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Blue Cross Blue Shield of Michigan Mutual Ins. Co.

Plan ID: H9572-3-4

Medicare Plus Blue PPO Assure (PPO)

2025 Medicare Plus Blue PPO Assure (PPO) H9572 — 003 — 4 is a Medicare Advantage plan with drug coverage. It has received a 4.5-out-of-5 star rating from CMS for 2025.

Learn more about Medicare Plus Blue PPO Assure (PPO) H9572 - 003 - 4, including the health and drug services it covers, by reading our easy-to-use guide. Or contact a licensed insurance agent for help now.

4.5 / 5 stars for 2025

$213.00 /mo

Monthly premium

Drug deductible

$3425.00

Out-of-pocket maximum

Enroll online

Call to enroll

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1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week!

Overview Benefits & Costs Drug Coverage Additional Benefits

Plan Overview

2025 Medicare Plus Blue PPO Assure (PPO) H9572 — 003 — 4 is a PPO offered in State of Michigan by Blue Cross Blue Shield of Michigan Mutual Ins. Co.. It has a monthly premium of $213.00.

Premium Breakdown

Standard Part B Premium

$185.00

Part B premium reduction

- $0

Monthly Plan Premium

$213.00

Total Premium:

$398.00

Note:

The standard Medicare Part B premium for 2025 is $185.00. Your premium may differ based on factors like late enrollment, income (IRMAA), or disability status. Most people enrolled in Medicare Part B are required to pay this premium.

Special needs plan type

Out-of-pocket maximum

$3425.00

Plan Organization:

Blue Cross Blue Shield of Michigan Mutual Ins. Co.

Plan Type:

PPO

Location:

State of Michigan

Drugs Covered:

Yes

Drug Formulary:

Formulary Link

Pharmacies:

Pharmacies Link

Doctor Choice:

Doctors Link:

Doctors Link

Deductibles

The amount you must pay each year before your plan starts to pay for covered services or drugs.

Drug deductible

Sign up for Medicare Plus Blue PPO Assure (PPO)

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Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week

Drug Coverage

Medicare Plus Blue PPO Assure (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Benefit Type

Enhanced Alternative

Prescription drug deductible

Part D Premium Reduction

This plan's premium may be reduced for you if you qualify for the low-income subsidy (also known as LIS or "Extra help"). The following is what you'll pay for with LIS.

Part D	LIS Full
$84.20	$57.60

Initial Coverage Phase

After you pay your $0.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $2000.00. Once you reach that amount, you will enter the next coverage phase.

30 Days

60 Days

90 Days

Tier	Preferred Pharmacy	Standard Pharmacy	Preferred Mail	Standard Mail
1. Preferred Generic	-	$5.00 Copay	-	$5.00 Copay
2. Standard Generic	-	-	-	-
3. Preferred Brand	-	-	-	-
4. Non-Preferred Drug	-	-	-	-
5. Specialty Tier	-	-	-	-

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit.

Additional Benefits

Medicare Plus Blue PPO Assure (PPO) also provides the following benefits.

Note:

Limits, Authorizations, and Referrals may apply for the benefits below. Contact the plan for details.

Comprehensive dental

Endodontics

In-Network: No Coins - No Co pay

Out-Of-Network: 50% Coins - No Copay

Oral and Maxillofacial Surgery

In-Network: No Coins - No Co pay

Out-Of-Network: 50% Coins - No Copay

Periodontics

In-Network: No Coins - No Co pay

Out-Of-Network: 50% Coins - No Copay

Restorative Services

In-Network: No Coins - No Co pay

Out-Of-Network: 50% Coins - No Copay

Preventive dental

Dental X-Rays

In-Network: No Coins - No Copay

Out-Of-Network: 50% Coins - No Copay

Fluoride Treatment

In-Network: No Coins - No Copay

Out-Of-Network: 50% Coins - No Copay

Oral Exams

In-Network: No Coins - No Copay

Out-Of-Network: 50% Coins - No Copay

Prophylaxis (cleaning)

