Medicare Plus Blue PPOSM benefit comparison

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For Medicare-eligible Michigan residents

Summary of most frequently used benefits. You may also wish to download this benefit comparison (PDF).

Benefit for Medicare-covered services PPO Essential PPO Vitality PPO Signature PPO Assure
In-network Out-of-network In-network Out-of-network In-network Out-of-network In-network Out-of-network
Out-of-pocket maximum for Medicare-covered medical services $6,400 $8,100
Combined in/out		 $5,400 $7,100
Combined in/out		 $4,400 $6,100
Combined in/out		 $3,400 $5,100
Combined in/out

The plan covers 100% of our allowed amount after the out-of-pocket maximums are reached.
Out-of-pocket maximum for durable medical equipment and prosthetic and orthotic devices

Durable medical equipment (DME) out-of-pocket is included in the in-network maximum out-of-pocket.
Deductible (combined) $95 $0 $500 $0 $500 $0
Inpatient hospital copay

Days 1-5:
$225 per day

Days 6-90
$0 Copayment

 30% coinsurance

Days 1-5:
$225 per day

Days 6-90:
$0 Copayment

 40% coinsurance

Days 1-5:
$160 per day

Days 6-90:
$0 Copayment

 40% coinsurance

Days 1-5:
$90 per day

Days 6-90:
$0 Copayment

 30% coinsurance
Skilled nursing facility (in a Medicare-certified skilled nursing facility)

Days 1-20:
$0 copay per day

Days 21-100:
$130 copay per day

 40% coinsurance for each stay

Days 1-20:
$0 copay per day

Days 21-100:
$130 copay per day

 40% coinsurance for each stay

Days 1-20:
$0 copay per day

Days 21-100:
$130 copay per day

 40% coinsurance for each stay

Days 1-20:
$0 copay per day

Days 21-100:
$130 copay per day

 30% coinsurance for each stay
Outpatient hospital services $125 to $200 copay 40% coinsurance $125 to $175 copay 40% coinsurance $100 to $150 copay 40% coinsurance $75 to $100 copay 30% coinsurance
Office visits: primary care physicians $30 copay 40% coinsurance $25 copay 40% coinsurance $20 copay 40% coinsurance $15 copay 30% coinsurance
Office visits: specialists $50 copay 40% coinsurance $50 copay 40% coinsurance $40 copay 40% coinsurance $35 copay 30% coinsurance

No referrals required.
Outpatient surgery $125 copay ambulatory; $200 hospital 40% coinsurance $125 copay ambulatory; $175 hospital 40% coinsurance $75 copay ambulatory; $150 hospital 40% coinsurance $50 copay ambulatory; $100 hospital 30% coinsurance
Ambulance services $50 copay 40% coinsurance $50 copay 40% coinsurance $50 copay 40% coinsurance $50 copay 30% coinsurance
Urgent care — worldwide

$35 copay
Emergency care — within the U.S.

$65 copay
Durable medical equipment 20% coinsurance 40% coinsurance 20% coinsurance 40% coinsurance 20% coinsurance 40% coinsurance 20% coinsurance 30% coinsurance
Preventive services $0 copay 40% coinsurnace $0 copay 40% coinsurance $0 copay 40% coinsurance $0 copay 30% coinsurance

Preventive services such as Welcome to Medicare exam, Personal Prevention Plan Services, bone mass measurement, colorectal screening, glaucoma screening, immunizations, mammograms, Pap smears and prostate screening.

Preventive benefits also include: screening and behavioral counseling interventions to reduce alcohol misuse, screening for depression in adults, screening for sexually transmitted infections and behavioral counseling to prevent STIs, and behavioral therapy for cardiovascular disease and obesity.
Chiropractic $20 copay 40% coinsurance $20 copay 40% coinsurance $20 copay 40% coinsurance $20 copay 30% coinsurance
Preventive dental in-network

Medicare-covered only

$0 copay for up to two exams a year, up to two cleanings a year, up to one set of bitewing x-rays every two years OR up to six periapical films every two years in lieu of bitewing x-rays every two years.
Vision in-network

