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Medicare Plus Blue PPOSM benefit comparison

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For Medicare-eligible Michigan residents

Summary of most frequently used benefits. You may also wish to download this benefit comparison (PDF 413KB).

Benefit for Medicare-covered services PPO Vitality PPO Signature PPO Assure
In-network Out-of-network In-network Out-of-network In-network Out-of-network
Out-of-pocket maximum for Medicare-covered medical services $5,500 $3,700 $5,000 $5,000 $4,000 $4,000

The plan covers 100% of our allowed amount after the out-of-pocket maximums are reached.
Out-of-pocket maximum for durable medical equipment and prosthetic and orthotic devices $1,000 $1,000 $1,000
Deductible $0 $500 $0 $500 $0 $0
Inpatient hospital care

Days 1-7:
$205 per day

Days 8-90:
$0 Copayment

 25% coinsurance

Days 1-5:
$160 per day

Days 6-90:
$0 Copayment

 40% coinsurance

Days 1-5:
$90 per day

Days 6-90:
$0 Copayment

 30% coinsurance
Skilled nursing facility (in a Medicare-certified skilled nursing facility)

Days 1-20:
$0 copay per day

Days 21-100:
$130 copay per day

 40% coinsurance for each stay

Days 1-20:
$0 copay per day

Days 21-100:
$130 copay per day

 40% coinsurance for each stay

Days 1-20:
$0 copay per day

Days 21-100:
$130 copay per day

 30% coinsurance for each stay
Outpatient hospital services $40 to $175 copay 40% coinsurance $30 to $150 copay 40% coinsurance $20 to $10 copay 30% coinsurance
Office visits: primary care physicians $25 copay 40% coinsurance $25 copay 40% coinsurance $15 copay 30% coinsurance
Office visits: specialists $45 copay 40% coinsurance $40 copay 40% coinsurance $35 copay 30% coinsurance

No referrals required.
Outpatient surgery $100 copay ambulatory; $175 hospital 40% coinsurance $75 copay ambulatory; $150 hospital 40% coinsurance $50 copay ambulatory; $100 hospital 30% coinsurance
Ambulance services $50 copay 40% coinsurance $50 copay 40% coinsurance $50 copay 30% coinsurance
Urgent care – worldwide $35 copay $35 copay $30 copay $30 copay $30 copay $30 copay
Emergency care – within the U.S. $65 copay $65 copay $65 copay $65 copay $65 copay $65 copay
Durable medical equipment 20% coinsurance 40% coinsurance 20% coinsurance 40% coinsurance 20% coinsurance 40% coinsurance
Preventive services $0 copay 40% coinsurance $0 copay 40% coinsurance $0 copay 30% coinsurance

Preventive services such as Welcome to Medicare exam, Personal Prevention Plan Services, bone mass measurement, colorectal screening, glaucoma screening, immunizations (including flu, pneumonia and Hepatitis B vaccines), mammograms, Pap smears and prostate screening.

New preventive benefits include: screening and behavioral counseling interventions to reduce alcohol misuse, screening for depression in adults, screening for sexually transmitted infections and behavioral counseling to prevent STIs, and behavioral therapy for cardiovascular disease and obesity. New preventive benefits PDF (Coming soon.)
Physical exams one per year - primary care physicians $25 copay 40% coinsurance $25 copay 40% coinsurance $15 copay 30% coinsurance
Physical exams one per year - specialists $45 copay 40% coinsurance $40 copay 40% coinsurance $35 copay 30% coinsurance
Chiropractic $20 copay 40% coinsurance $20 copay 40% coinsurance $20 copay 30% coinsurance
Podiatry $45 copay 40% coinsurance $40 copay 40% coinsurance $35 copay 30% coinsurance
Preventive dental Up to two exams a year, up to two cleanings a year, up to one dental x-ray every two years. $0 copay in-network. 50% of the approved amount out-of-network (for oral exams, cleanings and x-rays).
Vision Eye glasses or contacts every two years. Eye exams, one per year. Copays apply.
Hearing Up to two hearing aids every three years ($500 per ear every three years). Diagnostic exam every year, hearing test every year, hearing aid fitting evaluation every three years. Copays apply.
SilverSneakers fitness $0 copay for covered fitness program benefits provided by a SilverSneakers facility.
Bathroom safety bars 50% coinsurance for up to $100 combined annual maximum. Installation not covered. 50% coinsurance, after deductible, for up to $100 combined annual maximum. Installation not covered. 50% coinsurance for up to $100 combined annual maximum. Installation not covered. 50% coinsurance, after deductible, for up to $100 combined annual maximum. Installation not covered. 50% coinsurance for up to $100 combined annual maximum. Installation not covered. 50% coinsurance, after deductible, for up to $100 combined annual maximum. Installation not covered.
Part D prescription drugs—initial coverage period (until your total drug costs reach $2,930)

$320 deductible

25% coinsurance for most drugs
Tier 1 Preferred generic $3
Tier 2 Preferred brand $45
Tier 3 Non-preferred brand/generic $95
Tier 4 Injectable 25%*
Tier 5 Specialty 30%*

*of plan's approved amount
Tier 1 Preferred generic $3
Tier 2 Preferred brand $40
Tier 3 Non-preferred brand/generic $95
Tier 5 Injectable 25%*
Tier 4 Specialty 30%*

