Medicare Plus Blue Vitality (PPO)
Medicare Advantage Plan H9572-002-4 • 2026 • Lapeer County, MI
Medicare Plus Blue Vitality (PPO) Medicare Advantage Plan H9572-002-4 • 2026 • Lapeer County, MI
This Medicare Advantage PPO plan, identified by CMS Plan ID H9572-002-4, is offered by Blue Cross Blue Shield of Michigan for the 2026 plan year. The plan uses a Preferred Provider Organization (PPO) provider network and comes with prescription coverage (Part D ).
Medicare Plus Blue Vitality Overview
Plan Overview for H9572-002-4 |
|
|---|---|
| CMS Plan ID: | H9572-002-4 |
| Plan Type: | PPO |
| Plan Year: | 2026 |
| Monthly Premium: | $72.40 Plus your Medicare Part B premium. |
| Medical Deductible: | $0.00 |
| Maximum Out-of-Pocket: | $5000.00 (In-Network) |
| Part B Give Back: | Not offered |
| Prescription Drug Coverage: | Enhanced, $0.00 deductible |
| Additional Benefits: | Dental, Vision, Hearing |
| Service Area: | Lapeer County, MI |
| Enrollment (Nationwide) | 22,030 beneficiaries |
| Enrollment (CMS – Local) | 552 beneficiaries in Lapeer County |
| Provided By: | Blue Cross Blue Shield of Michigan |
Plan Overview for Medicare Plus Blue Vitality
This Medicare Advantage MAPD PPO plan combines hospital, medical, and prescription drug coverage and allows access to Medicare-approved providers. The monthly premium is $72.40, and the plan includes Medicare Part A and Part B benefits along with integrated prescription drug coverage. The annual Part D deductible is $0.00.
Primary care visits have a $0 copay | Out-of-network: 40% coinsurance, while specialist visits come with a $30 copay | Out-of-network: 40% coinsurance. Urgent care services carry a $0-$50 copay, and ground ambulance transportation is $325 copay | Out-of-network: $325 copay, 40% coinsurance. These costs apply toward the annual maximum out-of-pocket (MOOP) limit of $5000.00. After 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 {title_plan_id}. Cost-sharing details for key services are provided below.
Cost-Sharing Overview
Cost-sharing for Medicare Plus Blue Vitality 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 H9572-002-4.
This section outlines in-network costs for primary care and specialist office visits, along with related preventive services.
| Covered Service | In-Network Cost |
|---|---|
| Primary: | In-network: $0 copay | Out-of-network: 40% coinsurance |
| Specialist: | In-network: $30 copay | Out-of-network: 40% coinsurance |
This section outlines in-network costs for preventive and wellness services included in the plan.
| Covered Service | In-Network Cost |
|---|---|
| Annual wellness exam: | In-network: $0 copay |
| Telehealth benefit: | In-network: $0 copay |
| Routine chiropractic: | In-network: $30 copay | Out-of-network: 40% coinsurance |
| Fitness benefits: | In-network: $0 copay | Out-of-network: $0 copay, 0% coinsurance |
| 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): | Not covered |
This section outlines in-network costs for diagnostic services, lab tests, x-rays, and other imaging services.
| Covered Service | In-Network Cost |
|---|---|
| Diagnostic radiology services: | In-network: $100-$150 copay | Out-of-network: 40% coinsurance |
| Lab services: | In-network: $0-$40 copay | Out-of-network: 40% coinsurance |
| Outpatient x-rays: | In-network: $35-$150 copay | Out-of-network: 40% coinsurance |
| Diagnostic tests and procedures: | In-network: $0-$150 copay | Out-of-network: $0 copay, 40% coinsurance |
This section outlines in-network costs for emergency services, urgent care, ambulance transportation, inpatient hospital stays, and skilled nursing facility care.
| Covered Service | In-Network Cost |
|---|---|
| Emergency room care: | $130 copay |
| Worldwide emergency care: | $130 copay |
| 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 | $218 per day for days 21-100 | Out-of-network: | 40% per stay |
| Ground ambulance: | In-network: $325 copay | Out-of-network: $325 copay, 40% coinsurance |
This section outlines in-network costs for mental health services, including outpatient therapy and inpatient psychiatric care.
| Covered Service | In-Network Cost |
|---|---|
| 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 |
This section outlines in-network costs for rehabilitation services, including physical therapy, speech and language therapy, and occupational therapy.
| Covered Service | In-Network Cost |
|---|---|
| Physical therapy and speech and language therapy: | In-network: $40 copay | Out-of-network: 40% coinsurance |
| Occupational therapy: | In-network: $40 copay | Out-of-network: 40% coinsurance |
This section outlines in-network costs for medical equipment and supplies, including diabetes supplies, durable medical equipment, and prosthetics.
