5

5 out of 5 stars* for plan year 2024

Plan ID: H9572-004

What You Need to Know:

  • Medicare Plus Blue PPO Essential (PPO) is a Medicare Advantage Health Maintenance Organization Local PPO plan.
  • It must provide all of the same hospital and medical benefits as Medicare Part A and Part B, however, costs may be different.
  • It has additional benefits not included in Medicare Part A and Part B, including prescription drug coverage.
  • The plan's monthly premium is $0, which does not include your monthly Medicare Part B premium.
  • The annual deductible for this health plan is $100 (Tier 1 and 2 excluded from the Deductible.).
  • The plan includes an out-of-pocket maximum of $6,000 per year (in-network).
  • Medicare Plus Blue PPO Essential (PPO) includes a Part D prescription drug plan for prescription medication coverage. The annual deductible is $100 (Tier 1 and 2 excluded from the Deductible.).
  • This plan's Part D Initial Coverage Limit is $10.

* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.

$0

Monthly Premium

Medicare Plan Features
Monthly Premium: $0
Part C Premium: $0
Monthly Premium: Part C Premium: Part D Drug Premium: Part D Supplemental Premium: Total Part D Premium: Drug Deductible: Tiers with No Deductible:
$0 $0 $10.00 $0 $10.00 $100.0 1.0
Gap Coverage: No
Benchmark: not below the regional benchmark
Type of Medicare Health: Enhanced Alternative
Health Plan Type: Local PPO
Similar Plan: H9572-001
Special Needs Type: NULL
Chronic Condition: NULL
Additional Gap Coverage: No additional gap coverage, only the Donut Hole Discount
Maximum Out-of-Pocket Limit for Parts A & B (Moop): $6,000
Annual Deductible: $100 (Tier 1 and 2 excluded from the Deductible.)
Annual Initial Coverage Limit ICL: $4,130
Number of Members enrolled in this plan in Chippewa, Michigan: Plans Summary Star Rating: Customer Service Rating: Drug Cost Rating:
361 members 3.5 out of 5 Stars. 5 out of 5 Stars. 4 out of 5 Stars.
Plan Offers Mail Order: Yes
Plan Health Benefits
Total # of Formulary Drugs: 3,501 drugs
Number of Members Enrolled in this Plan in Chippewa, Michigan: NULL
Number of Drugs Per Tier: NULL
Preferred Pharmacy Cost Sharing During Initial Coverage Phase: NULL
Special Needs Plan SNP Eligibility Requirement: NULL
Monthly Premium Split as Follows:
Part C Premium Part D Base Premium Part D Supplemental Premium Total Premium
$0.00 $10.00 $0.00 $10.00
Monthly Premium with Extra Help Low Income Subsidy:
LIS100 Subsidy Total Monthly Premium with LIS Parts CD LIS25 Subsidy Monthly PartD Premium with LIS LIS25 Subsidy Total Monthly Premium with LIS Parts CD LIS50 Monthly PartD Premium with LIS LIS50 Subsidy Total Monthly Premium with LIS Parts CD LIS75 Monthly PartD Premium with LIS LIS75 Subsidy Total Monthly Premium with LIS Parts CD
$0.00 $7.50 $7.50 $5.00 $5.00 $2.50 $2.50
Formulary Drug Details:
Tier 1 # of Drugs per Tier Tier 1 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 2 # of Drugs per Tier Tier 2 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 3 # of Drugs per Tier Tier 3 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 4 # of Drugs per Tier Tier 4 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 5 # of Drugs per Tier Tier 6 Preferred Pharmacy Cost Sharing (initial coverage phase)
324 $2.00 1287 $11.00 342 $42.00 656 50% 690 31%

Other Medicare Advantage Plans in Chippewa, Michigan

Plan Name Type Premium MOOP Rx Deduct. Rating
Humana Honor (PPO) (2023)Local PPO *$5,500$-
4
HumanaChoice H8087-001 (PPO) (2023)Local PPO$5,900$75
5
Humana Value Plus H8087-002 (PPO) (2023)Local PPO$7,550$260
5
Medicare Plus Blue PPO Vitality (PPO) (2023)Local PPO$5,000$100
5
HumanaChoice R3887-001 (Regional PPO) (2023)Regional PPO *$5,500$-
5
Medicare Plus Blue PPO Assure (PPO) (2023)Local PPO$3,425$0
5
Upper Peninsula Health Plan Advantage (HMO-POS) (2023)Local HMO$7,550$0
Insufficient data to rate this plan.
Medicare Plus Blue PPO Signature (PPO) (2023)Local PPO$4,700$0
5
HumanaChoice R3887-002 (Regional PPO) (2023)Regional PPO$5,300$380
5
Upper Peninsula Health Plan Choice (HMO) (2023)Local HMO$7,550$285
Insufficient data to rate this plan.
Medicare Advantage Plans by Blue Cross Blue Shield of Michigan
Medicare Plus Blue PPO Vitality (PPO) (2023)Local PPO$5,000$100
5
Medicare Plus Blue PPO Assure (PPO) (2023)Local PPO$3,425$0
5
Medicare Plus Blue PPO Signature (PPO) (2023)Local PPO$4,700$0
5

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