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Medicare Plus Blue PPO Vitality (PPO) - H9572-002-006

4.5 out of 5 stars* for plan year 2025

$72.00

Monthly Premium

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

Plan ID: H9572-002-006

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

$72.00

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$72.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$0.00
Out-of-pocket maximum$5,000.00
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 visitIn-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $30
A member will be allowed one dermatological screening examination per lifetime if it is performed by a dermatologist.

Out-of-Network:

Doctor Specialty Visit Services:
Coinsurance for Medicare Covered Physician Specialist Office Visit 40%
A member will be allowed one dermatological screening examination per lifetime if it is performed by a dermatologist.
Inpatient hospital careIn-Network:

Acute Hospital Services:
$250 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: 40% of the cost per stay
Urgent care
Urgent Care:
Copayment for Urgent Care $0 to $50

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 $50
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 $325
Maximum Plan Benefit of $50,000
Ambulance transportationIn-Network:
Ground Ambulance:
Copayment for Ground Ambulance Services $325

Air Ambulance:
Copayment for Air Ambulance Services $325

Out-of-Network:
Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $325
Coinsurance for Medicare Covered Ambulance Services - Ground 40%
Copayment for Medicare Covered Ambulance Services - Air $325
Coinsurance for Medicare Covered Ambulance Services - Air 40%
(Please see Evidence of Coverage for details)

Health Care Services and Medical Supplies

Medicare Plus Blue PPO Vitality (PPO) covers a range of additional benefits. Learn more about Medicare Plus Blue PPO Vitality (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 $30
  • 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 40%
Coinsurance for Routine Care 40%
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) 40%
Diabetes supplies, training, nutrition therapy and monitoringIn-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: $0 copay
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 40%
Diagnostic tests, lab and radiology services, and X-raysIn-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0/$30/$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. $30 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 $100 to $150
Copayment for Medicare-covered Therapeutic Radiological Services $35
Copayment for Medicare-covered X-Ray Services $35 to $150
(Please see Evidence of Coverage for details)

Out-of-Network:

Medicare Covered Diagnostic Procedures/Tests Services:
Copayment for Medicare Covered Diagnostic Procedures/Tests $0
Coinsurance for Medicare Covered Diagnostic Procedures/Tests 40%
Coinsurance for Medicare Covered Lab Services 40%
Coinsurance for Medicare Covered Diagnostic Radiological Services 40%
Coinsurance for Medicare Covered Therapeutic Radiological Services 40%
Coinsurance for Medicare Covered Outpatient X-Ray Services 40%
$0 cost share applies to COVID-19 testing.
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:
$250 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: 40% of the cost per stay
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: 40% Coinsurance
Outpatient services/surgeryIn-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $150 to $220
Prior Authorization Required for Outpatient Hospital Services
Minimum copay applies to all non-surgical services performed in an outpatient setting, such as therapeutic services, pulmonary & osteopathic services. Maximum copay applies to surgical services performed in an outpatient setting.

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services $0

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0 to $125
Prior Authorization Required for Ambulatory Surgical Center Services
Minimum copay applies to arthroplasty knee and hip.$100 applies to non-surgical services performed in an ambulatory surgical center.Maximum copay applies to outpatient surgical services performed in an ambulatory surgical center.

Out-of-Network:

Medicare Covered Outpatient Hospital Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 40%
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 40%
Outpatient Observation Services:
Copayment for Medicare Covered Observation Services 40%
Outpatient substance abuse careIn-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $30
Copayment for Medicare-covered Group Sessions $30
Out-of-Network: 40% Coinsurance
Over-the-counter itemsIn-Network:

Over-The-Counter (OTC) Items:
Maximum plan allowance of $50.00 every three months for Over-The-Counter (OTC) Items(no rollover)
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 $30
Prior Authorization Required for Podiatry Services

Out-of-Network:

Medicare Covered Podiatry Services:
Coinsurance for Medicare Covered Podiatry Services 40%
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: 40% of the cost per stay

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-$30 copay
Out-of-network: 40% of the cost

$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): 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, 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 $30
Copayment for Routine Eye Exams $0
Maximum 1 Routine Eye Exam every year
Other Services- LASIK/RK $30

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.

Please see Evidence of Coverage for more details.

Out-of-Network:

Medicare Covered Eye Exams Services:
Coinsurance for Medicare Covered Eye Exams 40%
Coinsurance for Medicare Covered Eyewear 40%
Routine Eye Exams (Covered every year) 50%
Other Services-Lasik/RK 40%
(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 $30
Copayment for Routine Hearing Exams $0 to $30
  • 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:
Coinsurance for Medicare Covered Hearing Exams 50%
Coinsurance for Routine Hearing Exams 50%
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 programsIn-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
Shots:
  • COVID-19 shots
Flu shotsHepatitis B shotsPneumococcal shots
Tobacco use cessation
Yearly "Wellness" visit

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 1-800-298-2106 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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