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Medicare Plus Blue + Meijer (PPO) - H9572-007-004

4.5 out of 5 stars* for plan year 2025

$0.00

Monthly Premium

Medicare Plus Blue + Meijer (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Blue Cross Blue Shield of Michigan

Plan ID: H9572-007-004

* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.

$0.00

Monthly Premium

Michigan Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.

Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.

Learn more about Michigan Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.

Basic Costs and Coverage

CoverageDetails
Monthly plan premium$0.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$0.00
Out-of-pocket maximum$6,750.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$2,000.00
Primary care doctor visitIn-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0
Specialty doctor visit
Out-of-Network:

Doctor Specialty Visit Services:
Copayment for Medicare Covered Physician Specialist Office Visit $55
A member will be allowed one dermatological screening examination per lifetime if it is performed by a dermatologist. Specialty Care Physician cost share will apply for this procedure.
Inpatient hospital careIn-Network:

Acute Hospital Services:
$425 per day for days 1 to 7
$0 per day for days 8 to 90

Prior Authorization Required for Acute Hospital Services

Out-of-Network:
50% coinsurance for days 1 to 7
$0 per day for days 8 to 90
Urgent care
Urgent Care:
Copayment for Urgent Care $0 to $55

Minimum copayment amount applies to services provided in PCP office. Maximum copayment amount applies to a services provided in an urgent care facility.

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $55
Maximum Plan Benefit of $50,000
Emergency room visit
Emergency Care:
Copayment for Emergency Care $125

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $125
Copayment for Worldwide Emergency Transportation $290
Maximum Plan Benefit of $50,000
Ambulance transportationIn-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $350

Air Ambulance:
Copayment for Air Ambulance Services $350

Out-of-Network:

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $350
Coinsurance for Medicare Covered Ambulance Services - Ground 50%
Copayment for Medicare Covered Ambulance Services - Air $350
Coinsurance for Medicare Covered Ambulance Services - Air 50%
(Please see Evidence of Coverage for details)

Health Care Services and Medical Supplies

Medicare Plus Blue + Meijer (PPO) covers a range of additional benefits. Learn more about Medicare Plus Blue + Meijer (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

CoverageDetails
Chiropractic servicesIn-Network:

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $15
Copayment for Routine Care $50
1 Routine Care every year
Medicare covers limited acupuncture services for chronic low back pain.The copay for Medicare-covered acupuncture is the same as Medicare covered Chiropractic services.

Chiropractic X-rays (1 visit/year) $35


Out-of-Network:

Medicare Covered Chiropractic Services:
Coinsurance for Medicare Covered Chiropractic Services 50%
Copayment for Routine Care $55
Medicare covers limited acupuncture services for chronic low back pain.The copay for Medicare-covered acupuncture is the same as Medicare covered Chiropractic services.
Chiropractic X-rays (1 visit/year) 50%
Diabetes supplies, training, nutrition therapy and monitoring
In-Network:

Diabetic Supplies and Services:
Copayment for Medicare-covered Diabetic Supplies $0
Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0

Out-of-Network:
Copayment for Medicare-covered Diabetic Supplies $0
Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0
Durable medical equipment (DME)In-Network:

Durable Medical Equipment:
Coinsurance for Medicare-covered Durable Medical Equipment 0% to 20%
Prior Authorization Required for Durable Medical Equipment
Out-of-Network:

Medicare Covered Durable Medical Equipment Services:
Coinsurance for Medicare Covered Durable Medical Equipment 0% to 50%
Diagnostic tests, lab and radiology services, and X-raysIn-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0/$50/$150
Copayment for Medicare-covered Lab Services $0 to $40
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services
$0 cost share applies to COVID-19 testing. $50 applies to procedures performed in a professional office setting. The maximum applies to procedures performed in an outpatient setting.

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $150 to $250
Copayment for Medicare-covered Therapeutic Radiological Services $35
Copayment for Medicare-covered X-Ray Services $35 to $150

Out-of-Network:

Medicare Covered Diagnostic Procedures/Tests Services:
Copayment for Medicare Covered Diagnostic Procedures/Tests
$0 to $55
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%
$0 cost share applies to COVID-19 testing. $50 applies to procedures performed in a professional office setting. The maximum applies to procedures performed in an outpatient setting.
Home health careIn-Network:

Home Health Services:
Copayment for Medicare-covered Home Health Services $0
Prior Authorization Required for Home Health Services
Mental health inpatient careIn-Network:

Psychiatric Hospital Services:
$300 per day for days 1 to 7
$0 per day for days 8 to 90

Prior Authorization Required for Psychiatric Hospital Services

Out-of-Network:
50% coinsurance for days 1 to 7
$0 per day for days 8 to 90
Mental health outpatient careIn-Network:

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $20
Copayment for Medicare-covered Group Sessions $20


Out-of-Network: 50% Coinsurance
Outpatient services/surgery
Out-of-Network:

