Medicare Plus Blue Signature (PPO) Medicare Advantage Plan H9572-001-4 • 2027 • Lake County, MI
- Monthly Premium
- $132.00Plus Part B premium.
- Medical Deductible
- $0.00
- Maximum Out-of-Pocket
- $4300.00In-network
- Part B Giveback
- Not offered
- Prescription Coverage
- Enhanced, $200.00 deductible
- Additional Benefits
- Dental, Vision, Hearing
- Service Area
- Lake County, MI
- Local Enrollment
- 17 beneficiaries in Lake County
Medicare Plus Blue Signature (PPO) Introduction
Medicare Plus Blue Signature is a Medicare Advantage PPO plan offered by Blue Cross Blue Shield of Michigan. It uses a Preferred Provider Organization (PPO) provider network and comes with prescription drug coverage. For the 2027 plan year it has a $132.00 monthly premium, $0.00 medical deductible, and $4300.00 in-network maximum out-of-pocket. CMS Plan ID H9572-001-4 identifies this plan. The 2027 Part D prescription drug deductible is $200.00.
You must live in Lake County, Michigan to enroll in this plan. CMS reports 17 beneficiaries enrolled in this plan in Lake County. For assistance with this plan, new members can call (855)425-7720 (TTY 711).
Compare Similar Plans in Lake County
Compare this plan with the two most-enrolled PPO plans available in Lake County, Michigan. Enrollment is based on CMS local enrollment data.
| Plan Detail | Medicare Plus Blue Signature | Humana Full Access Giveback | Aetna Medicare Signature |
|---|---|---|---|
| CMS Plan ID | H9572-001-4 |
H7617-058-0 |
H5521-219-0 |
| Local Enrollment | 17 | 163 | 58 |
| Monthly Premium | $132.00 | $0.00 | $0.00 |
| Medical Deductible | $0.00 | $500 | $0.00 |
| Maximum Out-of-Pocket | $4,300.00 | $9,850.00 | $5,200.00 |
| Part B Giveback | Not offered | −$99.00 reduction | Not offered |
| Primary Care | $0 copay | $0 copay | $0 copay |
| Specialist | $30 copay | $50 copay | $0-$45 copay |
| Part D Deductible | $200.00 | $150.00 | $500.00 |
| CMS Star Rating | Not yet rated | Not yet rated | Not yet rated |
| Dental | $0 copay | $0 copay | $0 copay |
| Vision | $0 copay | $0 copay | $0 copay |
| Hearing | $0 copay | $0 copay | $0 copay |
Plan Benefits
Medicare Plus Blue Signature has cost-sharing, meaning there are out-of-pocket costs when receiving covered healthcare services. The tables below detail the most common in-network out-of-pocket expenses for plan H9572-001-4.
You can also compare 2027 costs and coverage with last year, side-by-side: Plan H9572-001-4 Cost Compare.
