Medicare Plus Blue PPO Essential (PPO)
Medicare Plus Blue PPO Essential (PPO) H9572-004 Plan Details
Medicare Plus Blue PPO Essential (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Blue Cross Blue Shield of Michigan
Plan ID: H9572-004
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Talk to a licensed agent today to find a plan that fits your needs.
$0.00
Monthly Premium
Medicare Plus Blue PPO Essential (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Blue Cross Blue Shield of Michigan
Plan ID: H9572-004
Have Medicare questions?
Talk to a licensed agent today to find a plan that fits your needs.
Medicare Plus Blue PPO Essential (PPO) H9572-004 Plan Details
Medicare Plus Blue PPO Essential (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Blue Cross Blue Shield of Michigan
Plan ID: H9572-004
Have Medicare questions?
Talk to a licensed agent today to find a plan that fits your needs.
$0.00
Monthly Premium
Michigan Counties Served
Gratiot
Montcalm
Ingham
Calhoun
Van Buren
Branch
Monroe
Saint Joseph
Hillsdale
Berrien
Eaton
Jackson
Kalkaska
Mason
Ottawa
Gladwin
Wayne
Kalamazoo
Oscoda
Midland
Cheboygan
Allegan
Montmorency
Isabella
Presque Isle
Iosco
Newaygo
Missaukee
Barry
Oakland
Lapeer
Macomb
Kent
Osceola
Tuscola
Wexford
Alcona
Alpena
Arenac
Muskegon
Antrim
Mecosta
Washtenaw
Bay
Lenawee
Clare
Genesee
Sanilac
Saginaw
Roscommon
Ogemaw
Shiawassee
Grand Traverse
Emmet
Crawford
Benzie
Otsego
Leelanau
Huron
Livingston
Oceana
Lake
Charlevoix
Saint Clair
Manistee
Gogebic
Baraga
Clinton
Keweenaw
Alger
Schoolcraft
Iron
Delta
Menominee
Dickinson
Mackinac
Cass
Marquette
Luce
Chippewa
Houghton
Ionia
Ontonagon
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $5200 Out-of-Network: N/A |
| Initial Coverage Limit | $5030 |
| Catastrophic Coverage Limit | $8,000 |
| Primary Care Doctor Visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0.00 Out-of-Network: Doctor Office Visit: Copayment for Medicare Covered Primary Care Office Visit $25.00 |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $45.00 Out-of-Network: Doctor Specialty Visit: Copayment for Medicare Covered Physician Specialist Office Visit $50.00 |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: $325.00 per day for days 1 to 6 $0.00 per day for days 7 to 90 Prior Authorization Required for Acute Hospital Services Prior authorization required Out-of-Network: Coinsurance for Acute Hospital Services per Stay 50% |
| Urgent Care | In- Network :Copayment for Urgent Care $0.00 to $50.00 Minimum copayment amount applies to services provided in PCP office. Maximum copayment amount applies to a services provided in an urgent care facility. Out-of-Network: Copayment for Urgent Care $0.00 to $50.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $50.00 Maximum Plan Benefit of $50,000 |
| Emergency Room Visit | Copayment for Emergency Care $90.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 3 days Worldwide Coverage: Copayment for Worldwide Emergency Coverage $90.00 Copayment for Worldwide Emergency Transportation $275.00 Maximum Plan Benefit of $50,000 Worldwide emergency urgently needed services and emergency transportation are subject to combined $50,000 lifetime maximum benefit. |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $275.00 Air Ambulance: Copayment for Air Ambulance Services $275.00 Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $275.00 Coinsurance for non-emergency- Ground 50% Copayment for Medicare Covered Ambulance Services - Air $275.00 Coinsurance for non-emergency - Air 50% |
Health Care Services and Medical Supplies
Medicare Plus Blue PPO Essential (PPO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).
