Medicare Plus Blue Giveback (PPO) Medicare Advantage Plan H9572-008 • 2026 • Branch County, MI

Medicare Plus Blue Giveback Overview

Plan Details for Medicare Plus Blue Giveback

This Medicare Advantage MAPD PPO plan includes Medicare Part A and Part B services along with integrated prescription drug coverage. The monthly premium is $0.00, and the plan allows access to Medicare-approved providers, with lower costs when using in-network providers. The annual Part D deductible is $150.00.

Primary care visits have a $0 copay | Out-of-network: $25 copay, and specialist visits come with a $55 copay | Out-of-network: 50% coinsurance. Urgent care services carry a $0-$40 copay, and ground ambulance transportation is $360 copay | Out-of-network: $360 copay, 50% coinsurance. These costs apply toward the annual maximum out-of-pocket (MOOP) limit of $9250.00. Once this limit is reached, in-network services are fully covered for the remainder of the year.

This plan is listed by CMS under Plan ID H9572-008. Cost-sharing details are provided below.

Cost-Sharing Overview

Cost-sharing for Medicare Plus Blue Giveback includes out-of-pocket expenses for covered healthcare services. The table below provides a summary of typical in-network out-of-pocket costs for plan H9572-008.

Certain preventive services are covered 100% by Medicare Plus Blue Giveback as a Part B benefit.

Prescription Drug Coverage

Medicare Plus Blue Giveback includes a Medicare Part D prescription drug plan (PDP). Plan type and coverage level are defined by CMS and may vary between basic and enhanced benefit designs.

This plan includes an enhanced benefit Medicare Part D plan (PDP), providing coverage beyond the standard CMS-defined minimum.

Prescription Drug Plan Premium

The Part D prescription drug plan premium is included in the overall Medicare Special Needs Plan cost. Additional adjustments may apply through the Low-Income Subsidy (LIS) program, also known as Extra Help, administered by Social Security. LIS benefits are separate from Medicare Special Needs Plan coverage.

For more details, visit the Social Security Extra Help program .

Prescription Drug Plan Deductible

This plan has a $150.00 annual Part D deductible. You'll pay this deductible at the pharmacy before Blue Cross Blue Shield of Michigan starts contributing towards your prescription costs.

Prescription Drug Plan Out-of-Pocket Costs

Beyond premiums and deductibles, Medicare Plus Blue Giveback may have additional costs at pharmacies. The table below outlines out-of-pocket expenses by drug tier.

CMS 5-Star Ratings

Medicare Advantage (Part C) and Part D plans are rated each year by CMS on a 5-star scale. Ratings summarize plan performance across clinical care and member experience measures.