare Advantage plans. 

Medicare Plus Blue PPO Essential (PPO) qualifies for a monthly Medicare Give Back Benefit of $3.00.

Premium Reduction:$3.00

Premium Breakdown

Medicare Plus Blue PPO Essential (PPO) has a monthly premium of $0.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.
Part B Part C Part D Part B Give Back Total
$185.00 $0.00 $0.00 $3.00 $
Please Note:
  • Your Part B premium may differ based on factors including late enrollment, income, and disability status.
  • You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.

Drug Info

Medicare Plus Blue PPO Essential (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible: $0.00
Drug Out-Of-Pocket maximum: $2,000.00
Drug Benefit Type: Enhanced Alternative

Part D Premium Reduction

The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.

The table below shows how the LIS impacts the Part D premium of this plan.

Part DLIS Full
$0.00$0.00

Initial Coverage Phase

After you pay your $0.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $2,000.00. Once you reach that amount, you will enter the next coverage phase.

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.

Additional Benefits

Medicare Plus Blue PPO Essential (PPO) also provides the following benefits.

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

    • In-Network: No

Comprehensive Dental

  • Endodontics
    • In-Network: No Coins – No Co pay
    • Out-of-Network: 50% Coins – No Copay
  • Oral and Maxillofacial Surgery
    • In-Network: No Coins – No Co pay
    • Out-of-Network: 50% Coins – No Copay
  • Periodontics
    • In-Network: No Coins – No Co pay
    • Out-of-Network: 50% Coins – No Copay
  • Restorative Services
    • In-Network: No Coins – No Co pay
    • Out-of-Network: 50% Coins – No Copay

Diagnostic and Preventive Dental

  • Dental X-Rays
    • In-Network: No Coins – No Copay
    • Out-of-Network: 50% Coins – No Copay
  • Fluoride Treatment
    • In-Network: No Coins – No Copay
    • Out-of-Network: 50% Coins – No Copay
  • Oral Exams
    • In-Network: No Coins – No Copay
    • Out-of-Network: 50% Coins – No Copay
  • Prophylaxis (cleaning)
    • In-Network: No Coins – No Copay
    • Out-of-Network: 50% Coins – No Copay

Diagnostic procedures/lab services/imaging

  • Diagnostic tests and procedures
    • Out-of-Network: $0-50 copay or 50% coinsurance (Authorization Required)
  • Lab services
    • Out-of-Network: 50% coinsurance (Authorization Required)
  • Diagnostic radiology services (e.g., MRI)
    • In-Network: $100-150 copay (Authorization Required)
    • Out-of-Network: 50% coinsurance (Authorization Required)
  • Outpatient x-rays
    • Out-of-Network: 50% coinsurance (Authorization Required)
    • In-Network: $35-150 copay (Authorization Required)
  • Diagnostic tests and procedures
    • In-Network: $0-150 copay (Authorization Required)
  • Lab services
    • In-Network: $0-40 copay (Authorization Required)

Doctor visits

  • Primary
    • In-Network: $0 copay
    • Out-of-Network: $25 copay per visit
  • Specialist
    • In-Network: $45 copay per visit
    • Out-of-Network: $50 copay per visit

Emergency care/Urgent care

  • Emergency
    • $125 copay per visit (always covered)
  • Urgent care
    • $0-50 copay per visit (always covered)

Foot care (podiatry services)

  • Foot exams and treatment
    • In-Network: $45 copay (Authorization Required)
    • Out-of-Network: $50 copay (Authorization Required)
  • Routine foot care
    • Not covered

Ground ambulance

    • Out-of-Network: $90-350 copay or 50% coinsurance
    • In-Network: $350 copay

Health plan deductible

    • $0

Hearing

  • Fitting/evaluation
    • Out-of-Network: 50% coinsurance (Limits Apply)
  • Hearing aids
    • Out-of-Network: $0 copay (Limits Apply)
  • Hearing aids OTC
    • Not covered
  • Fitting/evaluation
    • In-Network: $0 copay (Limits Apply)
  • Medicare-Covered Hearing Exam
    • In-Network: $0-45 copay
    • Out-of-Network: $50 copay
  • Hearing aids
    • In-Network: $0 copay (Limits Apply)

Inpatient hospital coverage

    • Out-of-Network: 50% per stay (Authorization Required)
    • In-Network: $420 per day for days 1 through 7
      $0 per day for days 8 through 90 (Authorization Required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

    • $6,250 In and Out-of-network
      $6,250 In-network

Medical equipment/supplies

  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • In-Network: 0-20% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • In-Network: 20% coinsurance per item (Authorization Required)
  • Diabetes supplies
    • Out-of-Network: $0 copay (Authorization Required)
    • In-Network: $0 copay (Authorization Required)
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • Out-of-Network: 0-50% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • Out-of-Network: 50% coinsurance per item (Authorization Required)

