2026 Medicare Plus BlueSM PPO Giveback
This Blue Cross Blue Shield of Michigan plan adds some of your Part B premium back into your Social Security check monthly. It also offers $0 primary care office visits.
- Puts money back in your pocket monthly thanks to a Part B credit.
- Preventive dental and vision exam coverage
- Hearing aid coverage through TruHearing®
- $0 in-network primary care office visits
NETWORK SIZE
MONTHLY PREMIUM
$0
Medical deductible
$650
$0.00 monthly payment for 48002
Monthly premium
Plan details
In-network services: $650
$150 deductible for tiers 3-5
In-network services: $9,250
Combined in- and out-of-network services: $11,000
Optional supplemental benefits don't count toward your out-of-pocket maximum.
You pay $0.
You pay $55.
You pay $0-$40.
Copays start at $0 for certain generic drugs filled at a preferred network pharmacy. Some drugs may cost more if you choose a pharmacy in our standard network.
See if this plan covers your medication. Find your prescription (PDF).
All benefits required by Original Medicare and more, including:
- $0 telehealth visits for primary care and behavioral health
- Worldwide emergency, urgent care and emergency transportation coverage
- Coverage for ambulance services not requiring transportation
- Mobile crisis and crisis stabilization for behavioral health
- Coverage while traveling outside of Michigan with the nationwide network of Blue Plan Providers program (PDF).
This is a PPO plan. PPO stands for preferred provider organization. It's a group of health care professionals that provide services to members. You can choose the doctors you want to see, but pay less when you see a doctor in our network. Find a doctor in this plan's network.
Includes services such as:
- Welcome to Medicare exam
- Personalized prevention plan services
- Bone mass measurement
- Screenings for cancer, glaucoma, depression, diabetes and sexually transmitted infections
- Immunizations (including flu, pneumonia and Hepatitis B vaccines)
- Screening mammograms
- Pap smears
- Behavioral counseling to reduce alcohol misuse
- Behavioral therapy for cardiovascular disease and obesity
You pay $0
In network
Primary care physician: $0 copay.
Specialists: You pay a $55 copay after deductible.
Out of network
You pay a $25 copay.
Specialists: You pay 50% of approved amount
In network
Medical: You pay a $0 copay.
Behavioral health: You pay a $0 copay.
In network
Ambulatory surgical center: You pay a $325 copay after deductible.
Hospital: You pay a $425 copay after deductible.
Out of network
You pay 50% of the approved amount.
In network per admission
Days 1-7: You pay a $385 copay per day after deductible.
Days 8-90: You pay $0.
Days 90 and beyond: You pay $0.
Out of network
You pay 50% of the approved amount.
You're covered for up to 100 days each benefit period at a Medicare-certified facility.
In network
Days 1-20: You pay a $0 copay per day.
Days 21-100: You pay a $218 copay per day after deductible.
Out of network
You pay 50% of the approved amount.
You pay a $0-$40 copay.
You pay a $115 copay.
You pay a $45 copay.
There's a combined $50,000 lifetime limit for emergency and urgent care services received outside the U.S. and its territories.
You pay a $115 copay.
There's a combined $50,000 lifetime limit for emergency and urgent care services received outside the U.S. and its territories.
You pay a $360 copay.
There's a combined $50,000 lifetime limit for emergency and urgent care services received outside the U.S. and its territories.
In network
You pay 0%-20% of the cost after deductible.
Out of network
You pay 0%-50% of the approved amount.
In network
Emergency: You pay a $360 copay.
Out of network
Emergency: You pay a $360 copay after deductible.
Non-emergency: You pay 50% of the approved amount.
In network
Spinal manipulation: You pay a $15 copay after deductible.
Out of network
You pay 50% of the approved amount for spinal manipulation
In network
You pay a $55 copay after deductible.
Out of network
You pay 50% of the amount
Includes individual and group therapy visits.
In network
You pay a $50 copay after deductible.
Out of network
You pay 50% of the amount.
In network
Occupational therapy: You pay a $35 copay after deductible.
