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Medicare Plus Blue PPO Vitality (PPO) - H9572-002-004
$67.00
Monthly Premium
Medicare Plus Blue PPO Vitality (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Blue Cross Blue Shield of Michigan
Plan ID: H9572-002-004
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$67.00
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 | $67.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $0.00 |
| Out-of-pocket maximum | $5,000.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,000.00 |
| Primary care doctor visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0 |
| Specialty doctor visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $30 A member will be allowed one dermatological screening examination per lifetime if it is performed by a dermatologist. Out-of-Network: Doctor Specialty Visit Services: Coinsurance for Medicare Covered Physician Specialist Office Visit 40% A member will be allowed one dermatological screening examination per lifetime if it is performed by a dermatologist. |
| Inpatient hospital care | In-Network: Acute Hospital Services: $250 per day for days 1 to 7 $0 per day for days 8 to 90 Prior Authorization Required for Acute Hospital Services Out-of-network: 40% of the cost per stay |
| Urgent care | Urgent Care: Copayment for Urgent Care $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 Maximum Plan Benefit of $50,000 |
| Emergency room visit | Emergency Care: Copayment for Emergency Care $125 Worldwide Coverage: Copayment for Worldwide Emergency Coverage $125 Copayment for Worldwide Emergency Transportation $325 Maximum Plan Benefit of $50,000 |
| Ambulance transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $325 Air Ambulance: Copayment for Air Ambulance Services $325 Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $325 Coinsurance for Medicare Covered Ambulance Services - Ground 40% Copayment for Medicare Covered Ambulance Services - Air $325 Coinsurance for Medicare Covered Ambulance Services - Air 40% (Please see Evidence of Coverage for details) |
Health Care Services and Medical Supplies
Medicare Plus Blue PPO Vitality (PPO) covers a range of additional benefits. Learn more about Medicare Plus Blue PPO Vitality (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 Copayment for Routine Care $30
Chiropractic X-rays (1 visit/year) $35 Out-of-Network: Medicare Covered Chiropractic Services: Coinsurance for Medicare Covered Chiropractic Services 40% Coinsurance for Routine Care 40% Medicare covers limited acupuncture services for chronic low back pain.The copay for Medicare-covered acupuncture is the same as Medicare covered Chiropractic services. Chiropractic X-rays (1 visit/year) 40% |
| Diabetes supplies, training, nutrition therapy and monitoring | In-Network: Diabetic Supplies and Services: Copayment for Medicare-covered Diabetic Supplies $0 Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0 Out-of-Network: $0 copay |
| 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 Out-of-Network: Medicare Covered Durable Medical Equipment Services: Coinsurance for Medicare Covered Durable Medical Equipment 0% to 40% |
| Diagnostic tests, lab and radiology services, and X-rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $0/$30/$150 Copayment for Medicare-covered Lab Services $0 to $40 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services $0 cost share applies to COVID-19 testing. $30 applies to procedures performed in a professional office setting. The maximum applies to procedures performed in an outpatient setting. Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $100 to $150 Copayment for Medicare-covered Therapeutic Radiological Services $35 Copayment for Medicare-covered X-Ray Services $35 to $150 (Please see Evidence of Coverage for details) Out-of-Network: Medicare Covered Diagnostic Procedures/Tests Services: Copayment for Medicare Covered Diagnostic Procedures/Tests $0 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% $0 cost share applies to COVID-19 testing. |
| Home health care | Out-of-Network: Medicare Covered Home Health Services: Coinsurance for Medicare Covered Home Health 40% |
| Mental health inpatient care | In-Network: Psychiatric Hospital Services: $250 per day for days 1 to 7 $0 per day for days 8 to 90 Prior Authorization Required for Psychiatric Hospital Services Out-of-network: 40% of the cost per stay |
| Mental health outpatient care | In-Network: Outpatient Mental Health Services: Copayment for Medicare-covered Individual Sessions $20 Copayment for Medicare-covered Group Sessions $20 Out-of-Network: 40% Coinsurance |