Medicare-covered only

$10 copay for up to one routine eye exam every year
$10 copay for up to one pair of medically necessary contact lenses every two years

or

$10 copay for up to one pair of eyeglasses (including lenses and frames) every two years
$100 coverage limit for eyeglass frames

or

elective contact lenses and exam every two years
Lasik/RK $50 copay 40% coinsurance $50 copay 40% coinsurance $40 copay 40% coinsurance $35 copay 30% coinsurance
Hearing

Medicare-covered only

$25 copay for Medicare-covered yearly hearing aid exam
$0 copay for up to one hearing aid fitting and evaluation every three years
$500 plan coverage limit for hearing aids every three years
SilverSneakers® fitness

Not covered

$0 copay for covered fitness program benefits provided by a SilverSneakers facility.
Bathroom safety bars

50% coinsurance for up to $100 combined annual maximum. Installation not covered
.
Part D prescription drugs—initial coverage period (until your total drug costs reach $2,970)

$325 deductible

25% coinsurance all tiers

$325 deductible

25% coinsurance all tiers

 $0 deductible
Tier 1 Preferred generic $3
Tier 2 Non-preferred generic $15
Tier 3 Preferred brand $45
Tier 4 Non-preferred brand $95
Tier 5 Specialty 30%*

*of plan's approved amount

 $0 deductible
Tier 1 Preferred generic $3
Tier 2 Non-preferred generic $10
Tier 3 Preferred brand $40
Tier 4 Non-preferred brand $95
Tier 5 Specialty 30%*

*of plan's approved amount
Part D prescription drugs — gap period (after your drug costs reach $2,970 until they reach $4,750) 21% plan benefit generics (member pays 79%) / 50% manufacturer discount brand plus plan discount of 2.5% (member pays 47.5%) 21% plan benefit generics (member pays 79%) / 50% manufacturer discount brand plus plan discount of 2.5% (member pays 47.5%) 21% plan benefit generics (member pays 79%) / 50% manufacturer discount brand plus plan discount of 2.5% (member pays 47.5%) Includes $3 and $10 generics; 21% plan benefit generics (member pays 79%) / 50% manufacturer discount brand plus plan discount of 2.5% (member pays 47.5%)
Part D prescription drugs — catastrophic period (after your drug costs reach $4,750)
$2.65 copay for generic drugs and $6.60 copay for other drugs or 5% coinsurance, whichever is greater (out of network, you will not be reimbursed for the difference between the pharmacy’s charge and our in-network allowable amount)

You don't need to be a member to get our help. If you have questions or concerns, would like to find an agent or need assistance with enrolling, please call: 1-877-469-2583

  • TTY users call 711
  • 8 a.m. to 9 p.m. Eastern time, Monday through Friday, Feb. 15 through Sept. 30; 8 a.m. to 9 p.m. Eastern time, seven days a week, Oct. 1 through Feb. 14

Monthly premium table for Medicare Plus Blue PPO plans

The premiums vary by the county in which you permanently reside.
Rates are based on the use and cost of health care services in each region.
You must continue to pay your Medicare Part B premium.

  1. Locate the region/county in which you permanently reside.
  2. Look at the plan options to find your monthly premium rate.
Counties by regions Essential Vitality Signature Assure
Region 1 Allegan, Barry, Ionia, Kalamazoo, Mason, Muskegon, Newaygo, Oceana, Ottawa $12.50 $41 $96 $151
Region 2 Berrien, Branch, Calhoun, Eaton, Gratiot, Hillsdale, Ingham, Jackson, Monroe, Montcalm, St. Joseph, Van Buren $12.50 $56 $128 $194
Region 3 Alcona, Alger, Alpena, Arenac, Baraga, Bay, Charlevoix, Cheboygan, Chippewa, Clare, Crawford, Gladwin, Huron, Iosco, Kalkaska, Keweenaw, Luce, Mackinac, Montmorency, Ogemaw, Ontonagon, Oscoda, Presque Isle, Roscommon, Saginaw, Sanilac, Schoolcraft, Shiawassee, Tuscola $12.50 $76 $132 $240
Region 4 Antrim, Benzie, Cass, Clinton, Delta, Dickinson, Emmet, Genesee, Gogebic, Grand Traverse, Houghton, Iron, Isabella, Kent, Lake, Lapeer, Leelanau, Lenawee, Livingston, Manistee, Marquette, Mecosta, Menominee, Midland, Missaukee, Osceola, Otsego, St. Clair, Wexford $12.50 $56 $123 $194
Region 6 Macomb, Oakland, Washtenaw, Wayne counties $12.50 $86 $125 $244

