Medicare Plus Blue Signature (PPO)
Medicare Advantage Plan H9572-001-6 • 2026 • Wayne County, MI
Medicare Plus Blue Signature (PPO) Medicare Advantage Plan H9572-001-6 • 2026 • Wayne County, MI
Medicare Plus Blue Signature is a Medicare Advantage PPO plan offered by Blue Cross Blue Shield of Michigan for the 2026 plan year. It is identified by CMS Plan ID H9572-001-6 and uses a Preferred Provider Organization (PPO) provider network. The plan comes with prescription drug coverage.
Medicare Plus Blue Signature Overview
Plan Overview for H9572-001-6 |
|
|---|---|
| CMS Plan ID: | H9572-001-6 |
| Plan Type: | PPO |
| Plan Year: | 2026 |
| Monthly Premium: | $145.20 Plus your Medicare Part B premium. |
| Medical Deductible: | $0.00 |
| Maximum Out-of-Pocket: | $4300.00 (In-Network) |
| Part B Give Back: | Not offered |
| Prescription Drug Coverage: | Enhanced, $0.00 deductible |
| Additional Benefits: | Dental, Vision, Hearing |
| Service Area: | Wayne County, MI |
| Enrollment (Nationwide) | 24,399 beneficiaries |
| Enrollment (CMS – Local) | 4,358 beneficiaries in Wayne County |
| Provided By: | Blue Cross Blue Shield of Michigan |
Plan Details for Medicare Plus Blue Signature
This Medicare Advantage MAPD PPO plan includes Medicare Part A and Part B services along with integrated prescription drug coverage. The monthly premium is $145.20, and the plan allows access to Medicare-approved providers, with lower costs when using in-network providers. The annual Part D deductible is $0.00.
Primary care visits have a $0 copay | Out-of-network: 40% coinsurance, and 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 $285 copay | Out-of-network: $285 copay, 40% coinsurance. These costs apply toward the annual maximum out-of-pocket (MOOP) limit of $4300.00. 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 {title_plan_id}. Cost-sharing details are provided below.
Out-of-Pocket Costs
Medicare Plus Blue Signature includes cost-sharing, which refers to out-of-pocket expenses for covered healthcare services. The table below outlines the most common in-network out-of-pocket costs associated with plan H9572-001-6.
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-$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 |
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 | $175 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: $285 copay | Out-of-network: $285 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 | $175 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: $35 copay | Out-of-network: 40% coinsurance |
| Occupational therapy: | In-network: $35 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: | 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 |
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 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 Advantage coverage.
| Basic Part D Premium: | $43.60 |
|---|---|
| Supplemental Part D Premium: | $0.00 |
| Total Part D Premium: | $43.60 |
| Low-Income Premium Subsidy: | $8.75 |
| Low-Income Premium Subsidy Paid by CMS: | $8.80 |
| Low-Income Subsidy Premium: | $34.80 |
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 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 | $10.00 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. | ||
Medicare Plan 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 plan’s monthly premium is $145.20 for 2026. The Part B premium is not included.
What is the MOOP for Medicare Plus Blue Signature in 2026?
For 2026, the in-network maximum out-of-pocket is $4300.00. The plan pays 100% of covered in-network services beyond this amount.
What is the CMS star rating for this plan?
The 2026 CMS star rating for Medicare Plus Blue Signature is ★4.5 out of 5.
What is the current enrollment for Medicare Plus Blue Signature?
The plan has 24,399 enrolled beneficiaries according to CMS.
What is the prescription drug deductible for 2026?
The plan’s Part D deductible is $0.00, applied to covered prescription drug costs.
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, "Compare types of Medicare Advantage Plans" — Last accessed 25 May, 2025
- Medicare.gov, "Joining a plan" — Last accessed 25 May, 2025
- Medicare.gov, "Explore your Medicare coverage options" — Last accessed 25 May, 2025
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