Physical therapy: You pay a $55 copay after deductible.
Speech therapy: You pay a $55 copay after deductible.
Out of network
You pay 50% of the amount.
In network
You pay a 20% of the cost after deductible.
Out of network
You pay 50% of the amount.
This plan has a $150 pharmacy deductible for tiers 3-5. You pay full price for drugs before you meet the deductible, except for Tiers 1 and 2, which has no deductible. You can save by going to a preferred pharmacy in our network. Check out the example of what you'll pay for a one-month supply at a preferred pharmacy compared with a standard pharmacy.
Commonly prescribed generic versions of brand medications. You’ll pay the least for these drugs at the pharmacy.
Preferred pharmacy: You pay $0.
Standard pharmacy: You pay $5.
Although you’ll pay more at the pharmacy for these generic drugs, they're more cost-effective than brand medications.
Preferred pharmacy: You pay $7.
Standard pharmacy: You pay $12.
Brand drugs that aren’t available yet as a generic.
Preferred pharmacy: You pay 20% of the cost.
Standard pharmacy: You pay 20% of the cost.
Because there are alternatives for the drugs in this tier, you’ll pay more for them at the pharmacy.
Preferred pharmacy: You pay 30% of the cost.
Standard pharmacy: You pay 30% of the cost.
Specialty drugs are used to treat complex conditions like cancer and multiple sclerosis. Although they can be generic or brand, they usually need special handling and approval. You may have to order them through a specialty pharmacy.
Preferred pharmacy: You pay 31% of the cost.
Standard pharmacy: You pay 31% of the cost.
Generic drugs: You pay a $0 copay.
Other drugs: You pay a $0 copay.
The benefit provides only preventive dental services
This plan covers the following dental services for $0 copay in-network and 50% coinsurance out-of-network (frequencies vary):
- Two oral exams per calendar year
- Two routine cleanings per calendar year
- Up to four bitewing X-rays or up to six periapical films every other calendar year
- Fluoride treatments one time per calendar year
Medicare-covered Dental: in-network $0-$55; out of network: 50% of the approved amount
What's not covered:
- Dental procedures like dentures, onlays and implants (available in optional supplemental benefit buy-up)
Add more dental and vision coverage (PDF) for an additional cost.
This plan covers these benefits:
Vision exams
- One routine eye exam every year for a $0 copay. You can choose any provider from the VSP Choice network.
- Out of network: 50% of the approved amount.
- $0 copay after deductible for one pair of Medicare-covered glasses or contact lenses after cataract surgery.
- Out of network: 50% of the approved amount
This plan also covers Medicare-covered exams. You'll just have a $0-$55 copayafter deductible. Out of network 50% of cost
Diabetic Retinopathy Eye Exam has a $0 copay after deductible.
How this compares:
- This plan offers more vision coverage than Original Medicare.
Add more dental and vision coverage (PDF) for an additional cost.
You pay:
- $0 for one hearing aid fitting and evaluation once a year through TruHearing.
- $0 copay for one routine hearing exam each year once a year through TruHearing
- New standard hearing aids once a year, per ear: $495-$1,695 copay through TruHearing.
- $0-$55 copay for Medicare-covered diagnostic hearing exams after deductible
- Out of network: 50% of the approved amount
How this compares:
Add more dental and vision coverage (PDF) for an additional cost.
This document lists important features and rules for this plan.
This booklet explains how to use this plan's benefits. It also lists some of the things this plan doesn't cover.
This brochure gives you an overview of all our Medicare Advantage PPO plans to help you compare.
Find a doctor or hospital in this plan's network:
Find a pharmacy in this plan's network:
If you meet certain income and resource limits, you may qualify for help paying for your prescription drug costs through the low-income subsidy.
If you're eligible, see what your monthly premium would be:
The easiest way to enroll in this plan is online. Or call us at 1-888-563-3307. TTY users call 711. You can also print, fill out and mail this paper application.
In-network services: $650
$150 deductible for tiers 3-5
In-network services: $9,250
Combined in- and out-of-network services: $11,000
Optional supplemental benefits don't count toward your out-of-pocket maximum.