You don't need to be a member to get our help. If you have questions or concerns, would like to find an agent or need assistance with enrolling, please call: 1-877-469-2583

  • TTY users call 711
  • 8 a.m. to 9 p.m. Eastern time, Monday through Friday, Feb. 15 through Sept. 30; 8 a.m. to 9 p.m. Eastern time, seven days a week, Oct. 1 through Feb. 14

H9572 S5584_W_Apr13BCBSMAdvWeb CMS Approved 04292013

Important information about these plans

Medicare Plus Blue PPOSM, BCN Advantage HMO-POSSM and BCN Advantage HMO FocusSM are health plans with Medicare contracts. Prescription Blue PDPSM is a stand-alone prescription drug plan with a Medicare contract.

Medicare Plus Blue PPO

Medicare Plus Blue PPO is available to all Medicare beneficiaries who are Michigan residents and are entitled to receive services under Medicare Part A and enrolled in Part B.

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 Original Medicare. Your out-of-pocket costs will be lower if you choose a network provider. To find a network provider, visit www.bcbsm.com/medicare/provdirectory.shtml.

Prescription Blue PDP

Prescription Blue PDP is available to all Medicare beneficiaries who are Michigan residents entitled to receive services under Medicare Part A and/or enrolled in Part B.

Medicare Plus Blue PPO and Prescription Blue PDP

Premiums vary by county. You must continue to pay your Medicare Part B premium.

Limitations, copayments and restrictions may apply.

Our network includes approximately 2,300 Michigan retail pharmacies, of which an estimated 86 percent are network pharmacies. Nationwide, most chain pharmacies are in our network, as well as long-term care and home infusion pharmacies and Indian/Tribal/Urban (Indian Health Service) pharmacies.

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. Quantity limitation and restrictions may apply. In addition, you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from Blue Cross Blue Shield of Michigan. For additional information on network pharmacies, please call Member Services at 1-877-241-2583, 8 a.m. to 8 p.m. Eastern time, Monday through Friday, with weekend hours Oct. 1 through Feb. 14. TTY users call 711. Certain services available 24/7 through our automated telephone response system. TTY users call 711. You may also write to: Blue Cross Blue Shield of Michigan, 600 E. Lafayette Blvd., Mail Code X510, Detroit, MI 48226.

If you decide to have your plan 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 is a brief summary, not a complete description of benefits. For more information contact the plan. Benefits, formulary, pharmacy network, premium and or copayments/coinsurance may change on Jan. 1 of each year.

Medicare beneficiaries may enroll in Medicare Plus Blue PPO, BCN Advantage HMO-POS, BCN Advantage HMO or Prescription Blue PDP through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov. BCBSM does not control Medicare's website and is not responsible for its content.

For more information, please contact Blue Cross Blue Shield of Michigan at 1-877-469-2583. TTY users call 711. Hours are: 8 a.m. to 8 p.m. Eastern time, Monday through Friday, with weekend hours Oct. 1 through Feb. 14. TTY users call 711. Certain services available 24/7 through our automated telephone response system.

You may only enroll in Medicare Plus Blue PPO or Prescription Blue PDP during specific times of the year. To learn more about enrollment periods, contact Member Services.

BCN Advantage HMO-POS

BCN Advantage HMO-POS is available in these counties: Allegan, Barry, Bay, Calhoun, Clare, Clinton, Crawford, Eaton, Genesee, Gladwin, Grand Traverse, Gratiot, Huron, Ingham, Ionia, Isabella, Jackson, Kalamazoo, Kalkaska, Kent, Lapeer, Livingston, Macomb, Mecosta, Midland, Missaukee, Monroe, Montcalm, Muskegon, Newaygo, Oakland, Oceana, Ottawa, Roscommon, Saginaw, St. Clair, Sanilac, Shiawassee, Tuscola, Van Buren, Washtenaw and Wayne. Premiums vary by county. You must continue to pay your Medicare Part B premium.

