Medicare Plus BlueSM PPO
benefit comparison

For Medicare-eligible Michigan residents

Here is a summary of the most frequently used benefits. You may also wish to download the Summary of Benefits (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.

Annual medical deductible $175 applies to both in and out-of-network Medicare-covered services $750 applies only to out-of-network Medicare-covered services $750 applies only to out-of-network Medicare-covered services $250 applies only to out-of-network Medicare-covered services
Inpatient hospital copay

Days 1-5:
$250 copay per day after deductible

Days 6-90
$0 copay

40% after deductible

Days 1-5:
$225 copay per day

Days 6-90:
$0 copay

40% after deductible

Days 1-5:
$160 copay per day

Days 6-90:
$0 copay

40% after deductible

Days 1-5:
$90 copay per day

Days 6-90:
$0 copay

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

Days 1-20:
$25 copay per day after deductible

Days 21-100:
$130 copay per day

40% coinsurance after deductible

Days 1-20:
$25 copay per day

Days 21-100:
$130 copay per day

40% coinsurance after deductible

Days 1-20:
$25 copay per day

Days 21-100:
$130 copay per day

40% coinsurance after deductible

Days 1-20:
$25 copay per day

Days 21-100:
$130 copay per day

30% coinsurance after deductible
Outpatient hospital services $125 to $200 copay after deductible 40% coinsurance after deductible $125 to $175 copay 40% coinsurance after deductible $100 to $150 copay 40% coinsurance after deductible $75 to $100 copay 30% coinsurance after deductible
Office visits: primary care physician $25 copay after deductible 40% coinsurance after deductible $20 copay 40% coinsurance after deductible $15 copay 40% coinsurance after deductible $10 copay 30% coinsurance after deductible
Office visits: specialist $50 copay after deductible 40% coinsurance after deductible $50 copay 40% coinsurance after deductible $45 copay 40% coinsurance after deductible $40 copay 30% coinsurance after deductible

No referrals required.

Outpatient surgery $125 copay ambulatory surgical center after deductible; $200 hospital after deductible 40% coinsurance after deductible $125 copay ambulatory surgical center; $175 hospital 40% coinsurance after deductible $75 copay ambulatory surgical center; $150 hospital 40% coinsurance after deductible $50 copay ambulatory surgical center; $100 hospital 30% coinsurance after deductible
Ambulance services $100 copay after deductible $100 after deductible in emergencies; 40% coinsurance after deductible for non-emergency $100 copay $100 after deductible in emergencies; 40% coinsurance after deductible for non-emergency $75 copay $75 after deductible in emergencies; 40% coinsurance after deductible for non-emergency $75 copay $75 after deductible in emergencies; 30% coinsurance after deductible for non-emergency
Urgent care — within the U.S. $45 after deductible $45 after deductible $45 copay $45 after deductible $35 copay $35 after deductible $35 copay $35 after deductible
Emergency care — within the U.S.

$65 copay

Emergency or urgent care is covered outside of the U.S.

20% coinsurance after $250 deductible; $50,000 lifetime maximum

Durable medical equipment 20% coinsurance after deductible 40% coinsurance after deductible 20% coinsurance 40% coinsurance after deductible 20% coinsurance 40% coinsurance after deductible 20% coinsurance 30% coinsurance after deductible
Preventive services $0 copay 40% coinsurance after deductible $0 copay 40% coinsurance after deductible $0 copay 40% coinsurance after deductible $0 copay 30% coinsurance after deductible

Preventive services include: Welcome to Medicare exam, Personal Prevention Plan Services, bone mass measurement, colorectal screening, glaucoma screening, immunizations (including flu, pneumonia and Hepatitis B vaccines), mammograms, Pap smear, prostate screening, abdominal aortic aneurysm screening, cardiovascular disease screening, diabetes screening and yearly wellness visit.

Also included: 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, behavioral therapy for cardiovascular disease and obesity, diabetes self-management training, medical nutrition therapy services and tobacco use cessation counseling.

Chiropractic $20 copay after deductible 40% coinsurance after deductible $20 copay 40% coinsurance after deductible $20 copay 40% coinsurance after deductible $20 copay 30% coinsurance after deductible
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 OR up to six periapical films (not both) every other calendar year

Vision in-network

Medicare-covered services only; deductible and copay apply

$0 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

Routine vision care must be from a VSP network provider.

Lasik/RK $50 copay 40% coinsurance $50 copay 40% coinsurance $45 copay 40% coinsurance $40 copay 30% coinsurance
Hearing

Medicare-covered services only; deductible and copays apply

Routine exam every year. Copays apply. 50% of the approved amount out-of-network.
$0 copay for up to one hearing aid fitting and evaluation every three years
Up to 2 hearing aids every 3 years ($500 allowance per ear)

SilverSneakers® fitness

Not covered

$0 copay for covered fitness program benefits provided at a SilverSneakers facility.

Bathroom safety bars

$100 annual maximum. Installation not covered.

Part D prescription drugs—initial coverage period (until your total drug costs reach $2,850)

$310 deductible

25% coinsurance all tiers

$310 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 33%*

*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 33%*

*of plan's approved amount

Part D prescription drugs — gap period (after your drug costs reach $2,850 until they reach $4,750)

You pay no more than:

  • 72% of the price for generic drugs
  • 47.5% of brand-name drugs

You pay no more than:

  • 72% of the price for generic drugs
  • 47.5% of brand-name drugs

You pay no more than:

  • 72% of the price for generic drugs
  • 47.5% of brand-name drugs

Tier 1 generics: $3

You pay no more than:

  • 72% of the price for generic drugs
  • 47.5% of brand-name drugs

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: 1-888-563-3307

  • TTY users call 711
  • 8 a.m. to 9 p.m. Eastern time, Monday through Friday, Feb. 15 through Sept. 30; with weekend hours 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 or 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 $17.50 $39 $99 $169
Region 2 Berrien, Branch, Calhoun, Eaton, Gratiot, Hillsdale, Ingham, Jackson, Monroe, Montcalm, St. Joseph, Van Buren $17.50 $74 $151 $222
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 $17.50 $94 $155 $268
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 $17.50 $74 $146 $222
Region 6 Macomb, Oakland, Washtenaw, Wayne $17.50 $99 $148 $272

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Important information about these plans

Medicare Plus Blue and Prescription Blue are PPO and PDP plans with a Medicare contract. Enrollment in Medicare Plus Blue and Prescription Blue depends on contract renewal.

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 http://www.bcbsm.com/medicare/find-a-doctor/.

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. You may enroll in only one Part D plan at a time.

Limitations, copayments and restrictions may apply.

Our network includes approximately 2,400 Michigan retail pharmacies, representing approximately 98 percent of all Michigan 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 9 p.m. Eastern time, Monday through Friday, Feb. 15 through Sept. 30, 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 also write to: Blue Cross Blue Shield of Michigan, 600 E. Lafayette Blvd., Mail Code X521, 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 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. You may only enroll in Medicare Plus Blue PPO or Prescription Blue PDP during specific times of the year.

For more information, please contact Blue Cross Blue Shield of Michigan at 1-888-563-3307. TTY users call 711. Hours are: 8 a.m. to 9 p.m. Eastern time, Monday through Friday, Feb. 15 through Sept. 30, with weekend hours Oct. 1 through Feb. 14.

LegacySM 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.