Office Visits
- Primary care
- In-network: $0 copay
Out-of-network: 40% coinsurance - Specialist
- In-network: $30 copay
Out-of-network: 40% coinsurance
Preventive and Wellness Services
- Annual wellness exam
- In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance - Telehealth benefit
- In-network: $0 copay
- Routine chiropractic
- In-network: $30 copay
Out-of-network: 40% coinsurance - Fitness benefits
- Coming soon
- Health education
- Not covered
- Counseling services
- Not covered
- Over-the-counter drug benefits
- In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance - Health transportation (non-emergency)
- Coming soon
Diagnostic, Lab, and Imaging Services
- Diagnostic radiology services
- In-network: $100-$125 copay
Out-of-network: 40% coinsurance - Lab services
- In-network: $0-$30 copay
Out-of-network: 40% coinsurance - Outpatient x-rays
- In-network: $35-$125 copay
Out-of-network: 40% coinsurance - Diagnostic tests and procedures
- In-network: $0-$125 copay
Out-of-network: $0 copay, 40% coinsurance
Emergency and Urgent Care Services
- Emergency room care
- $130 copay
- Worldwide emergency care
- Coming soon
- Urgent care
- $0-$50 copay
- Inpatient hospital care
- In-network:
Tier 1
$250 per day for days 1-7
$0 per day for days 8-90
$0 per stay
Out-of-network:
$0 and 40% per stay - Skilled Nursing Facility
- In-network:
Tier 1
$0 per day for days 1-20
$221 per day for days 21-100
Out-of-network:
40% per stay - Ground ambulance
- In-network: $285 copay
Out-of-network: $285 copay, 40% coinsurance
Mental Health Services
- Outpatient individual therapy
- In-network: $20 copay
Out-of-network: 40% coinsurance - Outpatient group therapy
- In-network: $20 copay
Out-of-network: 40% coinsurance - Inpatient psychiatric hospital care
- In-network:
Tier 1
$250 per day for days 1-7
$0 per day for days 8-90
$0 per stay
Out-of-network:
$0 and 40% per stay
Rehabilitation Services
- Physical therapy and speech and language therapy
- In-network: $35 copay
Out-of-network: 40% coinsurance - Occupational therapy
- In-network: $35 copay
Out-of-network: 40% coinsurance
Medical Equipment and Supplies
- Diabetes supplies
- In-network: 0%-20% coinsurance
Out-of-network: 0%-40% coinsurance - Durable medical equipment
- In-network: 0%-20% coinsurance
Out-of-network: 0%-40% coinsurance - Prosthetics
- In-network: 20% coinsurance
Out-of-network: 40% coinsurance
Medicare Part B Drugs
- Chemotherapy
- In-network: 0%-20% coinsurance
Out-of-network: 0%-40% coinsurance - Other Part B drugs (Medicare-covered)
- In-network: 0%-20% coinsurance
Out-of-network: 0%-40% coinsurance
Dental Services
- Oral exam
- In-network: $0 copay
Out-of-network: 50% coinsurance - Dental x-rays
- In-network: $0 copay
Out-of-network: 50% coinsurance - Cleaning
- In-network: $0 copay
Out-of-network: 50% coinsurance - Periodontics
- In-network: $0 copay
Out-of-network: 50% coinsurance - Endodontics
- In-network: $0 copay
Out-of-network: 50% coinsurance - Restorative services
- In-network: $0 copay
Out-of-network: 50% coinsurance - Implant services
- Not covered
- Orthodontics
- Not covered
- Oral/Maxillofacial surgery
- In-network: $0 copay
Out-of-network: 50% coinsurance
Vision Services
- Routine eye exam
- In-network: $0 copay
Out-of-network: 50% coinsurance - Contact lenses
- In-network: $0 copay
Out-of-network: 50% coinsurance - Eyeglass frames only
- In-network: $0 copay
Out-of-network: 50% coinsurance - Eyeglass lenses only
- In-network: $0 copay
Out-of-network: 50% coinsurance - Eyeglasses (frames & lenses)
- Not covered
- Upgrades
- Not covered
Hearing Services
- Hearing exam
- In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance - Fitting/evaluation
- In-network: $0 copay
Out-of-network: $0 copay, 0% coinsurance - Prescription hearing aids
- In-network: $495-$1695 copay
Out-of-network: $495-$1695 copay - OTC hearing aids
- Not covered
Additional and Special Needs Services
- Adult day health services
- Not covered
- Home-based palliative care
- Not covered
- Personal emergency response system
- Coming soon
- Weight management programs
- Not covered
- Wigs for chemotherapy-related hair loss
- Coming soon
- Alternative therapies
- Not covered
- Massage therapy
- Not covered
- Home/bathroom safety devices
- Not covered
Certain preventive services are covered 100% by Medicare Plus Blue Signature as a Part B benefit.