*of plan's approved amount
Part D prescription drugs - gap period (after your drug costs reach $2,930 until they reach $4,700) 100% coinsurance 100% coinsurance Includes $3 generics coverage in the coverage gap.
Part D prescription drugs - catastrophic period (after your drug costs reach $4,700) $2.60 copay for generic drugs and $6.50 copay for other drugs or 5% coinsurance, whichever is greater (out of network, you will not be reimbursed for the difference between the pharmacy’s charge and our in-network allowable amount)

You don't need to be a member to get our help. If you have questions or concerns, would like to find an agent or need assistance with enrolling, please call: 1-877-469-2583

  • TTY users call 1-800-481-8704
  • 8 a.m. to 8 p.m. seven days a week

Monthly Premium Table for Medicare Plus Blue PPO Plans

The premiums vary by the county in which you permanently reside.
Rates are based on the use and cost of health care services in each region.
You must continue to pay your Medicare Part B premium.

  1. Locate the region/county in which you permanently reside.
  2. Look at the plan options to find your monthly premium rate.
Region with counties in region Vitality Signature Assure
Region 1

Southwest Michigan
Allegan, Kent, Muskegon, Newaygo, Ottawa

 $38 $83 $139
Region 2

Mid-Michigan
Barry, Berrien, Cass, Clinton, Eaton, Ingham, Ionia, Kalamazoo, Van Buren

 $43 $118 $172
Region 3

Upper Michigan
Alcona, Alger, Alpena, Antrim, Baraga, Benzie, Charlevoix, Cheboygan, Chippewa, Crawford, Delta, Dickinson, Emmett, Gogebic, Grand Traverse, Houghton, Iron, Kalkaska, Keweenaw, Leelanau, Luce, Mackinac, Marquette, Menominee, Montmorency, Ontonagon, Oscoda, Otsego, Presque Isle, Schoolcraft

 $78 $128 $231
Region 4

South Michigan
Branch, Calhoun, Hillsdale, Jackson, Lenawee, Livingston, Monroe, St. Joseph, Washtenaw

 $63 $143 $204
Region 5

North/East Michigan
Arenac, Bay, Clare, Genesee, Gladwin, Gratiot, Huron, Iosco, Isabella, Lake, Lapeer, Manistee, Mason, Mecosta, Midland, Missaukee, Montcalm, Oceana, Ogemaw, Osceola, Roscommon, Saginaw, St. Clair, Sanilac, Shiawassee, Tuscola, Wexford

 $73 $163 $238
Region 6

Southeast Michigan
Macomb, Oakland, Wayne

 $78 $118 $222

You don't need to be a member to get our help. If you have questions or concerns, would like to find an agent or need assistance with enrolling, please call: 1-877-469-2583

  • TTY users call 1-800-481-8704
  • 8 a.m. to 8 p.m. seven days a week

H9572 S5584_W_12BCBSMAdvantageWebR2 CMS Approved 04262012

People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If eligible, Medicare could pay for up to seventy-five (75) percent of drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don't even know it. For more information about the Extra Help program, contact your local Social Security office or call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, seven days per week. TTY users should call 1-877-486-2048.

Important information about these plans

Medicare Plus Blue PPOSM is a health plan with a Medicare contract.

Medicare Plus Blue PPO is available to all Medicare beneficiaries who are Michigan residents and are entitled to receive services under Medicare Part A and enrolled in Part B.

With the exception of emergency or urgent care, it will cost more to get care from non-plan or non-preferred providers. Your responsibility will be greater out-of-network when the out-of-network coinsurance is based on the Medicare allowed amount and the contracted amount is lower. You may receive services from any provider who accepts Original Medicare. Your out-of-pocket costs will be lower if you choose a network provider. To find a network provider, visit www.bcbsm.com/medicare/provdirectory.shtml.

Premiums vary by county. You must continue to pay your Medicare Part B premium.

Limitations, copayments and restrictions may apply.

Our network includes approximately 2,300 Michigan retail pharmacies, of which 86 percent are network pharmacies. Nationwide, most chain pharmacies are in our network, as well as long-term care and home infusion pharmacies and Indian/Tribal/Urban (Indian Health Service) pharmacies.

In general, benefits are only available at contracted network pharmacies. Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost sharing amount if you get your drugs at an out-of-network pharmacy. Quantity limitation and restrictions may apply. In addition, you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from Blue Cross Blue Shield of Michigan. For additional information on network pharmacies, please call Member Services at 1-877-469-2583, 8 a.m. to 8 p.m. seven days a week. TTY users should call 1-800-481-8704. You may also write to: Blue Cross Blue Shield of Michigan, 600 E. Lafayette Blvd., Mail Code X435, Detroit, MI 48226.

If you decide to have your plan premium withheld from your Social Security check or deducted from your checking or savings account, it may take up to three months for the automatic deduction to begin. If your premium amount is currently withheld from your Social Security check or deducted from your checking or savings account and you wish to receive a monthly bill instead, the change may also take up to three months to become effective. During this time, you will be responsible for paying your premium.

The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact the plan. Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on Jan. 1, 2013.

Medicare beneficiaries may enroll in Medicare Plus Blue PPO through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov. For more information, please contact Blue Cross Blue Shield of Michigan at 1-877-469-2583, 8 a.m. to 8 p.m. seven days a week. TTY users should call 1-800-481-8704. To learn more about enrollment periods, please contact Member Services.