| Covered Service | In-Network Cost |
|---|---|
| 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 |
This section outlines in-network cost sharing for chemotherapy and other Medicare Part B-covered drugs.
| Covered Service | In-Network Cost |
|---|---|
| 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 |
This section outlines in-network cost sharing for dental services, including preventive care, exams, x-rays, cleanings, and comprehensive dental procedures.
| Covered Service | In-Network Cost |
|---|---|
| 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 |
This section outlines in-network cost sharing for vision services, including eye exams, eyeglasses, and contact lenses.
| Covered Service | In-Network Cost |
|---|---|
| Routine eye exam: | In-network: $0 copay | Out-of-network: 50% coinsurance |
| Contact lenses: | Not covered |
| Eyeglass frames only: | Not covered |
| Eyeglass lenses only: | Not covered |
| Eyeglasses (frames & lenses): | Not covered |
| Upgrades: | Not covered |
This section outlines in-network cost sharing for hearing-related services, including exams, fittings, and hearing aids.
| Covered Service | In-Network Cost |
|---|---|
| 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 |
This section outlines in-network cost sharing for additional and special needs services that may be included in the plan.
| Covered Service | In-Network Cost |
|---|---|
| Adult day health services: | Not covered |
| Home-based palliative care: | Not covered |
| Personal emergency response system: | Not covered |
| Weight management programs: | Not covered |
| Wigs for chemotherapy-related hair loss: | Not covered |
| Alternative therapies: | Not covered |
| Massage therapy: | Not covered |
| Home/bathroom safety devices: | Not covered |
Certain preventive services are covered 100% by Medicare Plus Blue Vitality as a Part B benefit.
Prescription Drug Coverage
Medicare Plus Blue Vitality 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 Advantage coverage.
| Basic Part D Premium: | $30.70 |
|---|---|
| Supplemental Part D Premium: | $0.00 |
| Total Part D Premium: | $30.70 |
| Low-Income Premium Subsidy: | $8.75 |
| Low-Income Premium Subsidy Paid by CMS: | $8.80 |
| Low-Income Subsidy Premium: | $21.90 |
For more details, visit the Social Security Extra Help program.
Prescription Drug Plan Deductible
This plan has a $0.00 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 Vitality 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 | $11.00 copay | Coming soon |
| Preferred Brand | 20% coinsurance | Coming soon |
| Non-Preferred Drug | 25% coinsurance | Coming soon |
| Specialty Tier | 33% coinsurance | Coming soon |
| *Deductible does not apply. | ||
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.
| CMS Measure | Star Rating |
|---|---|
| 2026 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 |
Is there a monthly premium for this plan in 2026?
The 2026 monthly premium is $72.40. The Medicare Part B premium is paid separately.
What is the annual out-of-pocket maximum (MOOP) for this plan?
The 2026 in-network MOOP is $5000.00. Once this limit is reached, covered in-network costs are fully covered.
What is the CMS star rating for this plan?
The 2026 CMS star rating for Medicare Plus Blue Vitality is ★4.5 out of 5.
What is the total enrollment for plan H9572-002-4?
Total enrollment is 22,030 beneficiaries based on the latest CMS data.
What is the Part D deductible for plan H9572-002-4?
For 2026, the prescription drug deductible is $0.00.
Contact Information for Blue Cross Blue Shield of Michigan
| Contact Type | Details |
|---|---|
| Website: | Blue Cross Blue Shield of Michigan Plan Page |
| New Members: | 1-855-425-7720 |
| Existing Members: | 1-877-241-2583 |
| Plan Address: | 600 East Lafayette Blvd. | MC 1401 | Detroit, MI 48226 |
Enrollment status and eligibility information are available through the Social Security Administration. Additional information about Medicare Advantage is available at medicare.gov.
- CMS.gov, Landscape Source Files — Last accessed May 2, 2026
- CMS.gov, Medicare Part C & D Performance — Last accessed May 2, 2026
- CMS.gov, Plan Benefits Package — Last accessed May 2, 2026
- CMS.gov, Monthly Enrollment by Contract/Plan/State/County — Last accessed May 2, 2026
Data sources and methodology documentation..
- Blue Cross Blue Shield of Michigan (official source), http://www.bcbsm.com/medicare — Last accessed October 13, 2025
- Medicare.gov, "Understanding Medicare Advantage Plans" — Last accessed 25 May, 2025
- AARP.org, "The Big Choice: Original Medicare vs. Medicare Advantage" — Last accessed 25 May, 2025
- Medicare.gov, "Your coverage options" — Last accessed 25 May, 2025
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