5

5 out of 5 stars* for plan year 2024

Plan ID: H9572-001

What You Need to Know:

  • Medicare Plus Blue PPO Signature (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 $97, which does not include your monthly Medicare Part B premium.
  • The annual deductible for this health plan is .
  • The plan includes an out-of-pocket maximum of $4,700 per year (in-network).
  • Medicare Plus Blue PPO Signature (PPO) includes a Part D prescription drug plan for prescription medication coverage. The annual deductible is .
  • This plan's Part D Initial Coverage Limit is $35.

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

$97

Monthly Premium

Medicare Plan Features
Monthly Premium: $97.00
Part C Premium: $116.9
Monthly Premium: Part C Premium: Part D Drug Premium: Part D Supplemental Premium: Total Part D Premium: Drug Deductible: Tiers with No Deductible:
$97.00 $116.9 $35.10 $0 $35.10 $0 0.0
Gap Coverage: Yes
Benchmark: not below the regional benchmark
Type of Medicare Health: Enhanced Alternative
Health Plan Type: Local PPO
Similar Plan: H9572-002
Special Needs Type: NULL
Chronic Condition: NULL
Additional Gap Coverage: Yes, some additional gap coverage.
Maximum Out-of-Pocket Limit for Parts A & B (Moop): $4,700
Annual Deductible: NULL
Annual Initial Coverage Limit ICL: $4,130
Number of Members enrolled in this plan in Houghton, Michigan: Plans Summary Star Rating: Customer Service Rating: Drug Cost Rating:
93 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 Houghton, 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
$86.90 $35.10 $0.00 $122.00
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
$91.90 $27.60 $114.50 $20.10 $107.00 $12.50 $99.40
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 $1.00 1287 $10.00 342 $42.00 656 48% 690 33%

Other Medicare Advantage Plans in Houghton, Michigan

Plan Name Type Premium MOOP Rx Deduct. Rating
Humana Honor (PPO) (2023)Local PPO *$5,500$-
4
Aetna Medicare Premier (PPO) (2023)Local PPO$4,800$0
5
Aetna Medicare Value (PPO) (2023)Local PPO$5,500$0
5
HumanaChoice H8087-001 (PPO) (2023)Local PPO$5,900$75
5
Aetna Medicare Eagle (PPO) (2023)Local PPO *$5,900$-
5
Medicare Plus Blue PPO Vitality (PPO) (2023)Local PPO$5,000$100
5
Humana Gold Choice H8145-006 (PFFS) (2023)PFFS$-$445
4
Humana Gold Choice H8145-121 (PFFS) (2023)PFFS *$-$-
4
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.
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 Plus Blue PPO Essential (PPO) (2023)Local PPO$6,000$100
5
Humana Value Plus H8087-002 (PPO) (2023)Local PPO$7,550$260
5
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 Essential (PPO) (2023)Local PPO$6,000$100
5

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