This Blue Cross Blue Shield of Michigan plan offers great coverage at an affordable price. You'll pay less for office visits, have a lower out-of-pocket maximum and access to doctors without a referral.
NETWORK SIZE
MONTHLY PREMIUM
$
Medical deductible
$0
$0.00 monthly payment for 48002
In-network services: $0
Out-of-network services: $0
$0
In-network services: $5,000
Combined in- and out-of-network services: $6,700
Optional supplemental benefits don't count toward your out-of-pocket maximum.
You pay $0.
You pay $30.
You pay $0-$50.
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:
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:
You pay $0
Primary care physician: $0 copay.
Specialists: You pay a $30 copay.
You pay 40% of the approved amount.
Medical: You pay a $0 copay.
Behavioral health: You pay a $0 copay.
Ambulatory surgical center: You pay $0-$125.
Hospital: You pay $220.
You pay 40% of the approved amount.
Days 1-7: You pay a $250 copay per day.
Days 8-90: You pay $0.
Days 90 and beyond: You pay $0.
You pay 40% of the approved amount.
You're covered for up to 100 days each benefit period at a Medicare-certified facility.
Days 1-20: You pay a $0 copay per day.
Days 21-100: You pay a $218 copay per day.
You pay 40% of the approved amount.
You pay a $0-$50 copay.
You pay a $130 copay.
You pay a $50 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 $130 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 $325 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 0%-20% of the cost.
You pay 0%-40% of the approved amount.
Emergency: You pay a $325 copay.
Emergency: You pay a $325 copay.
Non-emergency: You pay 40% of the approved amount.
Spinal manipulation: You pay a $15 copay.
Routine chiropractic, one visit per year: You pay a $30 copay.
X-rays, one visit per year: You pay a $35 copay.
You pay 40% of the approved amount.
You pay a $30 copay.
You pay 40% of the approved amount.
Includes individual and group therapy visits.
You pay a $20 copay.
You pay 40% of the approved amount.
You pay a $40 copay.
You pay 40% of the approved amount.
You pay a 20% of the cost.
You pay 40% of the approved amount.
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 $11.
Standard pharmacy: You pay $16.
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 25% of the cost.
Standard pharmacy: You pay 25% 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 33% of the cost.
Standard pharmacy: You pay 33% of the cost.
Generic drugs: You pay a $0 copay.
Other drugs: You pay a $0 copay.
The benefit provides a $1,500 maximum per calendar year for combined in-network and out-of-network dental services.
This plan covers the following dental services for $0 copay in-network and 50% coinsurance out-of-network (frequencies vary):
Medicare-covered Dental exam: In-network $0-$30, Out of network 40% of the approved amount
What's not covered:
Add more dental and vision coverage (PDF) for an additional cost.
This plan covers these benefits:
Vision exams
This plan also covers Medicare-covered exams. You'll just have a $30 copay. Out of network: 40% of approved amount
Diabetic Retinopathy Eye Exam has a $0 copay.
Out of network: 40% of approved amount
How this compares:
Add more dental and vision coverage (PDF) for an additional cost.
You pay:
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 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: $0
Out-of-network services: $0
$0
In-network services: $5,000
Combined in- and out-of-network services: $6,700
Optional supplemental benefits don't count toward your out-of-pocket maximum.
You pay $0.
You pay $30.
You pay $0-$50.
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:
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:
You pay $0
Primary care physician: $0 copay.
Specialists: You pay a $30 copay.
You pay 40% of the approved amount.
Medical: You pay a $0 copay.
Behavioral health: You pay a $0 copay.
Ambulatory surgical center: You pay $0-$125.
Hospital: You pay $220.
You pay 40% of the approved amount.
Days 1-7: You pay a $250 copay per day.
Days 8-90: You pay $0.
Days 90 and beyond: You pay $0.
You pay 40% of the approved amount.
You're covered for up to 100 days each benefit period at a Medicare-certified facility.
Days 1-20: You pay a $0 copay per day.
Days 21-100: You pay a $218 copay per day.
You pay 40% of the approved amount.
You pay a $0-$50 copay.
You pay a $130 copay.
You pay a $50 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 $130 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 $325 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 0%-20% of the cost.
You pay 0%-40% of the approved amount.
Emergency: You pay a $325 copay.
Emergency: You pay a $325 copay.
Non-emergency: You pay 40% of the approved amount.
Spinal manipulation: You pay a $15 copay.
Routine chiropractic, one visit per year: You pay a $30 copay.
X-rays, one visit per year: You pay a $35 copay.
You pay 40% of the approved amount.
You pay a $30 copay.
You pay 40% of the approved amount.
Includes individual and group therapy visits.
You pay a $20 copay.
You pay 40% of the approved amount.
You pay a $40 copay.
You pay 40% of the approved amount.
You pay a 20% of the cost.
You pay 40% of the approved amount.
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 $11.
Standard pharmacy: You pay $16.
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 25% of the cost.
Standard pharmacy: You pay 25% 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 33% of the cost.
Standard pharmacy: You pay 33% of the cost.
Generic drugs: You pay a $0 copay.
Other drugs: You pay a $0 copay.
The benefit provides a $1,500 maximum per calendar year for combined in-network and out-of-network dental services.
This plan covers the following dental services for $0 copay in-network and 50% coinsurance out-of-network (frequencies vary):
Medicare-covered Dental exam: In-network $0-$30, Out of network 40% of the approved amount
What's not covered:
Add more dental and vision coverage (PDF) for an additional cost.
This plan covers these benefits:
Vision exams
This plan also covers Medicare-covered exams. You'll just have a $30 copay. Out of network: 40% of approved amount
Diabetic Retinopathy Eye Exam has a $0 copay.
Out of network: 40% of approved amount
How this compares:
Add more dental and vision coverage (PDF) for an additional cost.
You pay:
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 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.
You can add an optional supplemental package to your Medicare Advantage plan for an additional monthly cost. It offers:
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.