Medicare Covered Outpatient Hospital Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 50%
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 50%

Copayment for Medicare Covered Observation Services 50%
Outpatient substance abuse careIn-Network:
Copayment for Medicare-covered Individual Sessions $50
Copayment for Medicare-covered Group Sessions $50


Out-of-Network: $55 copay
Over-the-counter itemsIn-Network:

Over-The-Counter (OTC) Items:
Maximum Plan allowance of $160 every three months
The benefit is administered through a plan approved network of retail and mail order partners.
(Please see Evidence of Coverage for details)
Podiatry servicesIn-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $55
Prior Authorization Required for Podiatry Services

Out-of-Network:

Medicare Covered Podiatry Services:
Copayment for Medicare Covered Podiatry Services $55
Skilled Nursing Facility (SNF) careIn-Network:

Skilled Nursing Facility Services:
$0 per day for days 1 to 20
$214 per day for days 21 to 100

Prior Authorization Required for Skilled Nursing Facility Services

Out-of-Network:
50% coinsurance

Dental Benefits

The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Dental careIn-network: $0-$50 copay
Out-of-network: $55 copay

$1,500 combined in- and out-of-network allowance for preventative and comprehensive dental
Preventive dental services: Cleaning (2 every calendar year): In-network: You pay nothing Out-of-network: 50% of the cost
Dental x-ray(s) One set of up to 4 bitewings or 6 periapical films every 2 calendar years) Full Mouth X-Rays (every 5 years) : In-network: You pay nothing Out-of-network: 50% of the cost
Fluoride Treatment (1 visit per calendar year)In-network: You pay nothing Out-of-network: 50% of the cost

$0 copay in-network and 50% coinsurance out-of-network for the following services: Restorative Services: Amalgam and resin fillings once per tooth every 48 months, Crown repairs, Crowns (once per permanent tooth every 84 months), Endodontic:Root canals once/lifetime per tooth, Periodontics-Deep Cleaning 1 per 24 months per quadrant, Extractions-Simple extractions once per tooth per lifetime, Oral Surgery (Prosthodontics/Other/Oral Maxiofacial Surgery and other services), Brush Biopsy 2 per calendar year
(Please see Evidence of Coverage for details)

Vision Benefits

The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage

CoverageDetails
Vision careIn-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0 to $50
Copayment for Routine Eye Exams $0
Maximum 1 Routine Eye Exam every year
Other Services-Lasik/RK $50
Eyewear:
Copayment for Medicare-Covered Benefits $0
Copayment for Contact Lenses $0
Maximum 1 Pair (Please see Evidence of Coverage for details)
Copayment for Eyeglass Lenses $0
Maximum 1 Pair (Please see Evidence of Coverage for details)
Copayment for Eyeglass Frames $0
Maximum 1 Pair (Please see Evidence of Coverage for details)
Maximum Plan Benefit of $150 every year
The mandatory vision benefit provides a $150 maximum benefit every calendar year that applies to frames and elective contact lenses only. The maximum does not apply to eyeglass lenses or medically necessary contact lenses. Benefit may be used for contact lenses or one pair of frames, but not both. One pair of lenses for glasses covered every calendar year.Routine vision care must be obtained through a plan contracted vision provider.

Out-of-Network:

Medicare Covered Eye Exams Services:
Coinsurance for Medicare Covered Eye Exams $55
Coinsurance for Medicare Covered Eyewear 50%
Routine Eye Exams (Covered every year) 50%
Other Services-Lasik/ $55
(Please see Evidence of Coverage for details)

Hearing Benefits

The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Hearing careIn-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $0 to $50
Copayment for Routine Hearing Exams $0 to $50
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0
  • Maximum 1 visit every three years
Minimum copay reflects Primary Care Physician services and maximum applies to Specialty Care Physician services.

Hearing Aids:
Copayment for Hearing Aids $0
  • Maximum 2 Hearing Aids every three years
Maximum Plan Benefit of $750 every three years
Hearing Aids $1,500 maximum allowance for both ears (up to $750 per ear) every 3 years for new hearing aids.

Out-of-Network:

Medicare Covered Hearing Exams Services:
Copayment for Medicare Covered Hearing Exams $55
Copayment for Routine Hearing Exams $55
Coinsurance for Fitting/Evaluation for Hearing Aids 50%

(Please see Evidence of Coverage for details)

Preventive Services and Health/Wellness Education Programs

The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Preventive services and health/wellness education programs
Out-of-Network:

Medicare Covered Medicare-covered Preventive Services:
Copayment for Medicare Covered Medicare-covered Preventive Services $0

When reviewing Michigan Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.

You may be able to find plans in your part of Michigan that offer similar benefits at similar or lower prices than the plan above. Call 1-888-876-5731 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.

Plan Documents

Links to plan documents

Michigan Counties Served

We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.

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