2022 Medicare Plus Blue PPO Assure (PPO)

Medicare Plus Blue PPO Assure (PPO) H9572-003 is a 2022 Medicare Advantage Plan or Part-C by Blue Cross Blue Shield of Michigan available to residents in Michigan. This plan includes additional prescription drug (Part-D) coverage. The Medicare Plus Blue PPO Assure (PPO) has a monthly premium of $201.00 and has an in-network maximum out-of-pocket limit of $3,425 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $3,425 out-of-pocket. This can be a extremely nice safety net.

Medicare Plus Blue PPO Assure (PPO) is a Local PPO. A preferred provider organization (PPO) is a Medicare plan that has created contracts with a network of "preferred" providers for you to choose from at reduced rates. You do not need to select a primary care physician and you do not need referrals to see other providers in the network. Offering you a little more flexibility overall. You can get medical attention from a provider outside of the network but you will have to pay the difference between the out-of-network bill and the PPOs discounted rate.

Blue Cross Blue Shield of Michigan works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Medicare Plus Blue PPO Assure (PPO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Blue Cross Blue Shield of Michigan and not Original Medicare. With Medicare Advantage you are always covered for urgently needed and emergency care. Plus you receive all the benefits of Original Medicare from Blue Cross Blue Shield of Michigan except hospice care. Original Medicare still provides you with hospice care even if you sign up for Medicare Advantage.

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2022 Blue Cross Blue Shield of Michigan Medicare Advantage Plan Costs

Medicare Plus Blue PPO Assure (PPO) Part-C Premium

Blue Cross Blue Shield of Michigan charges a $197.70 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.

H9572-003 Part-D Deductible and Premium

Medicare Plus Blue PPO Assure (PPO) has a monthly drug premium of $54.80 and a $0.00 drug deductible. This Blue Cross Blue Shield of Michigan plan offers a $54.80 Part-D Basic Premium that is not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $48.50 this Premium covers any enhanced plan benefits offered by Blue Cross Blue Shield of Michigan above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments and coverage of non-Part D drugs. The Part D Total Premium is $103.30. The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.

Blue Cross Blue Shield of Michigan Gap Coverage

In 2022 once you and your plan provider have spent $4430 on covered drugs. (combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 25% for prescription drugs unless your plan offers additional coverage. This Blue Cross Blue Shield of Michigan plan does offer additional coverage through the gap.

Premium Assistance

The Low Income Subsidy (LIS) helps people with Medicare pay for prescription drugs, and lowers the costs of Medicare prescription drug coverage. Depending on your income level you may be eligible for full 75%, 50%, 25% premium assistance. The Medicare Plus Blue PPO Assure (PPO) medicare insurance offers a $71.80 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $79.70 for 75% low income subsidy $87.60 for 50% and $95.40 for 25%.

H9572-003 Formulary or Drug Coverage

Medicare Plus Blue PPO Assure (PPO) formulary is divided into Tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers. By reviewing different Medicare Drug formularies, you can pick a Medicare Advantage plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price. You can see complete 2022 Medicare Plus Blue PPO Assure (PPO) H9572-003 Formulary here.

Drug Tier	Copay Preferred Pharmacy	Copay Nonpreferred Pharmacy
Tier 1	$0	$5
Tier 2	$7	$12
Tier 3	$37	$42
Tier 4	45%	45%
Tier 5	33%	33%

*Initial Coverage Phase and 30 day supply

2021 Medicare Plus Blue PPO Assure (PPO) Summary of Benefits

*This will be updated with 2022 data when available.

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Additional Benefits

Yes

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Comprehensive Dental

Diagnostic services	Not covered
Endodontics	Not covered
Extractions	Not covered
Non-routine services	Not covered
Periodontics	Not covered
Prosthodontics, other oral/maxillofacial surgery, other services	Not covered
Restorative services	Not covered

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Deductible

$0

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Diagnostic Tests and Procedures

Diagnostic radiology services (e.g., MRI)	30% coinsurance (Out-of-Network)
Diagnostic radiology services (e.g., MRI)	$75 copay
Diagnostic tests and procedures	$0-75 copay
Diagnostic tests and procedures	30% coinsurance (Out-of-Network)
Lab services	30% coinsurance (Out-of-Network)
Lab services	$0-20 copay
Outpatient x-rays	$35-75 copay
Outpatient x-rays	30% coinsurance (Out-of-Network)

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Doctor Visits

Primary	30% coinsurance per visit (Out-of-Network)
Primary	$0 copay
Specialist	$0 copay
Specialist	30% coinsurance per visit (Out-of-Network)

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Emergency care/Urgent Care

Emergency	$90 copay per visit (always covered)
Urgent care	$0-40 copay per visit (always covered)

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Foot Care (podiatry services)

Foot exams and treatment	$0 copay
Foot exams and treatment	30% coinsurance (Out-of-Network)
Routine foot care	Not covered

