It's easy to enroll in our individual Medicare Plus Blue PPOSM plan. Contact us to enroll, or use the Medicare Plus Blue PPOSM enrollment form to sign up. Refer to Summary of Benefits for a description of the plan. For detailed benefit information, refer to Evidence of Coverage.
Download Enrollment Form Below
Please select the form below. You will be presented with the enrollment form for Medicare Plus Blue PPOSM. Fill out the form and be sure to make a copy of it to save for your records. Put the form in a stamped 9" x 11" envelope and return to us at:
Blue Cross Blue Shield of Michigan Medicare Plus Blue PPOSM Enrollment
P.O. Box 440
Southfield, MI 48037-9953
Fax: 248-448-4041
You may request the Medicare Plus Blue PPOSM enrollment form in alternative formats by calling 877-469-2583 from 8 a.m. to 8 p.m., seven days a week. TTY users should call 1-800-481-8704).
Medicare beneficiaries may enroll in Medicare Plus Blue PPOSM through the Centers for Medicare and Medicaid Services Online Enrollment Center, located at medicare.gov.
Please remember:
Do not send us your enrollment form until November 15, 2009.
You must be a permanent resident of Michigan.
You will need one form for each person enrolling in a plan.
You can only enroll in one plan.
Do not enclose payment with your enrollment form. We'll bill you or, if you requested it through use of the automatic deduction form, above, we'll automatically deduct your premium from your bank account. Social Security deductions can also be arranged after you have received a member ID card.
If you currently have Medicare supplemental and/or prescription drug coverage from an employer group or union and are considering enrolling in Medicare Plus Blue PPO, call your group benefits representative first to determine if you need this coverage.
To Complete an Enrollment Form We Sent You
If you received an enrollment form in the mail from us, please fill it out completely. Be sure to check which plan you want to enroll in and to save a copy for your records. Put the completed enrollment form (do not fold it) in the 9" x 11" postage-paid envelope we sent you and mail it back to us. If you have not received this enrollment form, you can call us for one or download the appropriate enrollment form from this Web site.
Medicare Plus Blue PPOSM is a health plan with a Medicare contract.
Medicare Plus Blue PPOSM Medicare Plus Blue PPOSM is available to all Medicare beneficiaries who are Michigan residents who reside within the plan's 75-county service area and are entitled to receive services under Medicare Part A and enrolled in Part B. Premiums vary by county. You must continue to pay your Medicare Part B premium.
Medicare Plus Blue PPOSM is available in these counties: Alcona, Alger, Allegan, Alpena, Arenac, Baraga, Barry, Bay, Berrien, Branch, Calhoun, Cass, Chippewa, Clare, Clinton, Crawford, Delta, Dickinson, Eaton, Genesee, Gladwin, Gogebic, Gratiot, Hillsdale, Houghton, Huron, Ingham, Ionia, Iosco, Iron, Isabella, Jackson, Kalamazoo, Kent, Keweenaw, Lake, Lapeer, Lenawee, Livingston, Luce, Mackinac, Macomb, Manistee, Marquette, Mason, Mecosta, Menominee, Midland, Missaukee, Monroe, Montcalm, Montmorency, Muskegon, Newaygo, Oakland, Oceana, Ogemaw, Ontonagon, Osceola, Oscoda, Otsego, Ottawa, Presque Isle, Roscommon, Saginaw, Sanilac, Schoolcraft, Shiawassee, St. Clair, St. Joseph, Tuscola, Van Buren, Washtenaw, Wayne, Wexford.
With the exception of emergency or urgent care, it will cost more to get care from non-plan or non-preferred providers. Your responsibility will be greater out-of-network when the out-of-network coinsurance is based on the Medicare allowed amount and the contracted amount is lower. You may receive services from any provider who accepts your Medicare Plus Blue PPOSM ID card. Your out-of-pocket costs will be lower if you choose a network provider. To find a network provider, visit bcbsm.com/medicare/search.shtml.
Medicare Plus Blue PPOSM provides reimbursement for all covered benefits regardless of whether they are received in-network, as long as they are medically necessary.
In Michigan, 86 percent of pharmacies are network pharmacies; nationwide, more than 80 percent of pharmacies are in the network, including the majority of chain pharmacies, as well as long-term care and home infusion pharmacies and Indian/Tribal/Urban (Indian Health Service) pharmacies (Source: 2010 Pharmacy Directory). In general, benefits are only available at contracted network pharmacies. Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost sharing amount if you get your drugs at an out-of-network pharmacy. In addition, you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from Medicare Plus Blue PPOSM. For additional information on network pharmacies, please call Customer Service at 1-877-469-2583, 8 a.m. to 8 p.m., seven days a week. TTY users should call 1-800-481-8704. You may also write to: Medicare Plus Blue PPOSM, 600 E. Lafayette Blvd., Mail Code X435, Detroit, MI 48226.
If you decide to have your Medicare Plus Blue PPOSM premium withheld from your Social Security check or deducted from your checking or savings account, it may take up to three months for the automatic deduction to begin. If your premium amount is currently withheld from your Social Security check or deducted from your checking or savings account and you wish to receive a monthly bill instead, the change may also take up to three months to become effective. During this time, you will be responsible for paying your premium.
The benefit information provided herein is a brief summary, but not a comprehensive description of available benefits. Additional information about benefits is available to assist you in making a decision about your coverage. This is an advertisement; for more information contact the plan Benefits, formulary, pharmacy, network, premium and/or coinsurance may change on Jan. 1, 2011. Please contact Blue Cross Blue Shield of Michigan for details.
In addition to enrolling through this Web site, Medicare beneficiaries may enroll in Medicare Plus Blue PPOSM through the Centers for Medicare & Medicaid Services Online Enrollment Center, located at medicare.gov. For more information, please contact Medicare Plus Blue PPOSM at 1-877-469-2583, 8 a.m. to 8 p.m. seven days a week. TTY users should call 1-800-481-8704. You may only enroll in Medicare Plus Blue PPOSM during specific times of the year. To learn more about enrollment periods, please contact Customer Service.
This document is available in alternate formats or languages. For more information, call 1-877-469-2583, 8 a.m. to 8 p.m. seven days a week. TTY users should call 1-800-481-8704.
Medicare Plus Blue PPOSM is issued by Blue Cross Blue Shield of Michigan, which contracts with the federal government. Medicare Plus Blue PPO'sSM contract with CMS is renewed annually and the availability of coverage beyond the end of the contract year is not guaranteed.
You may be able to get extra help to pay for your prescription drug premiums and costs. To see if you qualify for getting extra help, call:
1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048, 24 hours a day, seven days a week;
The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call 1-800-325-0778; or
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