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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 $10.90. 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) prescription drug plan features an annual drug deductible of $150. For Tier 1 preferred generic drugs, you will pay no copay for a 1-month or 3-month supply when using preferred pharmacies or preferred mail order. Tier 2 generic drugs are also highly affordable, costing as little as a $5 copay for a 1-month supply or no copay for a 3-month supply through preferred channels. For higher-tier medications, cost-sharing transitions to coinsurance across all pharmacy types. Tier 3 preferred brand drugs require a 20% coinsurance, while Tier 4 non-preferred drugs require a 25% coinsurance for both 1-month and 3-month supplies. Tier 5 specialty drugs carry a 31% coinsurance for a 1-month supply at both preferred and standard pharmacies.
Additional Benefits
The Medicare Plus Blue Essential (PPO) plan offers comprehensive medical coverage featuring no coinsurance for many core services, including inpatient hospital stays, outpatient care, and emergency services. Members benefit from no copay for primary care visits, telehealth services, and preventative care, while specialist visits and physical therapy carry a $45 copay. For inpatient hospital care, acute stays require a $350 daily copay for the first seven days, followed by no copay for any additional days. Additionally, the plan covers home health care, diagnostic lab tests, and most dental services up to a $950 annual limit with no copay and no coinsurance. While diagnostic hearing exams and routine eye exams are covered with low-to-no copays, routine hearing aids and prescription eyewear are not covered. Skilled nursing facility stays feature no copay for the first 20 days, and durable medical equipment is available with no copay and coinsurance ranging up to 20%.
Inpatient Hospital See details
Medicare Plus Blue Essential (PPO) provides partially covered inpatient hospital services with no coinsurance, though prior authorization is required and upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered. Acute stays require a $350 daily copay for days 1 through 7 followed by no copay for unlimited additional days, while psychiatric stays require a $300 daily copay for days 1 through 7 and no copay for days 8 through 90.
Outpatient Services See details
Medicare Plus Blue Essential (PPO) covers outpatient services with no coinsurance, offering ambulatory surgical center and blood services with no copay. Covered outpatient hospital services require a $125 to $350 copay, observation services have a $130 copay per stay, and outpatient substance abuse sessions require a $45 copay.
Partial Hospitalization See details
Medicare Plus Blue Essential (PPO) covers partial hospitalization services with a $45 copay and no coinsurance. Prior authorization is required for some of these covered services.
Ambulance and Transportation Services See details
Medicare Plus Blue Essential (PPO) covers ground and air ambulance services with a $350 copay and no coinsurance, which is not waived if you are admitted to the hospital. Routine transportation services to health-related locations are not covered.
Emergency Services See details
Medicare Plus Blue Essential (PPO) covers emergency services with a $130 copay, which is waived if admitted to the hospital within three days, and no coinsurance. Urgently needed services require no copay to a $50 copay and no coinsurance, while worldwide emergency services are covered up to a $50,000 limit with no coinsurance and copays ranging from $50 to $350.
Primary Care See details
Medicare Plus Blue Essential (PPO) covers primary care, telehealth, and opioid treatment with no copay and no coinsurance. Specialist visits, occupational therapy, and physical therapy require a $45 copay with no coinsurance, while mental health sessions cost a $20 copay with no coinsurance. Podiatry and routine chiropractic services are not covered.
Preventive Services See details
Preventive services are covered by Medicare Plus Blue Essential (PPO) with no copay and no coinsurance, including annual physical exams, kidney disease education, and diabetes self-management training. However, these benefits are only partially covered, as health education, in-home safety assessments, PERS, medical nutrition therapy, medication reconciliation, re-admission prevention, chemotherapy wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional benefits, palliative care, in-home support, caregiver support, fitness benefits, disease management, telemonitoring, home safety devices, and counseling services are not covered.
Hearing Services See details
Medicare Plus Blue Essential (PPO) hearing services are partially covered, offering diagnostic hearing exams with no copay, no coinsurance, and no deductible, though routine exams and fitting evaluations are not covered. While prescription hearing aids are technically listed as covered, no specific types—including inner ear, outer ear, and over-the-ear devices—nor over-the-counter hearing aids are actually covered under this plan.
Vision Services See details
Medicare Plus Blue Essential (PPO) covers one routine eye exam per year with no coinsurance and a copay ranging from no copay to $45, while other eye exams are not covered. For eyewear, some services are covered with no copay or coinsurance, but contact lenses, eyeglasses, lenses, frames, and upgrades are not covered.
Dental Services See details
Medicare Plus Blue Essential (PPO) partially covers dental services up to a $950 annual limit, with no copay and no coinsurance for most preventive and comprehensive care, while Medicare-covered dental services require a $0 to $45 copay and no coinsurance. Orthodontics, maxillofacial prosthetics, other diagnostic dental, and other preventive dental services are not covered.
Home Infusion bundled Services See details
Medicare Plus Blue Essential (PPO) covers home infusion bundled services with no copay, subject to prior authorization. Associated Medicare Part B drugs, including chemotherapy, radiation, and insulin, require no coinsurance up to 20% coinsurance, with insulin also carrying a $35 copay.
Dialysis Services See details
Medicare Plus Blue Essential (PPO) covers dialysis services with no copay and a 20% coinsurance.
Medical Equipment See details
Medical equipment is partially covered by Medicare Plus Blue Essential (PPO) with no copays, though prior authorization is required. Durable medical equipment and diabetic supplies range from no coinsurance to 20% coinsurance, and prosthetic devices and medical supplies have a 20% coinsurance, while 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. Lab services have no copay, outpatient diagnostic procedures have a copay of $0 to $150, and radiological services require copays starting at $35 for x-rays and therapeutic services, and at least $100 for diagnostic radiology.
Home Health Services See details
Medicare Plus Blue Essential (PPO) covers Home Health Services with no copay and no coinsurance.
Cardiac Rehabilitation Services See details
Cardiac rehabilitation services are covered by Medicare Plus Blue Essential (PPO) with no copay and no coinsurance. While some services are covered, specific programs including standard cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for peripheral artery disease (PAD) rehabilitation are not covered in practice.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Medicare Plus Blue Essential (PPO) with no coinsurance, requiring no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, and while a prior three-day hospital stay is not needed, additional days beyond the standard 100-day limit are not covered.
Other Services See details
Medicare Plus Blue Essential (PPO) partially covers other services, offering non-Medicare-covered mobile mental health for a $20.00 copay with no coinsurance and ambulance non-transport services for a $90.00 copay with no coinsurance. Acupuncture, over-the-counter (OTC) items, and meal benefits are not covered.
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