In-Network: No Coins - No Copay

Out-Of-Network: 50% Coins - No Copay

Diagnostic procedures/lab services/imaging

Lab services

In-Network: $0-20 copay

Out-Of-Network: 30% coinsurance

Diagnostic radiology services

Outpatient x-rays

In-Network: $35-75 copay

Out-Of-Network: 30% coinsurance

Diagnostic tests and procedures

In-Network: $0-75 copay

Out-Of-Network: $0 copay or 30% coinsurance

Doctor visits

Primary

In-Network: $0 copay

Out-Of-Network: 30% coinsurance per visit

Specialist

In-Network: $0 copay

Out-Of-Network: 30% coinsurance per visit

Emergency care/Urgent care

Emergency

$125 copay per visit (always covered)

Urgent care

$0-40 copay per visit (always covered)

Foot care (podiatry services)

Foot exams and treatment

In-Network: $0 copay

Out-Of-Network: 30% coinsurance

Routine foot care

Not covered

Ground ambulance

All service types

In-Network: $250 copay

Out-Of-Network: $90-250 copay or 30% coinsurance

Hearing

Hearing aids OTC

Not covered

Fitting/evaluation

In-Network: $0 copay

Out-Of-Network: 50% coinsurance

Hearing aids

In-Network: $0 copay

Out-Of-Network: $0 copay

Medicare-Covered Hearing Exam

In-Network: $0 copay

Out-Of-Network: 50% coinsurance

Inpatient hospital coverage

All service types

In-Network: $100 per day for days 1 through 7 $0 per day for days 8 through 90

Out-Of-Network: 30% per stay

Outpatient hospital coverage

All service types

In-Network: $75-150 copay per visit

Out-Of-Network: 30% coinsurance per visit

Optional benefits

All service types

Yes

Medical equipment/supplies

Durable medical equipment

Diabetes supplies

In-Network: $0 copay

Out-Of-Network: $0 copay

Prosthetics

Medicare Part B drugs

Chemotherapy

In-Network: 0-20% coinsurance

Out-Of-Network: $0-35 copay or 0-30% coinsurance

Other Part B drugs

In-Network: 0-20% coinsurance

Out-Of-Network: $0-35 copay or 0-30% coinsurance

Mental health services

Outpatient group therapy visit

In-Network: $20 copay

Out-Of-Network: 30% coinsurance

Outpatient individual therapy visit

In-Network: $20 copay

Out-Of-Network: 30% coinsurance

Outpatient individual therapy visit with a psychiatrist

In-Network: $20 copay

Out-Of-Network: 30% coinsurance

Inpatient hospital - psychiatric

In-Network: $100 per day for days 1 through 7 $0 per day for days 8 through 90

Out-Of-Network: 30% per stay

Outpatient group therapy visit with a psychiatrist

In-Network: $20 copay

Out-Of-Network: 30% coinsurance

Preventive care

All service types

In-Network: $0 copay

Out-Of-Network: $0 copay

Rehabilitation services

Occupational therapy visit

In-Network: $30 copay

Out-Of-Network: 30% coinsurance

Physical therapy and speech and language therapy visit

In-Network: $30 copay

Out-Of-Network: 30% coinsurance

Skilled Nursing Facility

All service types

In-Network: $0 per day for days 1 through 20 $214 per day for days 21 through 100

Out-Of-Network: 30% per stay

Transportation

All service types

In-Network: $0 copay

Out-Of-Network: $0 copay

Vision

Contact lenses

In-Network: $0 copay

Out-Of-Network: 50% coinsurance

Eyeglass frames

In-Network: $0 copay

Out-Of-Network: 50% coinsurance

Eyeglasses (frames and lenses)

Not covered

Upgrades

Not covered

Other

In-Network: $0 copay

Out-Of-Network: 30-50% coinsurance

Routine eye exam

In-Network: $0 copay

Out-Of-Network: 30-50% coinsurance

Eyeglass lenses

In-Network: $0 copay

Out-Of-Network: 50% coinsurance

Wellness programs (eg, fitness, nursing hotline)

All service types

Covered

Plan Providers

Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Anthem Blue Cross, Aspire Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, GlobalHealth, Health Care Service Corporation, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Baylor Scott & White Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.

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1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week

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Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.

* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.

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