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Ground Ambulance

$250 copay
$250 copay or 30% coinsurance (Out-of-Network)

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Hearing

Fitting/evaluation	$0 copay
Fitting/evaluation	50% coinsurance (Out-of-Network)
Hearing aids	$0 copay (Out-of-Network)
Hearing aids	$0 copay
Hearing exam	$0 copay
Hearing exam	50% coinsurance (Out-of-Network)

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Inpatient Hospital Coverage

30% per stay (Out-of-Network)
$100 per day for days 1 through 6 $0 per day for days 7 through 90

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Medical Equipment/Supplies

Diabetes supplies	$0 copay
Diabetes supplies	$0 copay (Out-of-Network)
Durable medical equipment (e.g., wheelchairs, oxygen)	30% coinsurance per item (Out-of-Network)
Durable medical equipment (e.g., wheelchairs, oxygen)	20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs)	30% coinsurance per item (Out-of-Network)
Prosthetics (e.g., braces, artificial limbs)	20% coinsurance per item

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Medicare Part B Drugs

Chemotherapy	20% coinsurance
Chemotherapy	0-30% coinsurance (Out-of-Network)
Other Part B drugs	0-20% coinsurance
Other Part B drugs	0-30% coinsurance (Out-of-Network)

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Mental Health Services

Inpatient hospital - psychiatric	30% per stay (Out-of-Network)
Inpatient hospital - psychiatric	$100 per day for days 1 through 6 $0 per day for days 7 through 90
Outpatient group therapy visit	$40 copay
Outpatient group therapy visit	30% coinsurance (Out-of-Network)
Outpatient group therapy visit with a psychiatrist	30% coinsurance (Out-of-Network)
Outpatient group therapy visit with a psychiatrist	$40 copay
Outpatient individual therapy visit	30% coinsurance (Out-of-Network)
Outpatient individual therapy visit	$40 copay
Outpatient individual therapy visit with a psychiatrist	$40 copay
Outpatient individual therapy visit with a psychiatrist	30% coinsurance (Out-of-Network)

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MOOP

$5,150 In and Out-of-network $3,425 In-network

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Option

No

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Optional supplemental benefits

Yes

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Outpatient Hospital Coverage

30% coinsurance per visit (Out-of-Network)
$75-150 copay per visit

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Package #1

Deductible
Monthly Premium	$21.40

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Preventive Care

$0 copay (Out-of-Network)
$0 copay

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Preventive Dental

Cleaning	50% coinsurance (Out-of-Network)
Cleaning	$0 copay
Dental x-ray(s)	50% coinsurance (Out-of-Network)
Dental x-ray(s)	$0 copay
Fluoride treatment	Not covered
Oral exam	50% coinsurance (Out-of-Network)
Oral exam	$0 copay

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Rehabilitation Services

Occupational therapy visit	$30 copay
Occupational therapy visit	30% coinsurance (Out-of-Network)
Physical therapy and speech and language therapy visit	30% coinsurance (Out-of-Network)
Physical therapy and speech and language therapy visit	$30 copay

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Skilled Nursing Facility

$0 per day for days 1 through 20 $178 per day for days 21 through 100
30% per stay (Out-of-Network)

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Transportation

Not covered

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Vision

Contact lenses	50% coinsurance (Out-of-Network)
Contact lenses	$0 copay
Eyeglass frames	50% coinsurance (Out-of-Network)
Eyeglass frames	$0 copay
Eyeglass lenses	$0 copay
Eyeglass lenses	50% coinsurance (Out-of-Network)
Eyeglasses (frames and lenses)	Not covered
Other	$0 copay
Other	50% coinsurance (Out-of-Network)
Routine eye exam	50% coinsurance (Out-of-Network)
Routine eye exam	$0 copay
Upgrades	Not covered

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Wellness Programs (e.g. fitness nursing hotline)

Covered

CMS Star Ratings for Medicare Plus Blue PPO Assure (PPO) H9572

Staying Healthy, Screening, Testing, & Vaccines

Managing Chronic And Long Term Care for Older Adults

Member Experience with Health Plan

Member Complaints and Changes in Medicare Plus Blue PPO Assure (PPO) Plans Performance

Health Plan Customer Service Rating for Medicare Plus Blue PPO Assure (PPO)

Medicare Plus Blue PPO Assure (PPO) Drug Plan Customer Service Ratings

Ratings For Member Complaints and Changes in the Drug Plans Performance

Member Experience with the Drug Plan

Drug Safety and Accuracy of Drug Pricing

Ready to Enroll?

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1-855-778-4180
Mon-Fri 8am-8pm EST
Sat 8am-8pm EST

Coverage Area for Medicare Plus Blue PPO Assure (PPO)

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Source: CMS.
Data as of September 1, 2021.
Notes: Data are subject to change as contracts are finalized. For 2022, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part-D benefit. Includes 2022 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.