You pay $0.
You pay $55.
You pay $0-$40.
Copays start at $0 for certain generic drugs filled at a preferred network pharmacy. Some drugs may cost more if you choose a pharmacy in our standard network.
See if this plan covers your medication. Find your prescription (PDF).
All benefits required by Original Medicare and more, including:
- $0 telehealth visits for primary care and behavioral health
- Worldwide emergency, urgent care and emergency transportation coverage
- Coverage for ambulance services not requiring transportation
- Mobile crisis and crisis stabilization for behavioral health
- Coverage while traveling outside of Michigan with the nationwide network of Blue Plan Providers program (PDF).
This is a PPO plan. PPO stands for preferred provider organization. It's a group of health care professionals that provide services to members. You can choose the doctors you want to see, but pay less when you see a doctor in our network. Find a doctor in this plan's network.
Includes services such as:
- Welcome to Medicare exam
- Personalized prevention plan services
- Bone mass measurement
- Screenings for cancer, glaucoma, depression, diabetes and sexually transmitted infections
- Immunizations (including flu, pneumonia and Hepatitis B vaccines)
- Screening mammograms
- Pap smears
- Behavioral counseling to reduce alcohol misuse
- Behavioral therapy for cardiovascular disease and obesity
You pay $0
In network
Primary care physician: $0 copay.
Specialists: You pay a $55 copay after deductible.
Out of network
You pay a $25 copay.
Specialists: You pay 50% of approved amount
In network
Medical: You pay a $0 copay.
Behavioral health: You pay a $0 copay.
In network
Ambulatory surgical center: You pay a $325 copay after deductible.
Hospital: You pay a $425 copay after deductible.
Out of network
You pay 50% of the approved amount.
In network per admission
Days 1-7: You pay a $385 copay per day after deductible.
Days 8-90: You pay $0.
Days 90 and beyond: You pay $0.
Out of network
You pay 50% of the approved amount.
You're covered for up to 100 days each benefit period at a Medicare-certified facility.
In network
Days 1-20: You pay a $0 copay per day.
Days 21-100: You pay a $218 copay per day after deductible.
Out of network
You pay 50% of the approved amount.
You pay a $0-$40 copay.
You pay a $115 copay.
You pay a $45 copay.
There's a combined $50,000 lifetime limit for emergency and urgent care services received outside the U.S. and its territories.
You pay a $115 copay.
There's a combined $50,000 lifetime limit for emergency and urgent care services received outside the U.S. and its territories.
You pay a $360 copay.
There's a combined $50,000 lifetime limit for emergency and urgent care services received outside the U.S. and its territories.
In network
You pay 0%-20% of the cost after deductible.
Out of network
You pay 0%-50% of the approved amount.
In network
Emergency: You pay a $360 copay.
Out of network
Emergency: You pay a $360 copay after deductible.
Non-emergency: You pay 50% of the approved amount.
In network
Spinal manipulation: You pay a $15 copay after deductible.
Out of network
You pay 50% of the approved amount for spinal manipulation
In network
You pay a $55 copay after deductible.
Out of network
You pay 50% of the amount
Includes individual and group therapy visits.
In network
You pay a $50 copay after deductible.
Out of network
You pay 50% of the amount.
In network
Occupational therapy: You pay a $35 copay after deductible.
Physical therapy: You pay a $55 copay after deductible.
Speech therapy: You pay a $55 copay after deductible.
Out of network
You pay 50% of the amount.
In network
You pay a 20% of the cost after deductible.
Out of network
You pay 50% of the amount.
This plan has a $150 pharmacy deductible for tiers 3-5. You pay full price for drugs before you meet the deductible, except for Tiers 1 and 2, which has no deductible. You can save by going to a preferred pharmacy in our network. Check out the example of what you'll pay for a one-month supply at a preferred pharmacy compared with a standard pharmacy.
Commonly prescribed generic versions of brand medications. You’ll pay the least for these drugs at the pharmacy.
Preferred pharmacy: You pay $0.
