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Medicare Plus Blue Essential (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Medicare Plus Blue Essential (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Medicare Plus Blue Essential (PPO) in 2026, please refer to our full plan details page.
Medicare Plus Blue Essential (PPO) is a PPO plan offered by Blue Cross Blue Shield of Michigan Mutual Ins. Co. available for enrollment in 2025 to people living in State of Michigan. This plan received an overall rating of 4.5 out of 5 stars in 2026.
It's important to know that Medicare Plus Blue Essential (PPO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Medicare Plus Blue Essential (PPO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Medicare Plus Blue Essential (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $25.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $9.20. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $150.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $6250.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $6250.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Medicare Plus Blue Essential (PPO) plan features an annual drug deductible of $150. For Tier 1 preferred generic drugs, members pay no copay for a 1-month or 3-month supply at preferred pharmacies and mail-order services, while standard locations charge a $5 copay for 1-month and $15 for 3-month fills. Tier 2 generic prescriptions require a $5 copay for a 1-month supply and no copay for a 3-month supply at preferred pharmacies, compared to a $10 copay for 1-month and $30 for 3-month supplies at standard pharmacies. For higher-tier medications, costs transition to coinsurance percentages across all pharmacy and mail-order options. Tier 3 preferred brand drugs require a 20% coinsurance, and Tier 4 non-preferred drugs carry a 25% coinsurance for both 1-month and 3-month supplies. Tier 5 specialty drugs are limited to a 1-month supply and require a 31% coinsurance at both preferred and standard pharmacies.
Additional Benefits
Medicare Plus Blue Essential (PPO) offers comprehensive coverage for essential medical needs, featuring no copays for primary care visits, telehealth services, and annual preventive screenings. Specialist visits, physical therapy, and partial hospitalization require a $45 copay, while inpatient hospital stays carry a daily copay of $300 to $350 for the first seven days with no coinsurance. Emergency services are covered with a $130 copay, and urgent care visits range from no copay to a $50 copay. For ancillary care, the plan includes dental coverage up to a $950 annual limit with no copay for most services, and routine eye exams are available for no copay to a $45 copay, though eyewear and hearing aids are not covered. Diagnostic lab tests and home health services are available with no copay, while medical equipment and Part B drugs may require up to 20% coinsurance. Skilled nursing facility stays are covered with no copay for the first 20 days, followed by a $218 daily copay.
Inpatient Hospital See details
Medicare Plus Blue Essential (PPO) covers inpatient hospital services with no coinsurance, requiring a $350 daily copay for days 1-7 of acute stays and a $300 daily copay for days 1-7 of psychiatric stays, with no copay for subsequent days. This benefit is partially covered, as upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Outpatient services are covered by Medicare Plus Blue Essential (PPO) with no coinsurance, featuring a $125 to $350 copay for hospital services and a $130 copay per stay for observation services. There is no copay or coinsurance for ambulatory surgical center and blood services, while outpatient substance abuse sessions require a $45 copay.
Partial Hospitalization See details
Partial hospitalization is covered by Medicare Plus Blue Essential (PPO) with a $45.00 copay and no coinsurance, although prior authorization may be required.
Ambulance and Transportation Services See details
Ambulance and transportation services are partially covered by Medicare Plus Blue Essential (PPO), offering ground and air ambulance services for a $350 copay and no coinsurance. While emergency ambulance services are covered, transportation services to plan-approved or any health-related locations are not covered.
Emergency Services See details
Medicare Plus Blue Essential (PPO) covers emergency services with a $130 copay and no coinsurance, with the copay waived if you are admitted to the hospital within three days. Urgently needed services are covered with a copay ranging from no copay to $50 and no coinsurance, while worldwide emergency, urgent, and transportation services are covered up to a $50,000 maximum with copays ranging from $50 to $350 and no coinsurance.
Primary Care See details
Medicare Plus Blue Essential (PPO) provides primary care, telehealth, and opioid treatment services with no copay and no coinsurance, while specialist visits and physical, occupational, or speech therapies require a $45 copay and no coinsurance. Mental health and psychiatric sessions have a $20 copay with no coinsurance, but chiropractic services are only partially covered and podiatry services are not covered.
Preventive Services See details
Medicare Plus Blue Essential (PPO) covers preventive services, including annual physical exams, kidney disease education, and select screenings, with no copay and no coinsurance. Additional preventive services are partially covered with no copay and no coinsurance for smoking cessation counseling and remote access technologies, though sub-services like fitness benefits, health education, and personal emergency response systems are not covered.
Hearing Services See details
Hearing services under Medicare Plus Blue Essential (PPO) are partially covered, providing hearing exams with no copay, no coinsurance, and no deductible, though routine hearing exams and fitting or evaluation services are not covered. Prescription and OTC hearing aids are also not covered under this plan.
Vision Services See details
Vision services are partially covered by Medicare Plus Blue Essential (PPO), which offers one routine eye exam every year with a $0 to $45 copay and no coinsurance, while other eye exams are not covered. Eyewear, including contact lenses, eyeglasses, lenses, and frames, is not covered under this plan.
Dental Services See details
Medicare Plus Blue Essential (PPO) offers partially covered dental services with a $950 annual maximum for in- and out-of-network care, featuring no copay and no coinsurance for most services, and a $0 to $45 copay with no coinsurance for Medicare-covered dental. Other diagnostic dental, other preventive dental, maxillofacial prosthetics, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by Medicare Plus Blue Essential (PPO) with no copay, though prior authorization is required. Covered Part B chemotherapy, radiation, and other drugs have no copay and a coinsurance of no coinsurance to 20%, while Part B insulin requires a $35 copay and a coinsurance of no coinsurance to 20%.
Dialysis Services See details
Medicare Plus Blue Essential (PPO) covers Dialysis Services with no copay and a 20% coinsurance.
Medical Equipment See details
Medicare Plus Blue Essential (PPO) partially covers medical equipment with no copayments, although prior authorization is required and coinsurance ranges from no coinsurance up to 20%. While durable medical equipment, prosthetics, and diabetic supplies are covered, diabetic therapeutic shoes and inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered under Medicare Plus Blue Essential (PPO) with no coinsurance, though prior authorization is required. Members pay no copay for lab services, a $35 copay for outpatient x-rays, and varying copays for diagnostic procedures ($0 to $150) and radiological services (minimum of $35 to $100).
Home Health Services See details
Home Health Services are covered by Medicare Plus Blue Essential (PPO) with no copay and no coinsurance, allowing you to receive medical care at home at no cost.
Cardiac Rehabilitation Services See details
Cardiac rehabilitation services are not covered under the Medicare Plus Blue Essential (PPO) plan, which includes no coverage for intensive cardiac, pulmonary, or supervised exercise therapy (SET) services. Consequently, there is no copay or coinsurance for these services.
Skilled Nursing Facility (SNF) See details
Medicare Plus Blue Essential (PPO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but no prior three-day hospital stay. There is no copay for days 1 through 20, followed by a $218 daily copay for days 21 through 100, with no coverage for additional days.
Other Services See details
Other Services under Medicare Plus Blue Essential (PPO) are partially covered, with acupuncture, over-the-counter items, and meal benefits not covered by the plan. Covered benefits include Non-Medicare-covered Mobile Mental Health for a $20 copay and no coinsurance, and Ambulance No transport for a $90 copay and no coinsurance.
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