Prescription Drug Coverage
Medicare Plus Blue Signature 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 Advantage 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.
| Part D Premium Component | Amount |
|---|---|
| Basic Part D Premium: | $15.90 |
| Supplemental Part D Premium: | $$0.00 |
| Total Part D Premium: | $15.90 |
| Low-Income Premium Subsidy: | $6.28 |
| Low-Income Premium Subsidy Paid by CMS: | $6.30 |
| Low-Income Subsidy Premium: | $9.60 |
For more details, visit the Social Security Extra Help program .
Prescription Drug Plan Deductible
This plan has a $200.00 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 Signature may have additional costs at pharmacies. The table below outlines out-of-pocket expenses by drug tier.
| Drug Tier | Retail | Mail Order |
|---|---|---|
| Preferred Generic | $0.00 copay | Coming soon |
| Generic | $5.00 copay | Coming soon |
| Preferred Brand | 20% coinsurance | Coming soon |
| Non-Preferred Drug | 28% coinsurance | Coming soon |
| Specialty Tier | 31% coinsurance | Coming soon |
| *Deductible does not apply. | ||
CMS 5-Star Performance Ratings (Contract ID: H9572)
The Centers for Medicare & Medicaid Services (CMS) rates Medicare Advantage (Part C) and Part D prescription drug plans each year using a 5-star system. These ratings measure plan performance in areas such as preventive care, management of chronic conditions, and member experience.
| CMS Measure | Star Rating |
|---|---|
| 2027 Overall Rating | |
| Staying Healthy: Screenings, Tests, Vaccines | |
| Managing Chronic (Long Term) Conditions | |
| Member Experience with Health Plan | |
| Complaints and Changes in Plans Performance | |
| Health Plan Customer Service | |
| Drug Plan Customer Service | |
| Complaints and Changes in the Drug Plan | |
| Member Experience with the Drug Plan | |
| Drug Safety and Accuracy of Drug Pricing |
Contact Information for Blue Cross Blue Shield of Michigan
- Website
- Blue Cross Blue Shield of Michigan Plan Page
- Providers
- Blue Cross Blue Shield of Michigan Providers Page
- Formulary
- Blue Cross Blue Shield of Michigan Formulary Page
- Pharmacy
- Blue Cross Blue Shield of Michigan Pharmacy Page
- New Member Health Plan Help
- (855)425-7720
- New Member Health Plan TTY
- 711
- New Member Part D Help
- (855)425-7720
- New Member Part D TTY Users
- 711
Enrollment status and eligibility information are available through the Social Security Administration. Additional information about Medicare Advantage is available at Medicare.gov.
Medicare Plan Data Sources and Methodology
| Data Source | Publisher | Last Accessed |
|---|---|---|
| Landscape Source Files | Centers for Medicare & Medicaid Services | October 5, 2026 |
| Medicare Part C & D Performance | Centers for Medicare & Medicaid Services | October 5, 2026 |
| Plan Benefits Package | Centers for Medicare & Medicaid Services | October 5, 2026 |
| Monthly Enrollment by Contract/Plan/State/County | Centers for Medicare & Medicaid Services | October 5, 2026 |
Data sources and methodology documentation.
| Publisher | Reference | Last Accessed |
|---|---|---|
| Blue Cross Blue Shield of Michigan (official source) | http://www.bcbsm.com/medicare | October 4, 2026 |
| Medicare.gov | Understanding Medicare Advantage Plans | 25 May, 2025 |
| NCOA.org | 5 Steps to Choosing the Right Medicare Plan for You | 25 May, 2025 |
| Medicare.gov | Compare Original Medicare & Medicare Advantage | 25 May, 2025 |
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Data provenance is documented in accordance with the U.S. Core Data for Interoperability (USCDI) Provenance standard.
Page content independently curated and maintained by David W. Bynon, Editorial Steward, using a standardized, data-driven methodology for accurate, non-commercial Medicare plan interpretation and resolution.