| Coverage | Cost |
|---|---|
| Chiropractic Services | In-Network: Copayment for Medicare-covered Chiropractic Services $15.00 Copayment for Routine Care $45.00
Out-of-Network: Coinsurance for Medicare Covered Chiropractic Services 50% Coinsurance for Non-Medicare Covered Chiropractic Services 50% (See Evidence of Coverage for details) |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Copayment for Medicare-covered Diabetic Supplies $0.00 Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0.00 Prior Authorization Required for Diabetic Supplies and Services Prior authorization required Out-of-Network: Copayment for Medicare Covered Diabetic Supplies and Services $0.00 |
| Durable Medical Eqipment (DME) | In-Network: Coinsurance for Medicare-covered Durable Medical Equipment 0% to 20% Prior Authorization Required for Durable Medical Equipment Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Durable Medical Equipment 0% to 50% |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00 to $150.00 Copayment for Medicare-covered Lab Services $0.00 to $40.00 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $100.00 to $150.00 Copayment for Medicare-covered Therapeutic Radiological Services $35.00 Copayment for Medicare-covered X-Ray Services $35.00 to $150.00 Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services Out-of-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare Covered Diagnostic Procedures/Tests $0.00 Coinsurance for Medicare Covered Diagnostic Procedures/Tests 50% Coinsurance for Medicare Covered Lab Services 50% Coinsurance for Medicare Covered Diagnostic Radiological Services 50% Coinsurance for Medicare Covered Therapeutic Radiological Services 50% Coinsurance for Medicare Covered Outpatient X-Ray Services 50% (Please see Evidence of Coverage for details) Prior authorization required |
| Home Health Care | In-Network: Copayment for Medicare-covered Home Health Services $0.00 Prior Authorization Required for Home Health Services Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Home Health 50% |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $300.00 per day for days 1 to 6 $0.00 per day for days 7 to 90 Prior Authorization Required for Psychiatric Hospital Services Prior authorization required Out-of-Network: Coinsurance for Psychiatric Hospital Services per Stay 50% |
| Mental Health Outpatient Care | In-Network: Copayment for Medicare-covered Individual Sessions $20.00 Copayment for Medicare-covered Group Sessions $20.00 Out-of-Network: Coinsurance for Medicare Covered Individual Sessions 50% Coinsurance for Medicare Covered Group Sessions 50% |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $150.00 to $275.00 Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services $0.00 Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0.00 to $125.00 Prior Authorization Required for Ambulatory Surgical Center Services Prior authorization required Out-of-Network: Outpatient Hospital and ASC Services: Coinsurance for Medicare Covered Outpatient Hospital Services 50% Coinsurance for Medicare Covered Ambulatory Surgical Center Services 50% |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $45.00 Copayment for Medicare-covered Group Sessions $45.00 Out-of-Network: Coinsurance for Medicare Covered Individual or Group Sessions 50% |
| Over-the-counter (OTC) Items | In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0.00 Maximum Plan Benefit of $125.00 every three months Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit Out-of-Network: Over-The-Counter (OTC) Items: Copayment for Non-Medicare Covered Over-The-Counter (OTC) Items $0.00 Maximum Plan Benefit of $125.00 The unused amount is carried over but must be used within the same calendar year. |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $45.00 Prior Authorization Required for Podiatry Services Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Podiatry Services 50% |
| Skilled Nursing Facility Care | In-Network: Skilled Nursing Facility Services: $0.00 per day for days 1 to 20 $188.00 per day for days 21 to 100 Prior Authorization Required for Skilled Nursing Facility Services Prior authorization required Out-of-Network: Coinsurance for Skilled Nursing Facility Services per Stay 50% |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | In-Network: Preventive Dental: Copayment for Oral Exams $0.00
Comprehensive Dental: Copayment for Medicare-covered Benefits $0.00 to $45.00 Copayment for Diagnostic Services $0.00
Out-of-Network: Medicare Covered Dental Services: Coinsurance for Medicare Covered Comprehensive Dental 50% Non-Medicare Covered Dental Services: Coinsurance for Non-Medicare Covered Preventive Dental 50% Coinsurance for Non-Medicare Covered Comprehensive Dental 50% |
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | In-Network: Eye Exams: Copayment for Medicare Covered Benefits $0.00 to $45.00 Copayment for Routine Eye Exams $0.00
Eyewear: Copayment for Medicare-Covered Benefits $0.00 Copayment for Eyeglass Lenses $0.00
Out-of-Network: Medicare Covered Vision Services: Coinsurance for Medicare Covered Eye Exams 50% Coinsurance for Medicare Covered Eyewear 50% Non-Medicare Covered Vision Services: Coinsurance for Non-Medicare Covered Eye Exams 50% Coinsurance for Non-Medicare Covered Eyewear 50% |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $0.00 to $45.00 Copayment for Routine Hearing Exams $0.00 to $45.00
Hearing Aids: Copayment for Hearing Aids $0.00
Hearing Aids $1,500 maximum allowance for both ears (up to $750 per ear) every 3 years for new hearing aids. OTC hearing aids may be purchased using the over-the-counter items benefit. Out-of-Network: Medicare Covered Hearing Services: Coinsurance for Medicare Covered Hearing Exams 50% Non-Medicare Covered Hearing Services: Coinsurance for Non-Medicare Covered Hearing Exams 50% Copayment for Non-Medicare Covered Hearing Aids $0.00 |
Preventive Services and Health/Wellness Education Programs
The following services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Preventive Services and Health/Wellness Education Programs | In-Network: $0.00 copay for Medicare Covered Preventive Services: Abdominal aortic aneurysm screening Alcohol misuse screenings & counseling Bone mass measurements (bone density) Cardiovascular disease screenings Cardiovascular disease (behavioral therapy) Cervical & vaginal cancer screening Colorectal cancer screenings Depression screenings Diabetes screenings Diabetes self-management training Glaucoma tests Hepatitis B (HBV) infection screening Hepatitis C screening test HIV screening Lung cancer screening Mammograms (screening) Nutrition therapy services Obesity screenings & counseling One-time Welcome to Medicare preventive visit Prostate cancer screenings(PSA) Sexually transmitted infections screening & counseling Immunization Shots:
Yearly "Wellness" visit Out-of-Network: Medicare-covered Zero Dollar Preventive Services: Copayment for Medicare Covered Medicare-covered Preventive Services $0.00 |
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