2014 Medicare Plus BlueSM PPO enrollment

It's easy to enroll in our individual Medicare Plus Blue PPO plan. Enroll now, or use the Medicare Plus Blue PPO Enrollment Application form to sign up. Read the Pre-enrollment brochure, then refer to Summary of Benefits for a description of the plan. For detailed benefit information, see the Evidence of Coverage.

Enrollment Information and Forms
Medicare Plus Blue PPO Pre-enrollment brochure Pre-enrollment booklet (PDF)
Medicare Plus Blue PPO Enrollment Application form Enrollment Application form (PDF)
Automatic Deduction form Automatic Deduction form (PDF)

Download Enrollment Application form

Please select the Medicare Plus Blue PPO Enrollment Application form above. 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 send it to us at:

Blue Cross Blue Shield of Michigan
Medicare Plus Blue PPO Enrollment
P.O. Box 44256
Detroit, MI 48244-0256
Fax: 1-866-562-2421

If you need more information, if you need information in another format, or to be referred to our foreign language line, contact Medicare Plus Blue PPO at 1-888-563-3307 from 8 a.m. to 9 p.m. Monday through Friday, Feb. 15 through Sept. 30, with weekend hours Oct. 1 through Feb. 14. TTY users call 711.

Also, you can visit our Member Services locations.

Medicare beneficiaries also may enroll in Medicare Plus Blue PPO through the Centers for Medicare and Medicaid Services Online Enrollment Center, located at www.medicare.gov.

Please remember:

To complete an Enrollment Application form we sent you

If you received an Enrollment Application form in the mail from us, please fill it out completely. Be sure to check which plan you want to enroll in and 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 website.

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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.