You must use plan providers except in emergency or urgent care situations or for out-of-area renal dialysis. If you obtain routine care from out-of-network providers, neither Medicare nor BCN Advantage will be responsible for the costs. Out-of-network services authorized by BCN Advantage will be covered. Our point-of-service benefit allows you to get care from providers not in our network under certain conditions. If you're traveling outside of Michigan, you're covered under our point-of-service BlueCard benefit and can access out-of-network doctors, specialists or hospitals that participate with Blues plans. You may receive most plan-covered services at in-network out-of-pocket cost sharing. You may need to pay higher cost-sharing for routine care from non-network providers.

If you are enrolled in BCN Advantage ClassicSM or PrestigeSM plans, you must use a network pharmacy to access your prescription drug benefit, except under non-routine circumstances when you cannot reasonably use a network pharmacy. Our pharmacy network includes the majority of chain pharmacies, mail order through Medco Pharmacy® (now a part of the Express Scripts family of pharmacies) or Walgreens, as well as long-term care and home infusion pharmacies. For additional information on network pharmacies, call Customer Service at 1-800-450-3680, 8 a.m. to 8 p.m., seven days a week. TTY users call 711. You may also write to: BCN Advantage, 2311 Green Road, Ann Arbor, MI 48105.

BCN Advantage HMO Focus

BCN Advantage HMO Focus is available only to residents of Wayne County. You must use BCN Advantage Focus plan providers except in emergency or urgent care situations or for out-of-area renal dialysis. If you obtain routine care from out-of-network providers, neither Medicare nor BCN Advantage will be responsible for the costs. You must continue to pay your Medicare Part B premium. The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan. Limitations, copayments and restrictions may apply. Medicare beneficiaries may also enroll in BCN Advantage through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov. BCN Advantage's contract with CMS is renewed annually and the availability of coverage beyond the end of the contract year is not guaranteed. Benefits, formulary, pharmacy, network, premium and/or coinsurance may change on Jan. 1 of each year.

BCN Advantage HMO Focus plan members must use a network pharmacy to access their prescription drug benefit, except under non-routine circumstances when they cannot reasonably use a network pharmacy. Our pharmacy network includes the majority of chain pharmacies, mail order through Medco Pharmacy® (now a part of the Express Scripts family of pharmacies) or Walgreens, as well as long-term care and home infusion pharmacies. For more information call the Customer Service number on the back of your ID card from 8 a.m. to 8 p.m., Monday through Friday, with weekend hours October 1 through February 14. TTY users should call 711. Certain services are available 24/7 through our automated telephone response system. You may also write to: BCN Advantage, 2311 Green Road, Ann Arbor, MI 48105.

The BCN Advantage benefit information provided on this website is not complete. Additional information should be requested before making a decision about your coverage. For full information on BCN Advantage benefits, current members should call our Customer Service department at 1-800-450-3680, from 8 a.m. to 8 p.m., seven days a week. TTY users call 711. Prospective members should call 1-877-469-2583. TTY users call 711. Hours are: 8 a.m. to 9 p.m. Eastern time, Monday through Friday, Feb. 15 through Sept. 30; 8 a.m. to 9 p.m. Eastern time, seven days a week, Oct. 1 to Feb. 14.

Benefits, formulary, pharmacy, network, premium and/or coinsurance may change on Jan. 1 of each year. Contact BCN Advantage for details.

If you decide to have your BCN Advantage 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. Medicare beneficiaries may enroll in BCN Advantage through the Centers for Medicare & Medicaid Services Online Enrollment Center, located at medicare.gov. For more information, contact BCN Advantage at 1-877-469-2583. TTY users call 711. Hours are: 8 a.m. to 9 p.m. Eastern time, Monday through Friday, Feb. 15 through Sept. 30; 8 a.m. to 9 p.m. Eastern time, seven days a week, Oct. 1 to Feb 14.

Legacy Medigap

Legacy Medigap offers access to any hospital, doctor or other health care provider in the U.S. or its territories that accepts Medicare assignment. The plan does not require members to use a specified provider network. Legacy Medigap is a Medigap health insurance policy administered by Blue Cross Blue Shield of Michigan. Neither Blue Cross Blue Shield of Michigan nor agents authorized to sell Blue Cross Blue Shield of Michigan policies are connected with Medicare.