Medicare Plus Blue Vitality (PPO) Medicare Advantage Plan H9572-002-3 • 2026 • Shiawassee County, MI

Medicare Plus Blue Vitality Overview

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 $81.70, 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 H9572-002-3. Cost-sharing details for key services are provided below.

Cost Sharing Expenses

Medicare Plus Blue Vitality has cost-sharing, meaning there are out-of-pocket costs when receiving covered healthcare services. The table below details the most common in-network out-of-pocket expenses for plan H9572-002-3.

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 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 $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.

Medicare Plan Star Ratings

CMS evaluates Medicare Advantage (Part C) and Part D plans annually using a 5-star rating system. Ratings reflect performance in preventive care, chronic condition management, and member experience.