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Medicare Plus Blue PPO Vitality (PPO)

H9572 - 002 - 4
4.5 out of 5 stars (4.5 / 5)

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

This page features plan details for 2025 Medicare Plus Blue PPO Vitality (PPO) H9572 – 002 – 4 available in State of Michigan.

Locations

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

Insurer:Blue Cross Blue Shield of Michigan
Health Plan Deductible:$0
MOOP:$6,700 In and Out-of-network
$5,000 In-network
Drugs Covered:Yes

Ready to sign up for Medicare Plus Blue PPO Vitality (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

Premium Breakdown

Medicare Plus Blue PPO Vitality (PPO) has a monthly premium of $67.00. 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 $59.10 $7.90 $ $
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 Vitality (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
$7.90$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 Vitality (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
    • In-Network: $0-150 copay (Authorization Required)
  • Lab services
    • In-Network: $0-40 copay (Authorization Required)
    • Out-of-Network: 40% coinsurance (Authorization Required)
  • Diagnostic radiology services (e.g., MRI)
    • In-Network: $100-150 copay (Authorization Required)
  • Diagnostic tests and procedures
    • Out-of-Network: $0 copay or 40% coinsurance (Authorization Required)
  • Diagnostic radiology services (e.g., MRI)
    • Out-of-Network: 40% coinsurance (Authorization Required)
  • Outpatient x-rays
    • In-Network: $35-150 copay (Authorization Required)
    • Out-of-Network: 40% coinsurance (Authorization Required)

Doctor visits

  • Primary
    • Out-of-Network: 40% coinsurance per visit
  • Specialist
    • Out-of-Network: 40% coinsurance per visit
  • Primary
    • In-Network: $0 copay
  • Specialist
    • In-Network: $30 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: $30 copay (Authorization Required)
    • Out-of-Network: 40% coinsurance (Authorization Required)
  • Routine foot care
    • Not covered

Ground ambulance

    • In-Network: $325 copay
    • Out-of-Network: $90-325 copay or 40% coinsurance

Health plan deductible

    • $0

Hearing

  • Hearing aids OTC
    • Not covered
  • Medicare-Covered Hearing Exam
    • In-Network: $0-30 copay
  • Fitting/evaluation
    • In-Network: $0 copay (Limits Apply)
  • Hearing aids
    • In-Network: $0 copay (Limits Apply)
  • Fitting/evaluation
    • Out-of-Network: 50% coinsurance (Limits Apply)
  • Hearing aids
    • Out-of-Network: $0 copay (Limits Apply)
  • Medicare-Covered Hearing Exam
    • Out-of-Network: 50% coinsurance

Inpatient hospital coverage

    • In-Network: $250 per day for days 1 through 7
      $0 per day for days 8 through 90 (Authorization Required)
    • Out-of-Network: 40% per stay (Authorization Required)

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

    • $6,700 In and Out-of-network
      $5,000 In-network

Medical equipment/supplies

  • Diabetes supplies
    • In-Network: $0 copay (Authorization Required)
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • Out-of-Network: 0-40% coinsurance per item (Authorization Required)
  • Diabetes supplies
    • Out-of-Network: $0 copay (Authorization Required)
  • 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)
    • Out-of-Network: 40% coinsurance per item (Authorization Required)

Medicare Part B drugs

  • Other Part B drugs
    • Out-of-Network: $0-35 copay or 0-40% coinsurance (Authorization Required)
  • Chemotherapy
    • In-Network: 0-20% coinsurance (Authorization Required)
  • Other Part B drugs
    • In-Network: 0-20% coinsurance (Authorization Required)
  • Chemotherapy
    • Out-of-Network: $0-35 copay or 0-40% coinsurance (Authorization Required)

Mental health services

  • Inpatient hospital – psychiatric
    • Out-of-Network: 40% per stay (Authorization Required)
  • Outpatient individual therapy visit with a psychiatrist
    • In-Network: $20 copay
    • Out-of-Network: 40% coinsurance
  • Outpatient group therapy visit
    • In-Network: $20 copay
  • Outpatient individual therapy visit
    • In-Network: $20 copay
  • Outpatient group therapy visit
    • Out-of-Network: 40% coinsurance
  • Outpatient group therapy visit with a psychiatrist
    • In-Network: $20 copay
  • Outpatient individual therapy visit
    • Out-of-Network: 40% coinsurance
  • Inpatient hospital – psychiatric
    • In-Network: $250 per day for days 1 through 7
      $0 per day for days 8 through 90 (Authorization Required)
  • Outpatient group therapy visit with a psychiatrist
    • Out-of-Network: 40% coinsurance

Optional supplemental benefits

    • Yes

Other health plan deductibles?

    • In-Network: No

Outpatient hospital coverage

    • Out-of-Network: 40% coinsurance per visit (Authorization Required)
    • In-Network: $150-220 copay per visit (Authorization Required)

Preventive care

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

Rehabilitation services

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

Skilled Nursing Facility

    • In-Network: $0 per day for days 1 through 20
      $214 per day for days 21 through 100 (Authorization Required)
    • Out-of-Network: 40% per stay (Authorization Required)

Transportation

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

Vision

  • Eyeglass frames
    • Out-of-Network: 50% coinsurance (Limits Apply)
  • Eyeglasses (frames and lenses)
    • Not covered
  • Other
    • Out-of-Network: 40-50% coinsurance
  • Upgrades
    • Not covered
  • Contact lenses
    • Out-of-Network: 50% coinsurance (Limits Apply)
  • Other
    • In-Network: $30 copay
  • Contact lenses
    • In-Network: $0 copay (Limits Apply)
  • Eyeglass frames
    • In-Network: $0 copay (Limits Apply)
  • Routine eye exam
    • In-Network: $0 copay (Limits Apply)
    • Out-of-Network: 40-50% coinsurance (Limits Apply)
  • Eyeglass lenses
    • In-Network: $0 copay (Limits Apply)
    • Out-of-Network: 50% coinsurance (Limits Apply)

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 Vitality (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

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