Standard pharmacy: You pay $5.
Although you’ll pay more at the pharmacy for these generic drugs, they're more cost-effective than brand medications.
Preferred pharmacy: You pay $7.
Standard pharmacy: You pay $12.
Brand drugs that aren’t available yet as a generic.
Preferred pharmacy: You pay 20% of the cost.
Standard pharmacy: You pay 20% of the cost.
Because there are alternatives for the drugs in this tier, you’ll pay more for them at the pharmacy.
Preferred pharmacy: You pay 30% of the cost.
Standard pharmacy: You pay 30% of the cost.
Specialty drugs are used to treat complex conditions like cancer and multiple sclerosis. Although they can be generic or brand, they usually need special handling and approval. You may have to order them through a specialty pharmacy.
Preferred pharmacy: You pay 31% of the cost.
Standard pharmacy: You pay 31% of the cost.
Generic drugs: You pay a $0 copay.
Other drugs: You pay a $0 copay.
The benefit provides only preventive dental services
This plan covers the following dental services for $0 copay in-network and 50% coinsurance out-of-network (frequencies vary):
- Two oral exams per calendar year
- Two routine cleanings per calendar year
- Up to four bitewing X-rays or up to six periapical films every other calendar year
- Fluoride treatments one time per calendar year
Medicare-covered Dental: in-network $0-$55; out of network: 50% of the approved amount
What's not covered:
- Dental procedures like dentures, onlays and implants (available in optional supplemental benefit buy-up)
Add more dental and vision coverage (PDF) for an additional cost.
This plan covers these benefits:
Vision exams
- One routine eye exam every year for a $0 copay. You can choose any provider from the VSP Choice network.
- Out of network: 50% of the approved amount.
- $0 copay after deductible for one pair of Medicare-covered glasses or contact lenses after cataract surgery.
- Out of network: 50% of the approved amount
This plan also covers Medicare-covered exams. You'll just have a $0-$55 copayafter deductible. Out of network 50% of cost
Diabetic Retinopathy Eye Exam has a $0 copay after deductible.
How this compares:
- This plan offers more vision coverage than Original Medicare.
Add more dental and vision coverage (PDF) for an additional cost.
You pay:
- $0 for one hearing aid fitting and evaluation once a year through TruHearing.
- $0 copay for one routine hearing exam each year once a year through TruHearing
- New standard hearing aids once a year, per ear: $495-$1,695 copay through TruHearing.
- $0-$55 copay for Medicare-covered diagnostic hearing exams after deductible
- Out of network: 50% of the approved amount
How this compares:
Add more dental and vision coverage (PDF) for an additional cost.
This document lists important features and rules for this plan.
This booklet explains how to use this plan's benefits. It also lists some of the things this plan doesn't cover.
This brochure gives you an overview of all our Medicare Advantage PPO plans to help you compare.
Find a doctor or hospital in this plan's network:
Find a pharmacy in this plan's network:
If you meet certain income and resource limits, you may qualify for help paying for your prescription drug costs through the low-income subsidy.
If you're eligible, see what your monthly premium would be:
The easiest way to enroll in this plan is online. Or call us at 1-888-563-3307. TTY users call 711. You can also print, fill out and mail this paper application.
Enhance your dental and vision coverage
You can add an optional supplemental package to your Medicare Advantage plan for an additional monthly cost. It offers:
- Extra coverage for dental work including dentures, bridges and implants.
- A generous allowance for elective contact lenses or glasses (lenses and frames). Polycarbonate lenses and anti reflective coating are covered in network.
To get help choosing a plan, call 1-866-875-1375. TTY users dial 711.
Information about SilverSneakers
SilverSneakers® is a registered trademark of Tivity Health, Inc.© 2025 Tivity Health, Inc. All rights reserved. Tivity Health is an independent corporation retained by Blue Cross Blue Shield of Michigan and Blue Care Network to provide health and fitness services to our members.
Information about TruHearing
TruHearing is an independent company contracted to provide hearing services on behalf of Blue Cross Blue Shield of Michigan and Blue Care Network.