| Outpatient services/surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $150 to $220 Prior Authorization Required for Outpatient Hospital Services Minimum copay applies to all non-surgical services performed in an outpatient setting, such as therapeutic services, pulmonary & osteopathic services. Maximum copay applies to surgical services performed in an outpatient setting. Outpatient Observation Services: Copayment for Medicare Covered Observation Services $0 Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0 to $125 Prior Authorization Required for Ambulatory Surgical Center Services Minimum copay applies to arthroplasty knee and hip.$100 applies to non-surgical services performed in an ambulatory surgical center.Maximum copay applies to outpatient surgical services performed in an ambulatory surgical center. Out-of-Network: Medicare Covered Outpatient Hospital Services: Coinsurance for Medicare Covered Outpatient Hospital Services 40% Coinsurance for Medicare Covered Ambulatory Surgical Center Services 40% Outpatient Observation Services: Copayment for Medicare Covered Observation Services 40% |
| Outpatient substance abuse care | In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $30 Copayment for Medicare-covered Group Sessions $30 Out-of-Network: 40% Coinsurance |
| Over-the-counter items | In-Network: Over-The-Counter (OTC) Items: Maximum plan allowance of $50.00 every three months for Over-The-Counter (OTC) Items (no rollover) The benefit is administered through a plan approved network of retail and mail order partners. (Please see Evidence of Coverage for details) |
| Podiatry services | In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $30 Prior Authorization Required for Podiatry Services Out-of-Network: Medicare Covered Podiatry Services: Coinsurance for Medicare Covered Podiatry Services 40% |
| Skilled Nursing Facility (SNF) care | In-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $214 per day for days 21 to 100 Prior Authorization Required for Skilled Nursing Facility Services Out-of-network: 40% of the cost per stay |
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 | In-network: $0-$30 copay Out-of-network: 40% of the cost $1,500 combined in- and out-of-network allowance for preventative and comprehensive dental Preventive dental services: Cleaning (2 every calendar year): In-network: You pay nothing Out-of-network: 50% of the cost Dental x-ray(s) One set of up to 4 bitewings or 6 periapical films every 2 calendar years): In-network: You pay nothing Out-of-network: 50% of the cost Fluoride Treatment (1 visit per calendar year)In-network: You pay nothing Out-of-network: 50% of the cost $0 copay in-network and 50% coinsurance out-of-network for the following services: Restorative Services: Amalgam and resin fillings once per tooth every 48 months, Crown repairs, Crowns (once per permanent tooth every 84 months), Endodontic:Root canals once/lifetime per tooth, Periodontics-Deep Cleaning 1 per 24 months per quadrant, Extractions-Simple extractions, Oral Surgery (Prosthodontics/Other/Oral Maxiofacial Surgery and other services), Brush Biopsy 2 per calendar year (Please see Evidence of Coverage for details) |
Vision Benefits
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 to $30 Copayment for Routine Eye Exams $0 Maximum 1 Routine Eye Exam every year Other Services- LASIK/RK $30 Eyewear: Copayment for Medicare-Covered Benefits $0 Copayment for Contact Lenses $0 Maximum 1 Pair (Please see Evidence of Coverage for details) Copayment for Eyeglass Lenses $0 Maximum 1 Pair (Please see Evidence of Coverage for details) Copayment for Eyeglass Frames $0 Maximum 1 Pair (Please see Evidence of Coverage for details) Maximum Plan Benefit of $150 every year The mandatory vision benefit provides a $150 maximum benefit every calendar year that applies to frames and elective contact lenses only. The maximum does not apply to eyeglass lenses or medically necessary contact lenses. Benefit may be used for contact lenses or one pair of frames, but not both. One pair of lenses for glasses covered every calendar year.Routine vision care must be obtained through a plan contracted vision provider. Please see Evidence of Coverage for more details. Out-of-Network: Medicare Covered Eye Exams Services: Coinsurance for Medicare Covered Eye Exams 40% Coinsurance for Medicare Covered Eyewear 40% (Please see Evidence of Coverage for details) |
Hearing Benefits
The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Hearing care | In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $0 to $30 Copayment for Routine Hearing Exams $0 to $30
Hearing Aids: Copayment for Hearing Aids $0
Hearing Aids $1,500 maximum allowance for both ears (up to $750 per ear) every 3 years for new hearing aids. Out-of-Network: Medicare Covered Hearing Exams Services: Coinsurance for Medicare Covered Hearing Exams 50% Coinsurance for Routine Hearing Exams 50% Coinsurance for Fitting/Evaluation for Hearing Aids 50% (Please see Evidence of Coverage for details) |
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 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 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
We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.