Medicare Part B drugs

  • Other Part B drugs
    • In-Network: 0-20% coinsurance (Authorization Required)
  • Chemotherapy
    • In-Network: 0-20% coinsurance (Authorization Required)
    • Out-of-Network: $0-35 copay or 0-50% coinsurance (Authorization Required)
  • Other Part B drugs
    • Out-of-Network: $0-35 copay or 0-50% coinsurance (Authorization Required)

Mental health services

  • Outpatient group therapy visit with a psychiatrist
    • In-Network: $20 copay
  • Outpatient individual therapy visit
    • Out-of-Network: 50% coinsurance
  • Outpatient individual therapy visit with a psychiatrist
    • In-Network: $20 copay
    • Out-of-Network: 50% coinsurance
  • Inpatient hospital – psychiatric
    • Out-of-Network: 50% per stay (Authorization Required)
  • Outpatient group therapy visit
    • In-Network: $20 copay
  • Inpatient hospital – psychiatric
    • In-Network: $300 per day for days 1 through 7
      $0 per day for days 8 through 90 (Authorization Required)
  • Outpatient group therapy visit
    • Out-of-Network: 50% coinsurance
  • Outpatient group therapy visit with a psychiatrist
    • Out-of-Network: 50% coinsurance
  • Outpatient individual therapy visit
    • In-Network: $20 copay

Optional supplemental benefits

    • Yes

Other health plan deductibles?

    • In-Network: No

Outpatient hospital coverage

    • In-Network: $150-350 copay per visit (Authorization Required)
    • Out-of-Network: 50% coinsurance per visit (Authorization Required)

Preventive care

    • Out-of-Network: $0 copay
    • In-Network: $0 copay

Rehabilitation services

  • Occupational therapy visit
    • Out-of-Network: 50% coinsurance
  • Physical therapy and speech and language therapy visit
    • In-Network: $40 copay
  • Occupational therapy visit
    • In-Network: $40 copay
  • Physical therapy and speech and language therapy visit
    • Out-of-Network: 50% coinsurance

Skilled Nursing Facility

    • Out-of-Network: 50% per stay (Authorization Required)
    • In-Network: $0 per day for days 1 through 20
      $214 per day for days 21 through 100 (Authorization Required)

Transportation

    • In-Network: $0 copay
    • Out-of-Network: $0 copay
    • In-Network: $0 copay (Limits Apply)
    • Out-of-Network: $0 copay (Limits Apply)

Vision

  • Eyeglass frames
    • In-Network: $0 copay (Limits Apply)
  • Routine eye exam
    • In-Network: $0 copay (Limits Apply)
  • Contact lenses
    • In-Network: $0 copay (Limits Apply)
  • Eyeglass lenses
    • In-Network: $0 copay (Limits Apply)
  • Eyeglasses (frames and lenses)
    • Not covered
  • Other
    • In-Network: $45 copay
  • Contact lenses
    • Out-of-Network: 50% coinsurance (Limits Apply)
  • Eyeglass frames
    • Out-of-Network: 50% coinsurance (Limits Apply)
  • Eyeglass lenses
    • Out-of-Network: 50% coinsurance (Limits Apply)
  • Routine eye exam
    • Out-of-Network: $50 copay (Limits Apply)
  • Other
    • Out-of-Network: $50 copay
  • Upgrades
    • Not covered

Wellness programs (e.g., fitness, nursing hotline)

    • Covered

Optional Dental and Vision

Comprehensive Dental

  • Restorative Services, Periodontics, Prosthodontics, removable, Implant Services, Prosthodontics, fixed, Adjunctive General Services
    • Monthly Premium: $21.80
    • Max Coverage: $1750.00
    • Coverage Periodicity: Other, Describe

Eyewear

  • Contact Lenses, Eyeglass frames
    • Monthly Premium: $21.80
    • Max Coverage: $1750.00
    • Coverage Periodicity: Other, Describe

Ready to sign up for Medicare Plus Blue PPO Essential (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Need more information on Medicare Plus Blue PPO Essential (PPO)? See 2025 Medicare Plus Blue PPO Essential (PPO) at MedicareAdvantageRX.com.

Table of Contents

Get Help Enrolling

Get help enrolling in a Medicare Advantage or Medicare Prescription Drug Plan by calling a licensed insurance agent today.

Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Anthem Blue Cross, Aspire Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, GlobalHealth, Health Care Service Corporation, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Baylor Scott & White Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint

SMID: MULTIPLAN_HCIHNDOGMED01PY25_M

Factsonmedicare.com is a free-to-use informational website by Dog Media Solutions LLC. All insurance agents and enrollment platforms linked to this site have their own terms and conditions.

Medicare has neither approved nor endorsed any information on this site.

This is a promotional communication.

Every year, Medicare evaluates plans based on a 5-star rating system.

Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.

All plan-related information on this site is from CMS.gov and Medicare.gov. We only use data released publicly each year. While our goal is always to provide fact-based, accurate information, information is subject to change, and some data may be inaccurate. Contact a plan for a Summary of Benefits.

Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period.

We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.

We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan’s contract renewal.

Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.

© All rights reserved | About | Contact | Legal and Privacy